Obesity - Epidemiology, Pa Tho Physiology and Prevention (2007)

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fm Page i Tuesday, January 30, 2007 9:37 AM
CRC Series in Modern Nutrition Science
Obesity
Epidemiology, Pathophysiology,
and Prevention
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CRC Series in
Modern Nutrition Science
Series Editor
Stacey J. Bell
Ideasphere, Inc.
Grand Rapids, Michigan
Phytopharmaceuticals in Cancer Chemoprevention

Edited by Debasis Bagchi and Harry G. Preuss
Handbook of Minerals as Nutritional Supplements

Robert A. DiSilvestro
Intestinal Failure and Rehabilitation: A Clinical Guide

Edited by Laura E. Matarese, Ezra Steiger,
and Douglas L. Seidner
Nutrition and Wound Healing

Edited by Joseph A. Molnar
A Clinical Guide for Management of Overweight

and Obese Children and Adults
Edited by Caroline M. Apovian and Carine M. Lenders
Obesity: Epidemiology, Pathophysiology, and Prevention

Edited by Debasis Bagchi and Harry G. Preuss
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CRC Series in Modern Nutrition Science
Obesity
Epidemiology, Pathophysiology,
and Prevention
EDITED BY
Debasis Bagchi
Harry G. Preuss
Boca Raton London New York
CRC Press is an imprint of the

Taylor & Francis Group, an informa business
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Library of Congress Cataloging-in-Publication Data
Obesity : epidemiology, pathophysiology, and prevention / edited by Debasis Bagchi and Harry G.
Preuss.
p. ; cm. -- (CRC series in modern nutrition science)
“A CRC title.”
Includes bibliographical references and index.
ISBN-13: 978-0-8493-3802-1 (hardcover : alk. paper)
ISBN-10: 0-8493-3802-6 (hardcover : alk. paper)
1. Obesity--Epidemiology. 2. Obesity--Pathophysiology. I. Bagchi, Debasis. II. Preuss, Harry G. III.
Series.
[DNLM: 1. Obesity--therapy. 2. Dietary Supplements. 3. Obesity--physiopathology. 4. Weight
Loss--drug effects. WD 210 O1121949 2007]
RC645.O23O2465 2007
616.3’98--dc22 2006102265
Visit the Taylor & Francis Web site at

http://www.taylorandfrancis.com
and the CRC Press Web site at
http://www.crcpress.com
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Dedication
Dedicated to my beloved father, the late Tarak Chandra Bagchi,

and my beloved father-in-law, the late Nakuleshwar Bardhan.
–Debasis Bagchi
Dedicated to my teachers, especially the late Rachel B. Lott

(third grade), the late MSG Thomas Hannon (CCD),
and the late Dr. Robert F. Pitts (postdoctoral training).
They along with many others prepared me for my career.
–Harry G. Preuss
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Contents
Preface .............................................................................................................................................. xi
Editors ............................................................................................................................................ xiii
Contributors......................................................................................................................................xv
PART I Introduction
1 Epidemiology of Obesity .......................................................................................................3
Giovanna Turconi and Hellas Cena
2 Epidemiology of Obesity: A Global Burden for the New Millennium..............................21

Gopal C. Pain
PART II Pathophysiology of Obesity

3 Environmental Estrogens, Endocrine Disruption, and Obesity...........................................33
Frederick S. vom Saal, James R. Kirkpatrick, and Benjamin L. Coe
4 Cigarette Smoking, Inflammation, and Obesity ..................................................................43

Saibal K. Biswas, Ian L. Megson, Catherine A. Shaw, and Irfan Rahman
5 Disordered Eating as a Correlate in the Development of Obesity .....................................63

Gwendolyn W. Pla
6 Role of Neurotransmitters in Obesity Regulation...............................................................71

Sunny E. Ohia and Catherine A. Opere
7 Neurobiology of Obesity .....................................................................................................81

Nina Eikelis
8 Leptin as a Vasoactive Adipokine: Link Between Metabolism and Vasculature ...............93

Anne Bouloumié, Cyrile Anne Curat, Alexandra Miranville,
Karine Lolmède, and Coralie Sengenès
9 Overview of Ghrelin, Appetite, and Energy Balance........................................................105

Rafael Fernández-Fernández and Manuel Tena-Sempere
10 Molecular Genetics of Obesity Syndrome: Role of DNA Methylation ...........................115

Rama S. Dwivedi, Atul Sahai, and Bernard L. Mirkin
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PART III Obesity and Degenerative Diseases
11 Oxidative Stress Status in Humans with Metabolic Syndrome ........................................123

Chung-Yen Chen and Jeffrey B. Blumberg
12 Obesity and Type 2 Diabetes.............................................................................................139

Subhashini Yaturu and Sushil K. Jain
13 Angiogenesis-Targeted Redox-Based Therapeutics ..........................................................155

Shampa Chatterjee, Debasis Bagchi, Manashi Bagchi, and Chandan K. Sen
14 Obesity as an Occult Risk Factor for Drug and Chemical Toxicities ..............................165
George B. Corcoran
PART IV Novel Concept in Obesity Drug Development
15 Adipose Drug Targets for Obesity Treatment ...................................................................177

Olivier Boss, Lorenz Lehr, and Jean-Paul Giacobino
PART V Safety of Obesity Drugs
16 Safety of Obesity Drugs ....................................................................................................199

Alok K. Gupta and Frank L. Greenway
PART VI Natural, Nutritional, and Physical

Approaches to Weight Management
17 The Fundamental Role of Physical Activity and Exercise in Weight Management ........219
Dawn Blatt and Cheri L. Gostic
18 Nutritional and Dietary Approaches for Weight Management: An Overview .................233

Sanjiv Agarwal
19 Gender Differences in Body Fat Utilization

during Weight Gain, Loss, or Maintenance.......................................................................239
Gabriel Keith Harris and David J. Baer
20 Appetite, Body Weight, Health Implications of a Low-Glycemic-Load Diet..................245

Stacey J. Bell, Wendy Van Ausdal, and Greg Grochoski
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Contents ix
21 Beyond Obesity Prevention: The Anti-Aging Effects of Caloric Restriction...................265

Kurt W. Saupe and Jacob D. Mulligan
22 Dietary Supplement Carbohydrate Digestion Inhibitors: A Review of the Literature .....279

Jay Udani, Mary Hardy, and Ben Kavoussi
23 Vegetarian Diets in the Prevention and Treatment of Obesity .........................................299

Kathryn T. Knecht, Hien T. Bui, Don K. Tran, and Joan Sabaté
24 The Atkins Paradigm .........................................................................................................315

Ariel Robarge and Bernard W. Downs
25 Polyphenols from Fruits and Vegetables in Weight Management and Obesity Control .....321
Dilip Ghosh and Margot A. Skinner
26 Chromium (III) in Promoting Weight Loss and Lean Body Mass...................................339

Manashi Bagchi, Harry G. Preuss, Shirley Zafra-Stone, and Debasis Bagchi
27 An Overview on (–)-Hydroxycitric Acid in Obesity Regulation......................................349

Shirley Zafra-Stone, Manashi Bagchi, Harry G. Preuss,
Gary J. Grover, and Debasis Bagchi
28 A Review of the Safety and Efficacy of Citrus aurantium in Weight Management .......371
Sidney J. Stohs and Michael Shara
29 Conjugated Linoleic Acid and Weight Control:

From the Biomedical Immune Viewpoint .........................................................................383
Zwe-Ling Kong
30 The Role of Tea in Weight Management ..........................................................................401

Chithan Kandaswami
31 Laboratory and Clinical Studies of Chitosan ....................................................................413

Harry G. Preuss, Debasis Bagchi, and Gilbert R. Kaats
32 Phaseolus vulgaris and α-Amylase Inhibition..................................................................423

Dennis E. Meiss
33 Glucomannan in Weight Loss: A Review of the Evidence...............................................433

Barbara Swanson and Joyce K. Keithley
34 Role of Caralluma fimbriata in Weight Management ......................................................443

Ramasamy V. Venkatesh and Ramaswamy Rajendran
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35 Role of Medium-Chain Triglycerides in Weight Management.........................................451

Mary G. Enig
36 Anti-Obesity by Marine Lipids .........................................................................................463

Kazuo Miyashita
37 Dairy Foods, Calcium, and Weight Management .............................................................477

Michael B. Zemel
38 Lessons from the Use of Ephedra Products as Dietary Supplements ..............................495

Madhusudan G. Soni, Kantha Shelke, and Rakesh Amin
39 Dietary Supplementation in Weight Loss: A Dietitian’s Perspective ...............................507

Betty Wedman-St. Louis
PART VII Child Obesity and Prevention
40 Treatment and Prevention of Childhood Obesity and Associated Metabolic Diseases..... 515
Michael I. Goran, Jaimie N. Davies, and Louise A. Kelly
PART VIII Bariatric Surgery in Weight Management
41 Bariatric Surgery in Obesity and Reversal of Metabolic Disorders .................................531

Melania Manco
Index ..............................................................................................................................................545
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Preface
The spread of obesity has been declared a worldwide epidemic by the World Health Organization
(WHO). In fact, a new term, globesity, has been coined to describe the recent upsurge of overweight
and obesity throughout the world’s population. How severe is the problem? According to WHO,
more than 1 billion adults are overweight and at least 315 million are clinically obese. To make
matters worse, the International Obesity Task Force estimates that 22 million of the world’s children
under age of 5 are overweight or obese [1–4]. In addition to type 2 diabetes, obesity has also been
linked to other broad-spectrum, degenerative diseases, including other metabolic disorders and
certain forms of cancer. Among the children diagnosed with type 2 diabetes, 85% are obese [2]. It
has been reported that 80% of type 2 diabetes, 70% of cardiovascular diseases, and 42% of breast
and colon cancers are related to obesity [1,2]. Obesity is the major factor behind 30% of gallbladder
perturbations leading to surgery and 26% of incidences of high blood pressure.
The unfortunate outcome of globesity has generated an unlimited array of weight-loss strategies
[1,2]. Products and programs that induce rapid weight loss and disturb metabolic homeostasis
dominate the focus of marketers and consumers alike; however, rapid weight loss is potentially
unhealthy and frequently induces undesirable rebound weight gain consequences. In addition, many
anti-obesity pharmaceuticals are accompanied by adverse reactions, making the cure worse than
the disorder itself; thus, it is very important to develop a strategic therapeutic intervention using
safe, novel, natural supplements supported by credible research. This book, intended for practicing
medical professionals, clinical nutritionists, dietitians, and researchers, addresses many issues
relevant to obesity: the molecular mechanisms and pathophysiology leading to obesity and meta-
bolic disorders, the safety of obesity drugs, drug development strategies, the influences of physical
activity and nutrition, and the benefits of research-supported nutraceutical supplements.
The forty-one chapters in this book have been written by experts in their fields. A world-
renowned nutritionist and a health professional have provided a world overview of the epidemiology
of obesity in the first part. Part II demonstrates the pathophysiology of obesity and correlates obesity
with environmental estrogens, endocrine disruption, inflammatory responses, tobacco, disordered
eating, and neurobiology and neurotransmitters. The significance of the hunger hormone ghrelin,
leptin, and the molecular genetics of obesity syndrome are discussed in subsequent chapters. Part
III correlates obesity with diverse degenerative diseases, including metabolic syndrome, type 2
diabetes, and cancer. Dr. Olivier Boss, a lead researcher on adipose drug targets, addresses new
concepts in obesity drug development in Part IV. Pennington Biomedical Research Center scientists
discuss the safety of obesity drugs in Part V, and Part VI summarizes natural, nutritional, and
physical approaches to weight management. The roles of physical activity, healthy dietary
approaches, gender effects, and caloric restriction are thoroughly explored, and this part also
provides a thorough discussion of carbohydrate blockers, polyphenolic compounds, trivalent chro-
mium, Garcinia cambogia, (–)-hydroxycitric acid, Citrus aurantium, Caralluma fimbriata, Phaseo-
lus vulgaris, α-amylase inhibition, conjugated linoleic acid, tea, chitosan, glucomannan, marine
lipids, calcium and dairy products, and medium-chain triglycerides. Also included is a chapter on
the Atkins paradigm, a chapter on the banned weight-loss supplement ephedra (which ruled the
market for at least a decade), and, finally, a chapter offering the reflections of a practicing dietitian
regarding weight-loss supplements. Part VII examines the complicated problem of childhood
obesity, including metabolic acidosis, and provides an intervention strategy. Part VIII demonstrates
how bariatric surgery can help in weight management and reversing metabolic disorders.
Finally, we extend our special thanks to all the authors for their invaluable contributions.
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xii Obesity: Epidemiology, Pathophysiology, and Prevention
REFERENCES
1. Worldwide Obesity: Trends Global Obesity Trends, Globesity the Growing Epidemic of Chronic
Overweight, 2006, http://www.annecollins.com/obesity/worldwide-obesity.htm.
2. Obesity Statistics: Weight Statistics — Adults, Children, Obesity-Related Diseases, 2006,
http://www.annecollins.com/obesity/statistics-obesity.htm.
3. WHO, World Health Statistics, World Health Organization, Geneva, 2006, pp. 42–48.
4. NCHS, Health, United States 2005, National Center for Health Statistics, Hyattsville, MD, 2005.
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Editors
Debasis Bagchi, Ph.D., FACN, CNS, MAIChE, received his Ph.D. in medicinal chemistry in
1982. He is a professor of toxicology in the Department of Pharmacy Sciences at Creighton
University Medical Center, Omaha, Nebraska. Dr. Bagchi is also the senior vice president of
research and development at InterHealth Nutraceuticals, Inc., in Benicia, California. Dr. Bagchi is
the vice president of the American College of Nutrtion and chair-elect of the Nutraceuticals and
Functional Foods division of the Institute of Food Technologists (IFT). His research interests include
free radicals, human diseases, carcinogenesis pathophysiology, mechanistic aspects of cytoprotec-
tion by antioxidants, regulatory pathways in obesity, and gene expression. Dr. Bagchi has written
225 papers that have been published in peer-reviewed journals. He has delivered invited lectures
and served as session chairperson for various national and international scientific conferences,
organized workshops, and group discussion sessions. Dr. Bagchi is a fellow of the American College
of Nutrition, member of the Society of Toxicology, member of the New York Academy of Sciences,
fellow of the Nutrition Research Academy, and member of the TCE Stakeholder Committee of the
Wright Patterson Air Force Base, Ohio. Dr. Bagchi is a member of the Study Section and Peer
Review Committee of the National Institutes of Health, Bethesda, Maryland, and serves as a
reviewer of U.S. Army research grants on Gulf War Illness. Dr. Bagchi is also serving as editorial
board member of numerous peer-reviewed journals, including Antioxidants and Redox Signaling,
Toxicology Letters, The Original Internist, Research Communications in Pharmacology and Toxi-
cology, and the International Journal of Geriatric Urology and Nephrology. Dr. Bagchi has received
research funding from various institutions and agencies, including the U.S. Air Force Office of
Scientific Research; National Institutes of Health (NIH); National Cancer Institute (NCI); National
Heart, Lung, and Blood Institute (NHLBI); American Heart Association; Nebraska State Depart-
ment of Health, Biomedical Research Support Grant; Health Future Foundation; The Procter &
Gamble Company; and Abbott Laboratories.
Harry G. Preuss, M.D., MACN, CNS, received his B.A. and M.D. from Cornell University, trained
for 3 years in internal medicine at Vanderbilt University Medical Center under Dr. David E. Rogers,
studied for 2 years as a fellow in renal physiology at Cornell University Medical Center under Dr.
Robert F. Pitts, and spent 2 years in clinical and research training in nephrology at Georgetown
University Medical Center under Dr. George E. Schreiner. During his training years, he was a
special research fellow of the National Institutes of Health (NIH) and an established investigator
of the American Heart Association. Following 5 years as an assistant and associate (tenured)
professor of medicine at the University of Pittsburgh Medical Center, he returned to Georgetown
Medical Center and is now a professor of physiology, medicine, and pathology (tenured). He
subsequently performed a 6-month sabbatical in molecular biology at the NIH in the laboratories
of Dr. Maurice Burg. His bibliography includes over 300 medical papers and more than 200
abstracts. Dr. Preuss has edited or co-edited seven books and three symposia published in well-
established journals. He is the co-author of three books written for the lay public: The Prostate
Cure, Maitake Magic, and the recently published The Natural Fat-Loss Pharmacy. He is currently
an advisory editor for six journals. In 1976, Dr. Preuss was elected to membership in the American
Society of Clinical Investigations. His previous government appointments included 4 years on the
Advisory Council for the National Institute on Aging, 2 years on the Advisory Council of the
director of the NIH, and 2 years on the Advisory Council for the Office of Alternative Medicine
of the NIH. He has been a member of many other peer research review committees for the NIH
xiii
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xiv Obesity: Epidemiology, Pathophysiology, and Prevention
and American Heart Association and is now a member of the National Cholesterol Education
Program of the NHLBI. Dr. Preuss was elected the ninth Master of the American College of
Nutrition (ACN). He is a former chairman of two ACN councils: the Cardiovascular and Aging
Council and the Council on Dietary Supplements, Nutraceuticals, and Functional Foods. After a
brief stint on the Board of Directors of the ACN, Dr. Preuss spent 3 years as secretary–treasurer
and 3 consecutive years as vice president, president-elect, and president. He is currently chairman
of the Nutritional Policy Institute of the ACN. Dr. Preuss is a member of the board of directors for
the American Association for Health Freedom (AAHF) and was their treasurer. Dr. Preuss wrote
the nutrition section for the Encyclopedia Americana and for seven years was president of the
Certification Board for Nutrition Specialists (CBNS) that gives the CNS certification. He is co-
chairman of the Institutional Review Board (IRB) at Georgetown University, which reviews all
clinical protocols at Georgetown University Medical Center. His research centers on the use of
dietary supplements and nutraceuticals to favorably influence or even prevent a variety of medical
perturbations, especially those related to obesity, insulin resistance, and cardiovascular perturba-
tions. Lately, he has also researched the ability of many oils and fats to overcome various infections,
including those resistant to antibiotics.
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Contributors
Sanjiv Agarwal Olivier Boss
ConAgra Foods, Inc. Sirtris Pharmaceuticals, Inc.
Omaha, Nebraska Cambridge, Massachusetts
Rakesh Amin Anne Bouloumié

Amin Law, LLC AVENIR
Chicago, Illinois INSERM U586, Obesity Research Unit
Paul Sabatier University
David J. Baer Louis Bugnard Institute IFR31
Diet and Human Performance Laboratory Toulouse, France
Beltsville Human Nutrition Research Center
Beltsville, Maryland Hien T. Bui
School of Pharmacy
Debasis Bagchi Loma Linda University
Department of Pharmacy Sciences Loma Linda, California
Creighton University Medical Center
Omaha, Nebraska; Hellas Cena
InterHealth Research Center Department of Applied Health Sciences
Benicia, California Section of Human Nutrition and Dietetics
Faculty of Medicine
Manashi Bagchi University of Pavia
InterHealth Research Center Pavia, Italy
Benicia, California
Shampa Chatterjee
Stacey J. Bell University of Pennsylvania School of Medicine
IdeaSphere, Inc. Philadelphia, Pennsylvania
Chung-Yen Chen
Saibal K. Biswas Antioxidant Research Laboratory
Department of Biochemistry Jean Mayer U.S.D.A. Human Nutrition
Dr. Ambedkar College Research Center on Aging
Deeksha Bhoomi, Nagpur, India Tufts University
Boston, Massachusetts
Dawn Blatt
Division of Rehabilitation Sciences Benjamin L. Coe
School of Health Technology and Management Division of Biological Sciences
Stony Brook University University of Missouri–Columbia
Stony Brook, New York Columbia, Missouri
Jeffrey B. Blumberg George B. Corcoran

Antioxidants Research Laboratory Department of Pharmaceutical Sciences
Jean Mayer U.S.D.A. Human Nutrition Eugene Applebaum College of Pharmacy and
Research Center on Aging Health Sciences
Tufts University Wayne State University
Boston, Massachusetts Detroit, Michigan
xv
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xvi Obesity: Epidemiology, Pathophysiology, and Prevention
Cyrile Anne Curat Michael I. Goran

Cardiovascular Physiology Institute Department of Preventive Medicine
Frankfurt/Main, Germany Keck School of Medicine
University of Southern California
Jaimie N. Davies Los Angeles, California
Department of Preventive Medicine
Keck School of Medicine Cheri L. Gostic
University of Southern California Division of Rehabilitation Sciences
Los Angeles, California School of Health Technology and Management
Stony Brook University
Bernard W. Downs Stony Brook, New York
Allied Nutraceutical Research
Lederach, Pennsylvania Frank L. Greenway
Medical Director and Professor
Rama S. Dwivedi Pennington Biomedical Research Center
Department of Pediatrics and Molecular Louisiana State University System
Pharmacology and Biological Chemistry Baton Rouge, Louisiana
Children’s Memorial Research Center
The Feinberg School of Medicine Greg Grochoski
Northwestern University Research and Development
Chicago, Illinois IdeaSphere, Inc.
Nina Eikelis
Human Neurotransmitter Laboratory Gary J. Grover
Baker Heart Research Institute Eurofins Scientific
Melbourne, Australia Dayton, New Jersey
Mary G. Enig Alok K. Gupta

Nutritional Sciences Division Pennington Biomedical Research Center
Enig Associates, Inc. Louisiana State University System
Silver Spring, Maryland Baton Rouge, Louisiana
Rafael Fernández-Fernández Mary Hardy

Department of Cell Biology, Physiology, Integrative Medicine Group, Cedars-Sinai
and Immunology Medical Center
University of Córdoba UCLA Center for Dietary Supplement
Córdoba, Spain Research in Botanicals
UCLA Center for Human Nutrition
Dilip Ghosh Department of Medicine, David Geffen/UCLA
Health and Food Group School of Medicine
The Horticulture and Food Research Institute UCLA Collaborative Centers for Integrative
of New Zealand Ltd. Medicine
Auckland, New Zealand Los Angeles, California
Jean-Paul Giacobino Gabriel Keith Harris

Growth and Development Laboratory Diet and Human Performance Laboratory
Rangos Research Center Beltsville Human Nutrition Research Center
Pittsburgh, Pennsylvania Beltsville, Maryland
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Contributors xvii
Sushil K. Jain Lorenz Lehr

Department of Pediatrics Department of Cell Physiology and Metabolism
Louisiana State University Health Sciences University of Geneva Medical School
Center Geneva, Switzerland
Shreveport, Louisiana
Karine Lolmède
Gilbert R. Kaats Cardio-Thoracic and Vascular Department
Health and Research Foundation University Vita-Salute San Raffaele
San Antonio, Texas Milano, Italy
Chithan Kandaswami Melania Manco

ADVOCARE International Liver Unit
Carrollton, Texas Bambino Gesù Paediatric Hospital and
Research Institute
Rome, Italy
Ben Kavoussi
Medicus Research, LLC
Northridge, California Ian L. Megson
Free Radical Research Facility
Department of Diabetes
Joyce K. Keithley
UHI Millennium Institute
Adult Health Nursing
Inverness, United Kingdom
Rush University College of Nursing
Chicago, Illinois
Dennis E. Meiss
ProThera®, Inc.
Louise A. Kelly Reno, Nevada
Department of Preventive Medicine
Keck School of Medicine
University of Southern California Alexandra Miranville
Los Angeles, California Cardiovascular Physiology Institute
Frankfurt/Main, Germany
James R. Kirkpatrick
Division of Biological Sciences Bernard L. Mirkin
University of Missouri–Columbia Department of Pediatrics and Molecular
Columbia, Missouri Pharmacology and Biological Chemistry
Children’s Memorial Research Center
The Feinberg School of Medicine
Kathryn T. Knecht Northwestern University
Department of Pharmaceutical Science Chicago, Illinois
School of Pharmacy
Loma Linda University
Kazuo Miyashita
Loma Linda, California
Hokkaido University
Hakodate, Japan
Zwe-Ling Kong
Cellular Immunology Lab Jacob D. Mulligan
Department of Food Science Departments of Medicine
National Taiwan Ocean University University of Wisconsin–Madison
Taiwan, Republic of China Madison, Wisconsin
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xviii Obesity: Epidemiology, Pathophysiology, and Prevention
Sunny E. Ohia Atul Sahai

Department of Pharmacological and National Institute of Diabetes and Digestive and
Pharmaceutical Sciences Kidney Diseases
College of Pharmacy National Institutes of Health
University of Houston Bethesda, Maryland
Houston, Texas
Kurt W. Saupe
Catherine A. Opere Departments of Medicine and Physiology
Department of Pharmacy Sciences University of Wisconsin–Madison
School of Pharmacy and Health Professions Madison, Wisconsin
Omaha, Nebraska Chandan K. Sen
The Ohio State University Medical Center
Gopal C. Pain Columbus, Ohio
National Consultant of India
World Health Organization Coralie Sengenès
New Delhi, India AVENIR
INSERM U586, Obesity Research Unit
Paul Sabatier University
Gwendolyn W. Pla
Louis Bugnard Institute IFR31
Department of Nutritional Sciences
Toulouse, France
Howard University
Washington, D.C.
Michael Shara
School of Pharmacy and Health Professions
Harry G. Preuss
Georgetown University Medical Center
Omaha, Nebraska
Washington, D.C.
Catherine A. Shaw
Irfan Rahman Centre for Cardiovascular Sciences
Department of Environmental Medicine Queen’s Medical Research Institute
Division of Lung Biology and Disease University of Edinburgh
University of Rochester Medical Center Edinburgh, United Kingdom
Rochester, New York
Kantha Shelke
Ramaswamy Rajendran Corvus Blue, LLC
Green Chem Chicago, Illinois
Bangalore, India Food Processing & Wellness Foods magazine
Itasca, Illinois
Ariel Robarge
Department of Nutrition Margot A. Skinner
Rothman Institute Health and Food Group
Philadelphia, Pennsylvania The Horticulture and Food Research Institute
of New Zealand Ltd.
Joan Sabaté Auckland, New Zealand
Department of Nutrition
School of Public Health Madhusudan G. Soni
Loma Linda University Soni and Associates
Loma Linda, California Vero Beach, Florida
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Contributors xix
Sidney J. Stohs Wendy Van Ausdal

ADVOCARE International IdeaSphere, Inc.
Carrollton, Texas American Fork, Utah
Ramasamy V. Venkatesh
Barbara Swanson
Gencor Pacific Limited
Adult Health Nursing
Discovery Bay, Hong Kong
Rush University College of Nursing
Chicago, Illinois
Frederick S. vom Saal
Division of Biological Sciences
Manuel Tena-Sempere University of Missouri–Columbia
Department of Cell Biology, Physiology, Columbia, Missouri
and Immunology
University of Córdoba Betty Wedman-St. Louis
Córdoba, Spain New York Chiropractic College and University
of Phoenix
Don K. Tran Licensed Nutritionist and Environmental
School of Pharmacy Health Specialist
Loma Linda University St. Petersburg, Florida
Loma Linda, California
Subhashini Yaturu
Overton Brooks Veterans Administration
Giovanna Turconi Medical Center
Department of Applied Health Sciences Louisiana State University Health Sciences
Section of Human Nutrition and Dietetics Center
Faculty of Medicine Shreveport, Louisiana
University of Pavia
Pavia, Italy Shirley Zafra-Stone
InterHealth Research Center
Jay Udani Benicia, California
David Geffen/UCLA School of Medicine
Integrative Medicine Program, Northridge Michael B. Zemel
Hospital The University of Tennessee Nutrition Institute
Medicus Research, LLC The University of Tennessee
Northridge, California Knoxville, Tennessee
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Part I
Introduction
1 Epidemiology of Obesity
Giovanna Turconi and Hellas Cena
CONTENTS
Introduction ........................................................................................................................................3
Prevalence of Obesity in the Adult Population .................................................................................5
Europe .........................................................................................................................................6
United States ...............................................................................................................................8
Latin America and Caribbean...................................................................................................10
Africa ........................................................................................................................................10
Japan, China, and Western Pacific Countries...........................................................................10
Prevalence of Obesity in Children and Adolescents .......................................................................11
Europe .......................................................................................................................................11
United States .............................................................................................................................13
Australia and China ..................................................................................................................14
Health Consequences of Obesity and Morbidity ............................................................................14
Benefits of Weight Loss...................................................................................................................14
Economic Costs of Obesity .............................................................................................................15
The Need for Action ........................................................................................................................16
References ........................................................................................................................................17
INTRODUCTION
Obesity is a complex, multifactorial, chronic disease involving environmental (social and cultural),
genetic, physiologic, metabolic, behavioral, and psychological components. It has been increasing
at an alarming rate throughout the world over the past two decades to the extent that it is now a
pandemic, affecting millions of people globally, and it is the second leading cause of preventable
death in the United States. The World Health Organization (WHO) has estimated that more than
300 million people are obese worldwide [1].
Obesity is defined as a condition of excess body fat, and it is associated with a large number
of debilitating and life-threatening disorders, such as major increases in associated cardiovascular,
metabolic, and other noncommunicable diseases [2]. It also contributes to increased mortality rates
from all causes, including cardiovascular diseases (CVDs) and cancer.
The obesity prevalence rate increase is evident in Westernized countries, where obesity has
been present for decades, but today it is also particularly noticeable in less developed countries that
previously had not experienced problems with overweight and obesity. For example, the prevalence
of obesity has increased by about 10 to 40% in the majority of European countries in the last
decade, and it currently affects nearly one third of the adult American population, as well as three
quarters of the adult population living in urban areas of Western Samoa in the Pacific [3].
Obesity in the developing world reflects the profound changes in society over the past 20 to
30 years that have created an environment that promotes a sedentary lifestyle and the consumption
of a high-fat, energy-dense diet, collectively known as the nutrition transition. As poor countries
3
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4 Obesity: Epidemiology, Pathophysiology, and Prevention
From least to most developed countries:

overweight is on the rise
Percentage of population
25
20
Underweight
Overweight
15
10
0
Global Least Developing Economies Developed
developed countries in transition market
countries economy
countries
As countries develop, they face many of the problems common

in industrialized nations. Obesity is one of the most worrisome.
FIGURE 1.1 From least to most developed countries, overweight is on the rise. As countries develop, they
face many of the problems common to industrialized nations. Obesity is one of the most worrisome. (From
FAO, The Developing World’s New Burden: Obesity, Food and Agriculture Organization, United Nations,
Geneva, Switzerland, 2002, http://www.fao.org/FOCUS/E/obesity/obes2.htm.)
become more prosperous, they acquire some of the benefits as well as some of the problems of
industrialized nations, including obesity (Figure 1.1) [4].
Because the direct measurement of body fat is difficult, the body mass index (BMI), a simple
weight-to-height ratio (kg/m2), is typically used to classify overweight and obese adults. Consistent
with this, the WHO has recently published international standards for classifying overweight and
obesity in adults (Table 1.1). Obesity is defined as a BMI ≥ 30 kg/m2, but it can be further subdivided
on the basis of the severity of the obesity [1].
TABLE 1.1
WHO Standard Classification of Obesity
Classification BMI (kg/m2) Risk of Comorbidities
Normal range 18.5–24.9 Average
Overweight 25.0–29.9 Mildly increased
Obesity class I 30.0–34.9 Moderate
Obesity class II 35.0–39.9 Severe
Obesity class III ≥40 Very severe
Source: WHO, Obesity: Preventing and Managing the Global

Epidemic, Report of a WHO Consultation, World Health Organi-
zation, Geneva, Switzerland, 2000, p. 256.
Epidemiology of Obesity 5
TABLE 1.2
Sex-Specific Waist Circumferences
for Increased Risk and Substantially
Increased Risk of Metabolic
Complications Associated with
Obesity in Caucasians
Risk of Obesity-Associated
Metabolic Complications
Substantially
Increased Increased
Men ≥94 cm ≥102 cm
Women ≥80 cm ≥88 cm
Note: The figures are population-specific and the

relative risk also depends on levels of obesity
(BMI) and other risk factors for CVD and NIDDM.
Source: WHO, Obesity: Preventing and Manag-

ing the Global Epidemic, Report of a WHO Con-
sultation, World Health Organization, Geneva,
Switzerland, 2000, p. 256.
Although the BMI provides a simple, convenient measurement of obesity, a more important
aspect of obesity is the regional distribution of excess body fat. Visceral or intraabdominal obesity,
in contrast to subcutaneous or lower body obesity, carries the greatest risk of a number of chronic-
degenerative diseases, including CVD and non-insulin-dependent diabetes mellitus (NIDDM). The
importance of central obesity is clear in populations (e.g., Asian) that tend to have relatively low
BMI values but high levels of abdominal fat and are particularly prone to NIDDM, hypertension,
and CVD. Methods for evaluating abdominal fat include measuring waist circumference. Changes
in waist circumference reflect changes in risk for CVD and other chronic diseases. As with the
BMI, cut-off values have been set to identify increased risk, but for waist circumference these must
be sex and population specific (Table 1.2) [1].
We must still recognize that overweight and obesity are part of a continuum and that health
risks increase with increasing weight in the individual. It has been estimated that the costs of obesity
account for up to 8% of the total healthcare costs in Western countries, and they represent an
enormous burden with regard to individual illness, disability, and early mortality as well as in terms
of the costs to employers, taxpayers, and society.
The mortality associated with excess weight increases as the degree of obesity and overweight
increases. One study estimated that between 280,000 and 325,000 deaths annually in the United
States could be attributed to overweight and obesity [5]. More than 80% of these deaths occur
among people with a BMI > 30 kg/m2. The increase in deaths due to obesity has been documented
in a number of studies from around the world (Table 1.3) [6–10].
PREVALENCE OF OBESITY IN THE ADULT POPULATION

It should be noted that it is often difficult to make a direct comparison of the prevalence of obesity
among countries due to the inconsistent classifications used to define obesity. This problem may
be overcome with the adoption in future surveys of the WHO standardized classifications for obesity.
From available data, the worldwide prevalence of obesity has been found to range from less than
TABLE 1.3
All-Cause and Disease-Specific Cause of Death from Several
Epidemiological Studies in Relation to Body Mass Index
All-Cause Mortality
(Deaths/1000 Patient-Years)
Study and BMI Criteria (kg/m2) Male Female
Nurses Health Study (ages 30–55 years, with 16 years’ follow-up) [7]
19.0–21.9 — 2.46
22.0–24.9 — 2.46
25.0–26.9 — 2.61
27–28.9 — 3.35
29–31.9 — 3.90
>32 — 4.64
British Regional Heart Study (ages 40–59 years, with 13.8 years’ follow-up) [8]
20–21.9 12.6 —
22–23.9 11.5 —
24–25.9 11.8 —
26–27.9 11.8 —
28–29.9 13.3 —
>30 16.8 —
Gothenberg Birth Cohort (ages 47–55 years, with 19.7 years’ follow-up) [9]
20.0–22.5 15.5 —
22.5–25.0 13.9 —
25.0–27.5 14.3 —
27.5–30 16.6 —
>30 21.1 —
Cancer Prevention Study II (ages 65–74 years) [10]

22.0–23.4 8.54 4.98
23.5–24.9 8.98 5.95
25.0–26.4 9.41 5.98
26.5–27.9 10.38 6.36
28.0–29.9 12.70 7.96
30.0–31.9 13.70 8.36
32.0–34.9 17.98 11.11
>35 27.67 12.99
Source: Caterson, J.D. et al., Circulation, 110, e476–e483, 2004. With permission.
5% in rural China, Japan, and some African countries to levels as high as 75% of the adult population
in urban Samoa. Table 1.4 [3] provides examples of secular trends of obesity for various countries.
Obesity levels also vary depending on ethnic origin. In the United States, particularly among women,
large differences exist in the prevalence of obesity among populations of different ethnic origins
within the same country.
EUROPE
Obesity is relatively common in Europe, especially among women and in Southern and Eastern
European countries. A marked trend toward increasing levels of adult overweight and obesity can
be found throughout Europe, although prevalence rates differ. Current prevalence data from a report
TABLE 1.4
Secular Trends of Obesity Worldwide (BMI > 30)
Country Year Ages Men Women
Australia 1989 20–69 9.3 11.1
Brazil 1975 25–64 3.1 8.2
1989 5.9 13.3
Canada 1991 18–74 15 15
China 1989 20–45 0.29 0.89
1991 0.36 0.86
1992 1.20 1.64
Czech Republic 1988 20–65 16 20
East Germany 1989 25–65 13 21
1992 21 27
England 1980 16–64 6 8
1986–1987 7 12
1991–1992 13 15
1995 15 16.5
Ghana 1987–1988 20+ 0.9 —
Japan 1982 20+ 0.9 2.6
1987 1.3 2.8
1993 1.8 2.6
Kuwait 1994 18+ 32 44
Quebec 1992 20–64 10 10
1998 13.5 11.7
Saudi Arabia 1990–1993 15+
Urban 18 28
Rural 12 18
South Africa Cape Peninsular 1990 15–64 8 44
The Netherlands 1994 20–59 10 11
United States 1973 20–74 11.6 16.1
1978 12.0 14.8
1991 19.7 24.7
West Germany 1991 25–69 16 21
Western Samoa (rural) 1978 25–69 17.7 37.0
1991 41.5 59.2
Western Samoa (urban) 1978 25–69 38.8 59.1
1991 58.4 76.8
Source: WHO, Obesity: Preventing and Managing the Global Epidemic, Report of WHO
Consultation on Obesity, World Health Organization, Geneva, 1998.
by the International Obesity Task Force (IOTF) suggest that the obesity prevalence in European
countries ranges from 10 to 27% for men and up to 38% for women [11]. Finland, Germany,
Greece, Cyprus, the Czech Republic, Slovakia, and Malta all have overweight rates that bypass
those of the United States. When judged on obesity alone, at least nine European countries have
male obesity rates above 20%, including Greece and Cyprus (27%). The prevalence of obesity has
increased by about 10 to 40% in most of the European countries in the last decade. In France,
obesity rose from 8.0% to 11.3% in women and from 8.4% to 11.4% in men, based on self-reported
surveys conducted between 1997 and 2003. In The Netherlands, obesity rose gradually from 6.2%
to 9.3% in women and from 4.9% to 8.5% in men from the late 1970s to the mid-1990s. The most
FIGURE 1.2 Prevalence of adult obesity in Europe (BMI ≥ 30 kg/m2). (From Rigby, N. and James, P., Waiting
for a Green Light for Health? Europe at the Crossroads for Diet and Disease, IOTF Position Paper, Interna-
tional Obesity Task Force, London, 2003, http://www.iotf.org/media/euobesity2.pdf.)
dramatic increase was recorded in the United Kingdom, where the obesity rate rose from 13.2%
to 22.2% in men and from 16.4% to 23.0% in women in just 10 years, up to 2003. Compare these
rates to an obesity rate of 6 to 7% in 1980 [11]. Figure 1.2 shows the prevalence of adult obesity
in Europe reported by the IOTF in 2003 [12].
UNITED STATES
National survey data from the United States show that the prevalence of overweight and obesity
among adults remained relatively constant over the 20-year period from 1960 to 1980. It began to
increase around the mid-1980s, and the past 25 years have witnessed a dramatic increase. In 1985,
only a few states participated in and provided obesity data to the Behavioral Risk Factor Surveillance
System (BRFSS) of the Centers for Disease Control and Prevention (CDC). In 1991, 4 states
reported obesity prevalence rates of 15 to 19%, and no states had rates at or above 20%. In 2004,
7 states had obesity prevalence rates of 15 to 19%, 33 states had rates of 20 to 24%, and 9 states
had rates higher than 25% (no data for one state). A recent IOTF report [11] shows that obesity
stands at 28% in men and 34% in women, although this rate rises to as high as 50% among black
women and includes a very significant component of morbid obesity. The data shown in Figure
1.3 [13] were collected through the CDC’s BRFSS. Each year, state health departments use standard
procedures to collect data through a series of monthly telephone interviews with U.S. adults.
Prevalence estimates generated for the maps may vary slightly from those generated for the states
by the BRFSS, as slightly different analytic methods are used.
It must be noted that overweight and obesity in the United States occur at higher rates among
racial or ethnic minority populations, such as African-Americans and Hispanic-Americans, compared
with Caucasian Americans. Asian-Americans have a relatively low prevalence for obesity. Women
and persons of low socioeconomic status within minority populations appear to be particularly
Obesity Trends* Among U.S. Adults

BRFSS, 1991, 1996, 2004
(*BMI ≥30, or about 30 lb overweight for 5ʼ4” person)
1991 1996
2004
No Data <10% 10% – 14% 15% – 19% 20% – 24% ≥25%
FIGURE 1.3 Trends in U.S. obesity from 1991 to 2004. (From CDC, Overweight and Obesity: Obesity
Trends—U.S. Obesity Trends 1985–2004, Centers for Disease Control and Prevention, Washington, D.C., 2005,
http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/index.htm.)
affected by overweight and obesity. Cultural factors that influence dietary and exercise behaviors
are reported to play a major role in the development of excess weight in minority groups [14]. The
prevalence of overweight and obesity increased over the last decade among the various racial and
ethnic groups, as shown in Table 1.5 [15]. Mexican-American and black (non-Hispanic) adults in
the United States are considerably more overweight and obese than Caucasian (non-Hispanic)
adults. The American Indian population also has high prevalence rates of overweight (where
overweight is defined as a BMI of ≥27.8 for men and ≥27.3 for women). The highest rates for
American Indians are 80% for women and 67% for men in Arizona, according to researchers of
TABLE 1.5
Increase in Overweight and Obesity Prevalence Among U.S. Adults by
Racial and Ethnic Group
Prevalence (%)
Overweight (BMI ≥ 25) Obesity (BMI ≥ 30)
Racial/Ethnic Group 1988 to 1994 1999 to 2000 1988 to 1994 1999 to 2000
Black (non-Hispanic) 62.5 69.6 30.2 39.9
Mexican-American 67.4 73.4 28.4 34.4
Caucasian (non-Hispanic) 52.6 62.3 21.2 28.7
Note: Ages 20 and older for 1999 to 2000 and ages 20 to 74 for 1988 to 1994.
Source: Flegal, K.M. et al., JAMA, 288(14), 1723–1727, 2002. With permission.
the 1995 Strong Heart Study. For women, the black (non-Hispanic) population has the highest
prevalence of overweight (78.0%) and obesity (50.8%). For men, the Mexican-American population
has the highest prevalence of overweight (74.4%) and obesity (29.4%). The prevalence of over-
weight, obesity, and severe obesity (BMI of 40 or more) has increased for both men and women
in the various racial and ethnic groups in the United States over the last decade [14].
LATIN AMERICA AND CARIBBEAN

Evidence of the impact of the nutrition transition is clear in the growing levels of obesity throughout
this region. Obesity rates are reported to vary for men from 7% in Peru and Brazil to more than
20% in Paraguay, but among women rates rise to as high as 36% in Paraguay [16]. Obesity is a
significant problem in the Caribbean and affects women more than men. Abdominal obesity, using
WHO waist circumference limits, ranged from 3% of men in St. Lucia to 8% in Barbados, but
among women it was found to be as high as 34% in Jamaica, 41% in St. Lucia, and 45% in Barbados
[17]. Brazil is the only Latin American country to have a nationally representative survey conducted
in the last 10 years. The Brazilian PNSN survey indicated that obesity is prevalent in Brazil and
is rising, especially among lower income groups. The problem of dietary deficit appears to be
rapidly shifting to one of dietary excess [3].
AFRICA
In contrast to most Western countries, the emphasis in Africa has been on undernutrition and food
security rather than overweight and obesity, so few data exist with regard to their current prevalence.
Regional studies do, however, indicate a growing prevalence of overweight and obesity in certain
socioeconomic groups. Wide disparities in levels of obesity can be found. The highest rates occur
in South Africa, where mean BMI values for men and women are 22.9 kg/m2 and 27.1 kg/m2,
respectively, but levels of central obesity among women have been assessed at 42% [18]. The South
African Health Review 2000 reported obesity rates ranging from 8% among black men to 20%
among Caucasian men, but among women the rates ranged from 20% for Indian/Asian women to
30.5% for black women. In North Africa, the prevalence of obesity among women is high. Half
of all women are overweight (BMI > 25), with rates of 50.9% in Tunisia and 51.3% in Morocco.
Obesity rates (BMI > 30) among this population of women are 23% in Tunisia and 18% in Morocco,
a threefold increase over 20 years [19]. In parts of Sub-Saharan Africa, obesity often exists alongside
undernutrition [20].
JAPAN, CHINA, AND WESTERN PACIFIC COUNTRIES

In Japan, obesity in men has doubled since 1982, whereas its rise in women has been restricted to
the younger age group (20 to 29 years), for which it has increased 1.8 times since 1976 [3]. Using
the obesity cut-off of a BMI > 25 as the standard, adult obesity in Japan would average 20%, rising
to 30% in men over 30 years old and in women over 40 years old, thus representing a three- to
fourfold increase over the last 40 years [21]. Obesity is increasing in China and is more common
in urban areas and among women. Between 1992 and 2002, the prevalence of overweight and
obesity increased in all gender and age groups and in all geographic areas. The Chinese obesity
standard shows an increase from 20.0% to 29.9%. The annual increase rate was highest in men
ages 18 to 44 years and women ages 45 to 59 years (approximately 1.6% and 1.0%, respectively).
In general, male subjects, urban residents, and high-income groups had a greater increase [22].
Obesity is not new to the Pacific and has long been regarded by Polynesian and Micronesian
societies of this region as a symbol of high social status and prosperity. The prevalence has risen
dramatically, however, in the last 20 years. The link between obesity and type 2 diabetes is most
manifest in this region, which has some of the highest levels of adult obesity. Obesity prevalence
rates of between 60 and 80% can be found among men and women in some islands, including
Samoa and Nauru. In Tonga, 60% of the adult population is obese, and recently 12% of men and
nearly 18% of women were identified with type 2 diabetes, a doubling of the rate over 25 years.
A further 20% were found to be at risk due to elevated blood sugar levels [23].
PREVALENCE OF OBESITY IN CHILDREN AND ADOLESCENTS

EUROPE
Recent concern has focused on child and adolescent obesity, which is a rapidly growing problem
in many countries. The concern is not only that young people who are already overweight and
obese are destined to remain so throughout their adult lives with heightened risks to health, but
also that youngsters are already developing diseases of old age, such as type 2 diabetes. Surveys
show overweight and obesity levels among children in Southern Europe to be higher than their
Northern European counterparts as the traditional Mediterranean diet gives way to more processed
foods rich in fat, sugar, and salt. The 2005 IOTF European Union platform briefing paper [11]
shows that the Mediterranean islands of Malta, Sicily, Gibraltar, and Crete, as well as the countries
of Spain, Portugal, and Italy, have reported overweight and obesity levels exceeding 30% among
children ages 7 to 11, as illustrated in Figure 1.4 [11]. In addition, England, Ireland, Cyprus, and
Percentage of adolescents ages 7 to 11

obese or overweight
Malta
Sicily
Spain
Gibraltar
Crete
Portugal
Italy
England
Ireland (Republic)
Cyprus
Sweden
Greece
France
Switzerland
Bulgaria
Poland
Czech Republic
Hungary
Germany
Denmark
Netherlands
0 10 20 30 40
obese oveweight
FIGURE 1.4 Overweight and obesity in adolescents ages 7 to 11. (From Lobstein, T. et al., EU Platform on
Diet, Physical Activity and Health, IOTF EU Platform Briefing Paper, in collaboration with EASO, Interna-
tional Obesity Task Force, London, 2005, http://ec.europa.eu/comm/health/ph_determinants/life_style/nutri-
tion/documents/iotf_en.pdf.)
Percentage of schoolchildren ages 13 to 17

obese or overweight
Crete
England
Italy
Cyprus
Ireland (Republic)
Greece
Bulgaria
Spain
Denmark
Hungary
Ireland (Northern)
Poland
Finalnd
Czech Republic
Germany
Netherlands
Slovakia
0 10 20 30 40
obese oveweight
FIGURE 1.5 Overweight and obesity in children ages 13 to 17. (From Lobstein, T. et al., EU Platform on
Diet, Physical Activity and Health, IOTF EU Platform Briefing Paper, in collaboration with EASO, Interna-
tional Obesity Task Force, London, 2005, http://ec.europa.eu/comm/health/ph_determinants/life_style/nutri-
tion/documents/iotf_en.pdf.)
Greece reported levels above 20%, while France, Switzerland, Poland, the Czech Republic, Hun-
gary, Germany, Denmark, The Netherlands, and even Bulgaria reported overweight and obesity
levels of 10 to 20% among this same age group [11]. For teenagers (ages 13 to 17), seven countries
reported overweight and obesity levels above 20%, with Crete peaking at 35%, as shown in Figure
1.5 [11]. The data in both Figure 1.4 and Figure 1.5 are from available surveys, so comparisons
require caution as the survey years may differ.
The IOTF’s international standard for analyzing childhood overweight and obesity data has
been widely adopted [24]. It provides growth curves that relate cut-off points for different age
groups to the adult categories for overweight (BMI ≥ 25 kg/m2) and obesity (BMI ≥ 30 kg/m2).
The IOTF method allows more realistic comparisons to be made among data from different
countries, whereas other assessment standards often relate to centiles, which indicate arbitrary
positions above a BMI centile value for overweight and obesity.
Childhood overweight and obesity are accelerating rapidly in some countries. The rise has been
particularly marked in recent years. IOTF estimates [11] prepared for WHO suggest that one out
of five children in Europe is overweight. An additional 400,000 children each year are becoming
overweight, and at least 3 million are obese. Annual increases in prevalence of around 0.2% during
the 1970s rose to 0.6% during the 1980s and up to 0.8% in the early 1990s, reaching as high as
2.0% in some cases by the 2000s.
TABLE 1.6
Increase in Obesity Prevalence (%)
Among U.S. Children (Ages 6 to 11)
Years Boys Girls
1999 to 2000 16.0 14.5
1988 to 1994 11.6 11.0
1971 to 1974 4.3 3.6
Source: Ogden, C.L. et al., JAMA, 288, 1728–1732,

2002. With permission.
TABLE 1.7
Increase in Obesity Prevalence (%)
Among U.S. Adolescents (Ages 12 to 19)
Years Males Females
1999 to 2000 15.5 15.5
1988 to 1994 11.3 9.7
1971 to 1974 6.1 6.2
Source: Ogden, C.L. et al., JAMA, 288, 1728– 1732,

2002. With permission.
UNITED STATES
Overweight and obesity for children and adolescents are defined as being at or above the 85th and
95th percentiles, respectively, of the gender-specific BMI for age growth charts. Approximately
30.3% of children (ages 6 to 11) are overweight, and 15.3% are obese. Among adolescents (ages
12 to 19), 30.4% are overweight and 15.5% are obese. Overweight prevalence is higher in boys
(32.7%) than girls (27.8%). In adolescents, overweight prevalence is about the same for females
(30.2%) and males (30.5%). The prevalence of obesity quadrupled over 25 years among children,
as shown in Table 1.6 [25,26], and more than doubled over 25 years among adolescent males and
females, as shown in Table 1.7 [25,26]. With regard to race and ethnicity, African-American,
Hispanic-American, and Native American children and adolescents have particularly high obesity
prevalence rates. Overweight and obesity prevalence for children and adolescents is presented by
racial group in Table 1.8 [25,26]. Among female youth, the highest overweight and obesity prev-
alence rates are found in black (non-Hispanic) girls (ages 6 to 11; 37.6% and 22.2%, respectively)
and black (non-Hispanic) adolescent females (ages 12 to 19; 45.5% and 26.6%, respectively).
Among male youth, the highest overweight and obesity prevalence rates are found in Mexican-
American boys (ages 6 to 11; 43.0% and 27.3%, respectively) and Mexican-American adolescent
males (ages 12 to 19; 44.2% and 27.5%, respectively). Overweight prevalence rates for Native
American children and adolescents (ages 5 to 17) were reported in a 1999 study to be 39.0% for
males and 38.0% for females in the Aberdeen area Indian Health Service. Asian-American adoles-
cents (ages 13 to 18) were reported to have an overweight prevalence of 20.6% in the 1996 National
Longitudinal Study of Adolescent Health. Asian-American and Hispanic-American adolescents
born in the United States from immigrant parents are more than twice as likely to be overweight
as foreign-born adolescents who move to the United States.
TABLE 1.8
Overweight (85th Percentile) and Obesity (95th Percentile) Prevalence for
Children and Adolescents by Racial Group
Children (Ages 6 to 11) Adolescents (Ages 12 to 19)
Prevalence (%) Prevalence (%)
Race Overweight Obesity Overweight Obesity
Black (non-Hispanic) 35.9 19.5 40.4 23.6
Mexican American 39.3 23.7 43.8 23.4
Caucasian (non-Hispanic) 26.2 11.8 26.5 12.7
Source: Ogden, C.L. et al., JAMA, 288, 1728–1732, 2002. With permission.
AUSTRALIA AND CHINA

In Australia, between 1985 and 1995, the prevalence of obesity among children ages 7 to 15 years
increased 4.6-fold among girls and 3.4-fold among boys [27]. Countries undergoing rapid urbaniza-
tion and economic development are experiencing double challenges: They have to fight both child-
hood undernutrition and a growing tide of obesity [28–30]. For example, in China, the prevalence
of overweight and obesity among children ages 7 to 9 years increased from 1% to 2% in 1985 to
17% among girls and 25% among boys in 2000 [30]. In addition, obesity prevalence varies across
socioeconomic strata. In developed countries, children of low socioeconomic status are more affected
than their wealthy counterparts [31–33]. The opposite is observed in developing countries, where
children in the upper socioeconomic status are more likely than poor children to be obese [34,35].
HEALTH CONSEQUENCES OF OBESITY AND MORBIDITY

Obesity has a great number of negative health, social, and economic consequences, as evidenced
by the higher mortality and morbidity rates among overweight and obese individuals than lean
people. Obese subjects have a 50 to 100% increased risk of premature death from all causes
compared to individuals with a healthy weight. The health consequences of obesity range from a
number of nonfatal complaints that impact the quality of life, such as respiratory difficulties,
musculoskeletal disorders, skin problems, and infertility, to complaints that lead to an increased
risk of premature death, including NIDDM, gallbladder disease, cardiovascular problems (hyper-
tension, stroke, and coronary heart disease), and certain cancers. Hypertension, diabetes, and raised
serum cholesterol are between two and six times more prevalent among heavier women. Severe
obesity is associated with a 12-fold increase in mortality in 25 to 35 year olds when compared to
lean individuals. The psychological consequences of obesity can range from lowered self-esteem
to clinical depression; the rates of anxiety and depression are three to four times higher among
obese individuals [3]. In addition to its physical consequences, obesity creates a massive social
burden in that negative attitudes toward the obese can lead to discrimination in many areas of their
lives, including health care and employment [3].
BENEFITS OF WEIGHT LOSS

Modest weight reduction can significantly reduce the risk of these serious health conditions. Weight
loss in overweight and obese individuals improves physical, metabolic, and endocrinological com-
plications, often dramatically. Weight loss in obese persons can also improve depression, anxiety,
psychosocial functioning, mood, and quality of life. In a 12-year study in the United States,
TABLE 1.9
Benefits of Weight Loss
Obesity Comorbidity Weight Loss Benefits of Weight Loss
Mortality 10 kg >20% reduction in total mortality
>30% reduction in diabetes-related death
Reduction in obesity-related cancer death
Diabetes 10 kg 50% reduction in fasting glucose
Blood pressure 10 kg 10-mmHg reduction in systolic pressure

20-mmHg reduction in diastolic pressure
Blood lipids 10 kg 10% reduction in TOT cholesterol
15% reduction in LDL cholesterol
30% reduction in triglycerides
8% increase in HDL cholesterol
Blood clotting indices — Reduced red cell aggregability
Improved fibrinolytic capacity
Physical complication 5–10 kg Improved back and joint pain
Improved lung function
Decreased breathlessness
Reduced frequency of sleep apnea
Ovarian function >5% Improved ovarian function
Source: WHO, Obesity: Preventing and Managing the Global Epidemic, Report of WHO
Consultation on Obesity, World Health Organization, Geneva, 1998.
intentional weight loss of 0.5 to 9.0 kg in overweight women with existing obesity-related disease
led to a 20% reduction in total mortality, a 40 to 50% reduction in mortality from obesity-related
cancers, and a 30 to 40% reduction in diabetes-related deaths [3]. Table 1.9 shows the major benefits
of weight loss on health status.
ECONOMIC COSTS OF OBESITY

Often overshadowed by the health and social consequences of obesity is the economic cost to
society and to the individual. The direct costs of diagnosis, treatment, and management of obesity
within national healthcare systems have been assessed in only a few countries to date. Although
the methodology varied considerably between studies, making it difficult to compare costs across
countries and to extrapolate the results from one country to another, these estimates suggest that
between 2 and 8% of the total healthcare costs in Western countries can be attributed to obesity
[3]. This represents a major fraction of national healthcare budgets comparable with, for example,
the total cost of cancer therapy. The potential impact on healthcare resources in the less-developed
healthcare systems of developing countries is likely to be even more severe. In addition to the direct
costs of obesity are costs in terms of the individual (including the intangible costs of poor health
and reduced quality of life) and society (such as the indirect costs of loss of productivity due to
sick-leave and premature pensions). Being able to determine the indirect costs of obesity that arise
from, for example, the loss of wages and productivity would raise the total cost of obesity even
higher. The IOTF is planning to investigate further the direct and indirect costs of obesity worldwide
as part of its implementation plan. Data collected by the IOTF in 2002 are summarized in Table
1.10 [36]. Prevention is clearly more cost effective than treatment, both in terms of economic and
personal costs.
TABLE 1.10
Examples of Direct Costs in European Union Compared with the United States
Direct Costs in Euros Percent of Health Expenditure
Country (millions) (%)
England (1995) 816 (+3270 indirect) 1.5
France (1992) 640–1320 1.5
Germany (1996) 10,600 —
Portugal (1996) 230 3.5
The Netherlands (1981–1989) 454 4.0
United States US$70,000 7.0
Note: Data not adjusted for inflation.
Source: IOTF and EASO, Obesity in Europe: The Case for Action, International Obesity Task Force and
European Association for the Study of Obesity, London, 2002 (http://www.iotf.org/media/euobesity.pdf).
THE NEED FOR ACTION

Obesity is a serious medical condition that requires urgent attention throughout the world. Despite
its high prevalence and our improved understanding of how the disease develops, only limited
effective obesity management systems are in place in national healthcare services around the world.
This is in contrast with other chronic diseases, such as diabetes and coronary heart disease, where
integrated care is frequently provided. It is clear, therefore, that the rational development of coor-
dinated healthcare services for the management of overweight and obese patients is needed in most
countries. Primary healthcare services should play the dominant role, although hospital and specialist
services are also required for dealing with more severe cases and the associated major life-threatening
complications. There is an urgent need for expanded training of all healthcare workers to improve
their levels of knowledge and skills with regard to obesity management strategies.
The IOTF was established in May 1996 to tackle the emerging global epidemic of obesity.
The IOTF is a part of the International Association for the Study of Obesity (IASO), an organi-
zation that represents 43 national obesity associations across the globe. The IOTF is composed
of world experts in the field of obesity and related diseases from around world, including China,
Japan, Chile, Australia, Brazil, the United States, Canada, and Europe. The IOTF collaborates
closely with the WHO and is engaged with other international health organizations and national
governments to raise awareness and help develop solutions to the global epidemic of obesity.
The IOTF aims to achieve taking action on the prevention and management of overweight and
obesity and endeavors to create an environment that encourages and supports the development
of appropriate public and health polices and programs for the prevention and management of
obesity. The IOTF initiative on the prevention and management of obesity has four main goals:
1. Increase the awareness among governments, healthcare professionals, and the community
that obesity is a serious medical condition and a major health problem with substantial
economic costs.
2. Provide evidence and guidance for the development of better prevention and management
strategies.
3. Secure the commitment of policymakers to take action.
4. Foster development of national, regional, and international structures that will enable and
support the implementation of taking action on the problems of overweight and obesity.
Management strategies are shown in Figure 1.6.

A systematic approach to management based on BMI and other risk factors
Assess overall health risk from BMI and other risk factors (e.g., waist circumference)
OVERALL HEALTH RISK
BMI Additional risk factors?
MANAGEMENT STRATEGIES
NO YES
Healthy diet and advice on preventing weight gain.
Average
BMI
Elevated waist circumference: institute weight management.
18.5–
Family history of obesity: prevent weight gain >3 kg.
24.9
Smoking: stop with dietary advice.
Increased
Lipids high: dietary advice.
Hypertensive: diet, exercise, weight maintenance.
Glucose intolerance: exercise, diet, weight maintenance.
BMI Increased Weight maintenance, healthy diet, exercise.

25–29.9
Goal for diet, exercise, behavior: primarily geared to risk management.
Weight loss needed if risk not reduced substantially within 3 months,
Moderate then aim for 5–10 kg over 24 weeks by mild energy deficit. If not
achieving this weight reduction at 24 weeks and risks persist, test
usefulness of drug to reduce risk by weight management.
BMI Moderate Goal of 5–10% weight loss without risk appropriate.
30–34.9
Consider very low calorie diet and drug therapy if diet, exercise, and
Severe lifestyle program is unsuccessful after 12 weeks in reducing all risk
factors.
BMI Severe Useful therapy including drugs to achieve >10% weight loss.
35–39.9
BMI Very Refer to specialist for separate management and consideration of

Very
severe surgery if conventional treatment fails. Aim for 20–30% weight reduction.
≥40 severe
FIGURE 1.6 A systematic approach to management based on BMI and other risk factors. (From WHO,
Obesity: Preventing and Managing the Global Epidemic, Report of WHO Consultation on Obesity, World
Health Organization, Geneva, 1998.)
In 1997, the WHO, together with the IOTF, held an expert consultation on obesity to review
the extent of the obesity problem and examine the need to develop public health policies and
programs to tackle the global problem of obesity. The consultation resulted in the publication of
the interim report Obesity: Preventing and Managing the Global Epidemic [3] and the subsequent
WHO Technical Report Series 894. The IOTF has identified a number of areas where our under-
standing of overweight and obesity must be improved. Specific working groups have examined the
following issues: childhood obesity, economic costs of obesity, management of obesity, public
health approaches to the prevention of obesity, and, finally, the training of health professionals.
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[8] Shaper, A.G., Wannamethee, S.G., and Walker, M., Body weight: implications for the prevention of
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[9] Rosengren, A., Wedel, J., and Wilhelmsen, L., Body weight and weight gain during adult life in men
in relationship to coronary heart disease and mortality: a prospective population study, Eur. Heart J.,
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[10] Calle, E.E. et al., Body mass index and mortality in a prospective cohort of U.S. adults, N. Engl. J.
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[11] Lobstein, T., Rigby, N., and Leach, R., EU Platform on Diet, Physical Activity and Health, IOTF EU
Platform Briefing Paper, in collaboration with the European Association for the Study of Obesity,
International Obesity Task Force, London, 2005, http://ec.europa.eu/comm/health/ph_determinants/
life_style/nutrition/documents/iotf_en.pdf.
[12] Rigby, N. and James, P., Waiting for a Green Light for Health? Europe at the Crossroads for Diet
and Disease, IOTF Position Paper, International Obesity Task Force, London, 2003, http://www.iotf.
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[14] AOA, Obesity in Minority Populations, AOA Fact Sheet, American Obesity Association, Washington,
D.C., 2002, http://www.obesity.org/subs/fastfacts/Obesity_Minority_Pop.shtml.
[15] Flegal, K.M. et al., Prevalence and trends in obesity among U.S. adults, 1999–2000, JAMA, 288(14),
1723–1727, 2002.
[16] Filozof, C. et al., Obesity prevalence and trends in Latin-American countries, Obes. Rev., 2, 99–106,
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[17] Okosun, I.S. et al., Abdominal adiposity in six populations of West African descent: prevalence and
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3802_C002.fm Page 21 Monday, January 29, 2007 1:14 PM
2 Epidemiology of Obesity:
A Global Burden for
the New Millennium
Gopal C. Pain
CONTENTS
Introduction ......................................................................................................................................21
Body Mass Index .............................................................................................................................21
Significance of Waist Circumference and Waist-to-Hip Ratio........................................................22
Prevalence of Obesity ......................................................................................................................22
Childhood Obesity ...........................................................................................................................25
Obesity and Morbidity .....................................................................................................................25
Obesity and Mortality ......................................................................................................................25
Age and Sex .....................................................................................................................................27
Roles of Physical Inactivity and Eating Habits...............................................................................27
Conclusion........................................................................................................................................27
References ........................................................................................................................................28
INTRODUCTION
Of the 1 billion overweight adults in the world, 300 million are clinically obese. This is an alarming
situation, even in light of the limited availability of population-based data. Even in Asian and
African countries experiencing acute starvation and underweight, obesity is still a problem. Obesity
and overweight are major risk factors for chronic diseases, including type 2 diabetes, coronary
heart disease, hypertension, stroke, and certain forms of cancer. An attempt has been made to review
the epidemiology of obesity. Obesity in general occurs from excess fat deposition and insufficient
energy expenditure. Body weight is usually measurable, and this approach is the one primarily
used in clinical practice. Ideal or desirable body weights have been developed by the Metropolitan
Insurance Company using weights associated with the lowest mortality so as to achieve maximum
life span. The tables that were prepared indicated that the average weight for height at age 30 was
ideal in terms of mortality [1]. In clinical practice, overweight is described as weighing 10% more
than the desirable weight.
BODY MASS INDEX

Though not a direct measure of obesity, the widely accepted means of assessing obesity is the body
mass index (BMI). A very good correlation has been found between BMI and the percentage of
body fat in a population. Table 2.1 provides the World Health Organization (WHO) classification
of adults according to the BMI:
kg Body weight in kg
BMI = =
m2 (Height in m)2
21
TABLE 2.1
WHO Classification of Adults According to BMI
Classification BMI Risk of Comorbidities
Underweight <18.50 Low (but risk of other clinical problems increased)
Normal range 18.50–24.99 Average
Overweight
Preobese 25.00–29.99 Increased
Obese class I 30.00–34.99 Moderate
Obese class II 35.00–39.99 Severe
Obese class III >40.00 Very severe
The BMI fails to distinguish general body obesity from abdominal obesity. The latter is more
serious and is related to osteoarthritis; breast, colon, and prostate cancers; decreased glucose
tolerance; and elevated low-density lipoprotein (LDL) cholesterol and triglycerides (together with
smoking and high blood pressure). In an analysis carried out by the World Health Report 2002,
approximately 58% of diabetes, 21% of ischemic heart disease, and 4 to 42% of certain cancers
globally were attributable to BMIs above 21 kg/m2 [2]. The BMI does not distinguish between
weight associated with muscles and weight associated with fat; therefore, the BMI may not
correspond to the same degree of fatness across a population.
SIGNIFICANCE OF WAIST CIRCUMFERENCE

AND WAIST-TO-HIP RATIO
A waist-to-hip ratio greater than 1.0 in men and 0.85 in women indicates abdominal fat accumulation
[3], but waist circumference alone provides a good indication of abdominal fat distribution that is
associated with ill health [4,5]. Table 2.2 shows the correlations among sex-specific waist circum-
ference, obesity, and the risk of metabolic dysfunctions and complications. A strong association
exists between upper body (android) obesity and the development of type 2 diabetes mellitus [6].
Accumulation of abdominal fat is an important risk factor indicator, and in this respect waist
circumference has an advantage over the BMI [7]. Table 2.3 highlights the relationship between
waist measurement and the odds ratio for risk factors.
PREVALENCE OF OBESITY
The prevalence of obesity is increasing worldwide at an alarming rate and is now a problem for
both developed and developing countries. Even India, where a third of the population falls below
the poverty line, has experienced steady growth in its relatively affluent urban middle class popu-
lation to 200 million, of which 40 to 50 million are overweight [8]. Starvation and malnutrition
TABLE 2.2
Sex-Specific Waist Circumference and Risk of
Metabolic Complications Associated with Obesity
Waist Circumference (cm)
Risk of Metabolic Complications Men Women
Increased >94 (≈37 in.) >80 (≈32 in.)
Substantially increased >102 (≈40 in.) >88 (≈35 in.)
Epidemiology of Obesity: A Global Burden for the New Millennium 23
TABLE 2.3
Relationship Between Waist Measurement and Odds Ratio for Risk Factors
Men Women
At Risk High Risk At Risk High Risk
Waist measurement (cm) 94–102 >102 80–88 >88
Odds ratio for risk factors 2.2 4.6 0.6 2.6
(1.8–2.8) (3.5–6.0) (1.3–2.1) (2.0–3.2)
Risk factors: >6.5 mmol/L total cholesterol; <0.9 mmol/L HDL cholesterol; >160 systolic or >95 mmHg
diastolic blood pressure.
TABLE 2.4
Obesity Prevalence in Some African Countries and Populations
Prevalence of
Obesity (%)
Age
Country or Population Year Group Men Women Ref.
Mauritius 1992 25–74 5 15 Hodge et al. [11]
Cape Peninsula, South Africa (blacks) 1990 15–64 8 44 Steyn et al. [10]
United Republic of Tanzania 1986–1989 35–64 0.6 3.6 Berrios et al. [12]
TABLE 2.5
Obesity Prevalence in Selected European Countries
Prevalence of
Obesity (%)
Age
Country Year Group Men Women Ref.
England 1995 16–64 15 16.5 Prescott-Clarke and
Primatesta [13]
Finland 1991–1993 20–75 14 11 Seidell and Rissanen [14]
Former Federal Republic of Germany 1992 25–65 20.5 26.8 Hoffmeister et al. [15]
Netherlands 1995 20–29 8.4 8.3 Seidell [16]
coexist with obesity in many developing countries. In spite of the limited availability of population-
based data and differing definitions of obesity and age standardization, WHO has provided a clear
global picture of the increased prevalence of obesity [9]. Table 2.4, Table 2.5, Table 2.6, Table 2.7,
Table 2.8, and Table 2.9 provide data on the prevalence of obesity (BMI ≥ 30) in various countries
as suggested by WHO. Table 2.8 provides insight into the prevalence of overweight (BMI ≥ 25),
obese, and severely obese (BMI ≥ 40) persons in the United States, and Table 2.9 shows the overall
global obesity prevalence in WHO regions. The most comprehensive data on obesity in Europe are
those of the WHO MONICA study [17]. It has been observed that over the last 10 years the
prevalence of obesity has increased by 10 to 40% in European countries. According to the Centers
for Disease Control and Prevention (CDC), over half of the U.S. population is overweight (approx-
imately 127 million), nearly one third is obese (60 million), and about 15 million are severely
obese. Emerging evidence suggests that overweight and obesity have reached epidemic proportions
globally.
TABLE 2.6
Obesity Prevalence in Selected Mediterranean Countries
Prevalence of
Obesity (%)
Age
Kuwait 1994 18+ 32 41 Al-Isa [18]
Saudi Arabia 1990–1993 15+ 16 24 Al-Nuaim et al. [19]
United Arab Emirates 1992 17+ 16 38 Musaiger [20]
TABLE 2.7
Obesity Prevalence in Selected Western Pacific Countries
Prevalence of
Obesity (%)
Age
Australia 1989 25–64 11.5 13.2 Bennett and Magnus [21]
China 1992 20–45 1.20 1.64 WHO [pers. comm.]
Japan 1993 20+ 1.7 2.7 WHO [pers. comm.]
New Zealand 1989 18–64 10 13 Ball et al. [22]
TABLE 2.8
Overweight, Obese, and Severely Obese Prevalence in the United States
Prevalence
Overweight Obese Severely Obese
(BMI ≥ 25 kg/m2) (BMI ≥ 30 kg/m2) (BMI ≥ 40 kg/m2)
Men 67.0% 27.7% 3.1%
Women 62.0% 34.0% 6.3%
Adolescents (ages 12–19) 30.4% 15.5% Not determined
Children (ages 6–11) 30.3% 15.3% Not determined
U.S. population 127 million 60 million 15 million
Source: WHO, Controlling the Global Obesity Epidemic, World Health Organization, Geneva, 2003,
www.who.int/nutrition/topics/obesity/en/.
TABLE 2.9
Obesity Prevalence in WHO Global Regions
Obese Adults (BMI ≥ 30 kg/m2)
Prevalence Number of People
WHO Region (%) (Millions)
The Americas 20.9 109.0
Europe 16.7 106.5
Western Pacific 3.8 42.5
Eastern Mediterranean 10.0 24.9
Global population 8.9 315.0
Source: Worldwide Obesity: Trends Global Obesity Trends, Globesity the Growing Epidemic
of Chronic Overweight, 2006, http://www.annecollins.com/obesity/worldwide-obesity.htm.
Papua New Guinea

Bangladesh
Philippines
Burkina Faso
Singapore
Togo
Tunisia
Rwanda
India
Indonesia
Belize
Jordan
Tahiti
Nicaragua
Brazil
Saint Lucia
United Kingdom
Yogoslavia
Antigua
Zambia
Venezuela
Italy
Panama
Peru
Barbados
Honduras
Lesotho
Bolivia
Trinidad & Tobago
Iran (Islamic Republic of)
Mauritius
Canada
Jamaica
Chile
0 2 4 6 8 10
Percentage of obese preschool children
FIGURE 2.1 Prevalence of obese preschool children (0 to 59 months) in selected countries and territories.
CHILDHOOD OBESITY
So far, no agreement has been reached with regard to the classification of overweight and obesity in
children and about a globally applicable reference population, yet an attempt has been made by WHO
to compile data on the global prevalence of obesity in childhood [25]. Children were defined as obese
when they exceeded the National Center for Health Statistics (NCHS) median weight for height plus
two standard deviations or Z-scores. According to Martorell [26], the prevalence of obesity in the
reference population was 2.3%. With the exception of Pakistan, where 2.6% of children were obese,
obesity was rare in South Asia (including India) and in Thailand. Figure 2.1 clearly illustrates that
the prevalence of obesity is high in most of the developing and developed parts of the world.
OBESITY AND MORBIDITY

According to Jung [27], obesity results in a multiplicity of problems, and a weight loss of 10 kg
can have beneficial health effects (see Table 2.10 and Table 2.11).
OBESITY AND MORTALITY

A close relationship exists between obesity and mortality. In the Nurses’ Health Study, Manson et
al. [28] demonstrated an almost linear and continuous relationship between BMI and premature
TABLE 2.10
Morbidity and Obesity
Aspect Effect of Obesity Aspect Effect of Obesity
Cardiovascular Hypertension Breast Breast cancer
system Coronary heart disease Male gynecomastia
Cerebrovascular disease Uterus Endometrial cancer
Varicose veins Cervical cancer
Deep venous thrombosis
Hypertension Urological Prostate cancer
Stress incontinence
Respiratory system Breathlessness
Sleep apnea Skin Sweat rashes
Hypoventilation syndrome Fungal infections
Lymphoedema
Gastrointestinal Hiatus hernia Cellulitis
system Gallstones and cholelithiasis Acanthosis nigracans
Fatty liver and cirrhosis
Hemorrhoids Orthopedic Osteoarthritis
Hernia Gout
Cancer (colorectal) Endocrine system Reduced growth hormone and IGF1
Metabolic system Hyperlipidemia Reduced prolactin response
Insulin resistance Hyperdynamic ACTH response to CRH
Diabetes mellitus Increased urinary free cortisol
Polycystic ovarian syndrome Altered sex hormones
Hyperandrogenization Pregnancy Obstetric complications
Menstrual irregularities Cesarean operation
Neurology Nerve entrapment Large babies
Neural tube defects
TABLE 2.11
Benefits of a 10-kg Weight Loss
Mortality 20–25% reduction in total mortality
30–40% reduction in diabetes-related deaths
40–50% reduction in obesity-related cancer deaths
Blood pressure 10-mmHg reduction in systolic pressure
20-mmHg reduction in diastolic pressure
Angina Symptoms reduced by 91%
33% increase in exercise tolerance
Lipids 10% reduction in total cholesterol
15% reduction in LDL cholesterol
30% reduction in triglycerides
8% increase in HDL cholesterol
Diabetes >50% reduction in risk of developing diabetes
30–50% reduction in fasting blood glucose
15% reduction in HbA1c
mortality (Figure 2.2). After removing confounding variables such as smoking and subclinical
disease, it was found that the relative risk of premature mortality gradually increases with increasing
BMI. After the analysis of numerous data, the American Institute of Nutrition concluded that the
lowest mortality risk is associated with a BMI between 18 and 25 kg/m2 [29].
2.5
All women
Women who never smoked

2.0
Women who never smoked
and recently had stable weight
Risk
1.5
1.0
0.5
<19.0 19.0-21.9 22.0-24.9 25-26.9 27-28.9 <29-31.9 ≥ 32.0
Body mass index (BMI)
FIGURE 2.2 Relationship between BMI and relative risk of premature mortality. (Adapted from Gill, T.P.,
Br. Med. Bull., 53, 359–388, 1997. With permission.)
AGE AND SEX

No age or sex is exempt from obesity. One third of obese infants grow up to be obese adults [30].
Women generally have a higher rate of obesity than men, although men have higher rates of
overweight. The BMI increases with successive pregnancies, but in developing countries, where
repeated pregnancies occur, weight loss instead of weight gain is found [9].
ROLES OF PHYSICAL INACTIVITY

AND EATING HABITS
Sedentary lifestyles in conjunction with physical inactivity lead to obesity [31]; for example,
affluence allows watching television for many hours a day and a sedentary life that lead to
obesity. A diet high in sweets, refined foods, and fats causes obesity, as does a diet of greater
energy intake than energy expenditure. It has been found that a child whose energy requirement
is 2000 kcal/day and who consumes an extra 100 kcal/day will gain about 5 kg a year [32].
Obesity is a consequence of excess energy intake over a prolonged period. No single factor
leading to obesity can be identified. Multifactorial causes are responsible: genetic, environmen-
tal, psychological, and managerial. A well-disciplined life with regular physical exercise and a
balanced diet lowers the chances of gaining excess weight. Health education in this respect is
an important factor.
CONCLUSION
Global obesity is a major challenge to health professionals and society. The epidemiological data
are alarming, and the obesity epidemic must be properly monitored and controlled with immediate
effect. Physical inactivity, sedentary lifestyles, overindulgence, and genetic predisposition are some
of the factors responsible for obesity; thus, it is a global task to educate people about the importance
and significance of caloric restriction, healthy lifestyles, and proper nutrition in conjunction with
increased physical activity and routine exercise to combat obesity.
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weight management, Br. Med. J., 311, 158, 1995.
[6] Vague, J., The degree of masculine differentiation of obesities: a factor determining predisposition to
diabetes, atherosclerosis, gout, uric calculous disease, Obes. Res., 4, 204, 1996.
[7] Han, T.S., et al., Waist circumference action levels in the identification of cardiovascular risk factors:
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[8] Gopalan, C., Obesity in the Indian urban ‘middle class,’ Bull. Nutr. Found. India, 19, 1, 1998.
Obesity, Technical Report Series No. 894, World Health Organization, Geneva, Switzerland, 2000.
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the BRISK study, S. Afr. Med. J., 79, 480, 1991.
[11] Hodge, A.M. et al., Incidence, increasing prevalence and predictors of change of obesity and fat
distribution over 5 years in the rapidly developing population of Mauritius, Int. J. Obes. Relat. Metab.
Disord., 20, 137, 1996.
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Part II
Pathophysiology of Obesity
3 Environmental Estrogens,
Endocrine Disruption,
and Obesity
Frederick S. vom Saal, James R. Kirkpatrick,
and Benjamin L. Coe
CONTENTS
Mechanisms Mediating Responses to Estrogenic Endocrine Disrupting Chemicals .....................33

Estrogenic Chemicals: Organizational Effects During
Development and Activational Effects in Adulthood....................................................................34
Estrogen and Obesity .......................................................................................................................35
Fetal Basis of Adult Disease ....................................................................................................35
Estrogen and the Differentiation and Regulation of Adipose Tissue ......................................36
The Estrogenic Chemical Bisphenol A and Obesity.......................................................................37
The Endocrine Disruptor Tributyltin and Obesity ..........................................................................37
Conclusions ......................................................................................................................................38
Acknowledgment..............................................................................................................................38
References ........................................................................................................................................38
MECHANISMS MEDIATING RESPONSES TO ESTROGENIC

ENDOCRINE DISRUPTING CHEMICALS
Since the early 1990s [1], evidence has accumulated that chemicals used in a wide range of
household products, such as building materials, plastics, cleaning fluids, cosmetics, and pesticides
have the capacity to disrupt the chemical messengers by which cells communicate [2–4]. These
chemicals are referred to as endocrine disruptors, even though their effects may include disruption
of signaling molecules not labeled as hormones, such as neurotransmitters. Of the different types
of environmental chemicals that disrupt endocrine function, the most well known are those cate-
gorized as environmental estrogens. These chemicals have the capacity to bind to classical nuclear
estrogen receptors (both the alpha and beta forms) associated with specific genes. These estrogenic
chemicals thus act as ligands that initiate or inhibit transcription of estrogen-responsive genes;
however, it is now clear that, although generally classified as estrogenic, the specific responses that
each chemical causes may differ from those caused by the most potent endogenous estrogen,
estradiol. In addition, specific responses caused by estrogenic chemicals and estradiol may vary
among tissues in the same species. Some estrogenic endocrine-disrupting chemicals are thus
categorized as selective estrogen receptor modulators (SERMs) [5]. Recent research has also
demonstrated that estradiol and estrogenic chemicals can cause effects by activating enzymes that
mediate responses initiated by receptors associated with the cell membrane [6–9]. These responses
are very rapid compared to those initiated by binding to nuclear receptors, and they also appear to
occur in response to extremely low doses within the range of human exposure [5].
33
ESTROGENIC CHEMICALS: ORGANIZATIONAL

EFFECTS DURING DEVELOPMENT AND
ACTIVATIONAL EFFECTS IN ADULTHOOD
Estrogens and other sex hormones regulate the functioning of tissues in adults. These effects occur
when the hormone is present and do not occur after the hormone is withdrawn; they are termed
activational effects. However, when exposure occurs during the time in development when cells
are differentiating (referred to as critical periods), estrogens and other hormones cause permanent
changes referred to as organizational effects. Extensive research is currently directed at elucidating
the mechanisms by which genes are programmed during cell differentiation under the influence of
hormones such as estradiol, as well as endocrine-disrupting chemicals. The mechanisms that
determine which genes in a cell are able to be transcribed, as well as the level at which transcription
occurs, involve epigenetic modifications of DNA as well as the associated histone proteins. A
schematic depicting the imprinting mechanisms that determine whether specific genes are silenced
or activated is shown in Figure 3.1 [10]. Data indicate that it is via these epigenetic changes that
estrogenic endocrine-disrupting chemicals program gene activity during critical periods in devel-
opment, with long-term consequences that impact the health status of the individual throughout
the remainder of life [11].
FIGURE 3.1 Schematic diagram showing the “epigenetic” chemical modifications of histone proteins by the
removal of acetyl groups and cytosine bases by the addition of methyl groups, resulting in repression of
transcription. Epigenetic changes that occur early in development are transmitted to daughter cells during
mitosis and thus can permanently alter gene transcription in tissues. (Adapted from Weinhold, B., Environ.
Health Perspect., 114(3), A160, 2006.)
Environmental Estrogens, Endocrine Disruption, and Obesity 35
ESTROGEN AND OBESITY

The typical view of estrogen is that it is associated with a reduction in food intake and body weight
in adults and that the loss of ovarian estrogen secretion associated with menopause in women
results in weight gain. Evidence is accumulating, however, that during critical periods in develop-
ment estrogenic chemicals can have unexpected effects on the differentiation of adipocytes as well
as postnatal growth [12]. Specifically, the hypothesis that the programming of obesity is related to
exposure to environmental estrogens during critical periods in organogenesis [13,14] may seem
counterintuitive, as considerable experimental evidence suggests that in adult mice estradiol acts
via estrogen receptor alpha (ERα) to have an inhibitory effect on adipocyte number and lipogenesis,
and the removal of estrogen by ovariectomy or via a genetic mutation also causes impaired glucose
tolerance and insulin resistance in addition to increased fat mass [15–18]. Estrogen has central
effects on food consumption and energy expenditure that also contribute to its overall inhibitory
effects on adipose deposition in adults; however, a maxim in developmental biology and pediatric
medicine is that it is inappropriate to use effects in adults to predict effects during development.
FETAL BASIS OF ADULT DISEASE

The hypothesis that obesity is related to events that occur during early development is known as
the fetal basis of adult disease hypothesis [19]. The incidence of metabolic syndrome, which
includes obesity, type 2 diabetes, heart disease, and hypertension, has increased dramatically over
the last few decades in the United States and in many other regions of the world [20]. The fetal
basis of adult disease hypothesis proposes that metabolic syndrome is related to factors that influence
growth in utero [21].
As indicated earlier, increasing experimental and epidemiological evidence suggests that fetal
programming of genetic systems is a contributing factor [22]. This has led to the hypothesis that
epigenetic changes associated with the increased use of manmade chemicals, such as chemicals
used in the manufacture of plastic products, may interact with other factors that influence fetal and
postnatal growth to contribute to the current obesity epidemic [23,24]. The hypothesis that epige-
netic mechanisms are involved in the etiology of obesity relates to the general issue of developmental
plasticity. The hypothesis is that individuals are adapted to function within a restricted range of
potential responses throughout life as a consequence of their underlying genetic potential being
acted on by environmental factors during the time in tissue differentiation when genetic program-
ming occurs [25]. Thus, a fetus that develops in a uterine environment with reduced placental blood
flow and nutrient transport is thought to develop a thrifty phenotype, such that the mechanisms
mediating weight homeostasis are permanently programmed for a lifetime of undernourishment.
When exposed to modern fast foods and their excessive calories, these individuals are unable to
regulate their body weight, resulting in weight gain. The question being posed here is whether,
during fetal and neonatal life, environmental chemicals are playing a role in programming a
phenotype that is prone to obesity.
Restriction of placental blood flow is one cause of reduced fetal growth, and light-at-term
human babies are at higher risk for subsequent obesity, type 2 diabetes, and hypertension [26].
Convincing evidence supports the hypothesis that, during fetal life, environmental factors that
influence fetal growth interact with factors that increase the rate of postnatal growth, resulting in
obesity and type 2 diabetes. The interaction between prenatal and postnatal factors is supported by
findings that the best predictor of insulin resistance in 8-year-old children is the combination of
being light at birth associated with a high postnatal growth velocity. The phenomenon of restricted
intrauterine growth followed by accelerated postnatal growth is referred to as centile crossing [20].
Recent evidence suggests that the age at which the rapid body weight increase occurs during
postnatal life is a critical factor in the eventual health status of a person [19].
ESTROGEN AND THE DIFFERENTIATION

AND REGULATION OF ADIPOSE TISSUE
Hormones are major regulators of adipose tissue and are critical for adipocyte development and
function. An extensive array of hormones and growth factors modulate adipocyte development and
activity, including growth hormone, thyroid hormone, catecholamines, glucagon, insulin and insu-
lin-like growth factors, glucocorticoids, and, relevant to this proposal, estradiol and thus chemicals
with estrogenic activity [14]. In humans, differentiation of preadipocytes into adipocytes begins
prior to birth, but the majority of preadipocytes differentiate postnatally. Adipocyte number increases
markedly between birth and 18 months of age, then continues to increase more slowly throughout
early childhood [27]. The developmental sequence by which the adipocyte phenotype arises from
undifferentiated connective tissue cells has been described in detail [28]. The adipocyte lineage
arises from undifferentiated mesenchymal cells, which can also give rise to other connective tissue
lineages. Mesenchymal cells become committed to an adipogenic lineage and give rise to preadi-
pocytes, which can remain undifferentiated and quiescent, proliferate but remain undifferentiated,
or differentiate as a post-mitotic adipocyte.
While preadipocytes in mice do not begin to differentiate into adipocytes prior to birth [29],
mouse preadipocytes develop from mesenchymal cells and proliferate during fetal life, and, as
discussed further below, they express estrogen receptors [12]. Mouse preadipocytes continue to
proliferate rapidly at birth, but then the majority enters the differentiation pathway neonatally to
give rise to post-mitotic adipocytes. By approximately 3 weeks of age, the basic adult number of
adipocytes has been established in most mouse strains [30]. A preadipocyte population still remains
in adults and can give rise to new adipocytes at any time during life in both mice and humans [31].
The genes critical for inducing adipocyte differentiation, as well as their temporal sequence of
expression during adipocyte differentiation, are being actively investigated [32]. For example, it is
known that CCAAT/enhancer-binding proteins (C/EBPs), such as C/EBPα, along with peroxisome
proliferator-activated receptor γ (PPARγ) play critical roles in adipocyte differentiation from the
preadipocyte to the fully functional, post-mitotic adipocyte [33], and that the transcription factor
CREB plays an important role in regulating these genes [34]. In humans, C/EBPα mRNA levels
in adipocyte tissue are elevated in those with an obese relative to lean phenotype [35]. PPARγ is
expressed in adult adipocytes. PPARγ and C/EBPα are regulators of lipogenesis in addition to
regulating adipocyte differentiation [33]. PPARγ activators result in increased fat deposition, and
an increase in PPARγ should be associated with an increase in adipocyte number [36].
A critical question to consider when postulating potential effects on adipocyte number and
subsequent function generated during development is whether such effects would be permanent or
transitory and reversible once the stimulus inducing the change in adipocyte is removed. Although
obesity typically involves adipocyte hypertrophy, adipocyte hyperplasia is also seen in certain types
of human obesity, and similar results have been obtained in rodents with various types of obesity
resulting from dietary modification or gene knockouts [28,30]. In summary, the fetal period is a
time in the mouse when changes in circulating estrogen (either exogenous or endogenous) could
result in changes in adipose tissue function during later life and changes in the methylation pattern
of genes in one potential mechanism. This prediction is consistent with evidence from other systems
that exposure to sex hormones and estrogenic endocrine-disrupting chemicals during fetal life can
have latent effects on the functioning of tissues after birth [14,37].
In recent years, the focus on obesity has involved the “big two” factors thought to be primarily
responsible for the dramatic increase in obesity over the last two decades: reduced physical activity
and overconsumption of junk food associated with food marketing practices [24]. It seems likely,
however, that environmental factors are also involved, and sorting out which factors are most
important has not received much attention. Thus, the role of environmental estrogens in the human
obesity epidemic has not been investigated in epidemiologic studies, although data from studies
with experimental animals as well as cell culture studies indicate that such studies are needed.
Estrogen is known to play an important role in regulating adipose deposition in males, and
estrogen regulates key developmental events in adipogenesis [18]; thus, although the factors regu-
lating whether preadipocytes proliferate or differentiate are not well understood, estrogen appears
to be one factor involved in their development. Adipose tissue expresses both ERα and ERβ. ERα
is expressed in adipocytes, preadipocytes, and stromal vascular cells, indicating that almost all cells
in adipose tissue are potentially estrogen responsive [38,39]. Estrogens appear to play a crucial
role in the establishment of adult adipocyte number, although the effects of estrogens on adipose
tissue are complex and may vary with cell type. A number of papers have shown that estradiol
increases proliferation in preconfluent 3T3-L1 preadipocyte cells or in human or rat preadipocytes
in vitro [40-42]. Estradiol treatment of cultured preadipocytes induces increased release of mitogenic
substances into the media [43].
Adipocyte hyperplasia is a particular problem because the increased adipocyte population
appears to make it very difficult to ever overcome the obesity and maintain a normal weight. It is
thus possible that during fetal life exposure to estrogenic chemicals may facilitate a particularly
intractable type of obesity, and this may occur via epigenetic programming of genes during critical
periods in development which results in permanent changes in gene activity [12].
THE ESTROGENIC CHEMICAL BISPHENOL A AND OBESITY

Bisphenol A (BPA) is one of the highest volume chemicals in worldwide production, with produc-
tion capacity exceeding 6 billion pounds per year [44] for use in manufacturing polycarbonate
plastic, the resin that lines metal cans, and as an additive in many other types of plastic. All human
fetuses that have been examined have measurable blood levels of BPA [5,45,46], and mean or
median levels found in humans are higher than levels in fetal mice in response to maternal doses
that increase postnatal growth [47].
Exposure to BPA during gestation and lactation has been shown to result in a wide range of
effects observed during postnatal life in mice, rats, and a wide range of other vertebrates and
invertebrate species [4,48]. We initially reported [49] and other studies have confirmed [2,50–53]
that prenatal exposure to very low doses of BPA increases the rate of postnatal growth in mice and
rats. In addition, neonatal exposure to a low dose (≤1 µg/kg/day) of the estrogenic drug diethylstil-
bestrol (DES) stimulated a subsequent increase in body weight, an increase in body fat, and other
effects in mice [13,54]. Related to these findings is the report that a high dose of BPA (2 µg/mL)
accelerated the conversion of mouse 3T3-L1 fibroblast cells into adipocytes and also increased
lipoprotein lipase activity and triacylglycerol accumulation; BPA resulted in the presence of larger
lipid droplets in the differentiated cells [55]. Insulin and BPA interacted synergistically to further
accelerate these processes. In a related study, BPA stimulated an increase in the glucose transporter
GLUT4 and glucose uptake into 3T3-F442A adiposities in cell culture [56]. In a separate study,
upregulation of GLUT4 increased basal and insulin-induced glucose uptake into adipocytes [57]. In
addition, very low doses of BPA stimulated the rapid secretion of insulin in mouse pancreatic β
cells in primary culture through a nonclassical, nongenomic, estrogen-response system. In contrast,
prolonged exposure to a low oral dose of BPA (10 µg/kg/day) resulted in stimulation of insulin
secretion in adult mice that was mediated by the classical nuclear estrogen receptors; the prolonged
hypersecretion of insulin was followed by insulin resistance [9].
THE ENDOCRINE DISRUPTOR TRIBUTYLTIN AND OBESITY

Recent publications have implicated some other environmental chemicals with changes in adipocyte
function. For example, organotin compounds were used for many years to protect the bottoms of
boats, and these persistent compounds remain a health problem even though their use has been
restricted in recent years. In addition, organotin compounds are used as stabilizers in polyvinyl-
chloride (PVC) plastic, which is used to manufacture the pipes that carry water into homes, and
organotin compounds leach out of PVC into water [58–60]. Tributyltin (TBT) is an organotin
compound and is an endocrine-disrupting chemical that results in imposex in gastropod mollusks.
This is a condition in which abnormal masculinization of females occurs due to the inhibition of
the estrogen-synthesizing enzyme aromatase, which results in an increase in testosterone; testoster-
one is the substrate that is aromatized by aromatase to form estradiol-17β [61]. TBT also inhibits
aromatase activity in human granulose cells in culture [62]. TBT is a ligand for PPARγ as well as
for retinoic X receptors (RXRs), which, along with estrogen receptors and PPARs, are members
of the nuclear receptor superfamily. In mice, treatment of pregnant females with TBT stimulated
adipocyte differentiation and increased fat mass in offspring (number and volume of adipocytes
were not reported). This finding is thus consistent with other findings described earlier regarding
PPARγ activation during adipogenesis and adds to other evidence that activation of RXRs is also
involved [63].
CONCLUSIONS
At this time, data are limited relating obesity with environmental chemicals and, specifically,
environmental chemicals that are estrogenic or otherwise disrupt estrogen homeostasis; however,
we now have increased awareness that energy expenditure and components of a person’s diet,
although important, cannot alone explain the rate of increase in obesity that has been documented
over the last two decades [23,24]. Although the contribution of environmental chemicals to the
obesity epidemic remains a largely unexamined issue, the dramatic increase in the incidence of
obesity has occurred in parallel with a dramatic increase in the use of plastic. Plastic materials
contain many types of endocrine-disrupting compounds in addition to bisphenol A. The initial
animal experiments showing a relationship between accelerated postnatal growth, insulin secretion
and sensitivity, and bisphenol A provide a strong argument for further research into the possibility
that developmental exposure to bisphenol A, as well as other endocrine-disrupting chemicals, is
contributing to the development of obesity later in life.
ACKNOWLEDGMENT
Support during the preparation of this chapter was provided by a grant from the National Institute
of Environmental Health Sciences (ES11283) to FvS.
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4 Cigarette Smoking,
Inflammation, and Obesity
Saibal K. Biswas, Ian L. Megson,
Catherine A. Shaw, and Irfan Rahman
CONTENTS
Introduction ......................................................................................................................................43
Energy Storage, Intake, and Expenditure ........................................................................................44
Cigarette Smoking, Appetite, and Energy Expenditure ...........................................................44
Smoking and Hormonal Mediators of Energy Homeostasis ...................................................45
Obesity, Metabolism, and Energy Expenditure: Signaling Molecules ....................................46
Cigarette-Smoke-Mediated Oxidative Stress and Obesity ..............................................................47
Role of iNOS in Obesity and Relation to Inflammation .........................................................49
Inflammation and Obesity ........................................................................................................50
Factors Overlapping Inflammation and Metabolic Disease ............................................................51
Oxidative/Nitrosative Stress in Cardiovascular Disease: Impact on Disease
Progression and Influence of Obesity and Smoking as Risk Factors ..........................................52
Oxidative Stress and the Endothelium .....................................................................................52
Oxidative Stress, Hypertension, and Obesity...........................................................................53
Oxidative Stress, Lipid Peroxidation, and Inflammation in Atherogenesis.............................53
Impact of Smoking and Obesity on Plaque Progression
and Rupture Leading to Thrombotic Events..........................................................................54
Phytochemical Treatment of Obesity and Related Diseases...........................................................55
Conclusions ......................................................................................................................................57
Acknowledgment..............................................................................................................................57
References ........................................................................................................................................57
INTRODUCTION
Obesity has already reached epidemic proportions in many countries, including the United States,
United Kingdom, and many developing economies, affecting approximately 33% of adults world-
wide. The body mass index (BMI; the weight in kilograms divided by the square of the height in
meters) is an indicator of obesity that is easy to calculate and is sufficiently correlated with direct
anthropometric measures of body. A BMI greater than 28 is generally associated with a three- to
fourfold increased risk of clinical conditions such as stroke, ischemic heart disease, or diabetes
mellitus [1]. A central distribution of body fat (as determined by the ratio of waist circumference
to hip circumference: 0.90 in women and 1.0 in men) is widely accepted to reflect so-called visceral
fat, which is associated with a higher risk than a more peripheral distribution and may be a better
indicator of the risk of morbidity than absolute fat mass. Childhood obesity increases the risk of
subsequent morbidity, whether or not obesity persists into adulthood [1].
43
Elevated Body Weight General Body Weight Reduced Body Weight

(lean/obese)
• Triiodothyronine • Triiodothyronine
• Energy expenditure during exercise • Energy expenditure during exercise
• Post-feeding thermic effect • Resting energy expenditure
• Sympathetic and parasympathetic • Sympathetic nervous tone
nervous tone • Parasympathetic
nervous tone
FIGURE 4.1 Metabolic alterations in adults due to weight gain or loss. Decreased body weight is associated
with reduced energy expenditure during exercise, sympathetic nervous tones, and resting state energy expen-
diture. An almost opposite phenomenon is observed for increased body weight.
ENERGY STORAGE, INTAKE, AND EXPENDITURE

Fat (or triglyceride) is the primary form in which potential chemical energy is stored in the body.
The amount of triglyceride in adipose tissue is the cumulative sum of the differences between
energy intake and energy expenditure. Although homeostatic mechanisms act to minimize the
difference, imbalances over a long period can have a large-scale effect. The degree of control
between energy intake and expenditure is achieved by coordinated effects mediated through endo-
crine and neural signals that arise from various tissues [2–6]. Such integration is central to the
regulation of body fat stores (Figure 4.1). A large number of factors originating throughout the
body relay afferent signals to a smaller number of functional centers in the central nervous system,
which in turn signal the efferent pathways to regulate energy expenditure (e.g., through the sym-
pathetic and parasympathetic nervous systems and thyroid hormones) and energy intake (through
eating behavior) [7,8]. These factors can interact at many levels; for example, the effect of chole-
cystokinin on satiety is increased by estradiol and insulin and is dependent on parasympathetic
afferent signals [9,10]. The release of insulin is increased by cholecystokinin and parasympathetic
efferent activity and is inhibited by sympathetic efferent signals [11]. The redundancy of interactions
within this system makes any pharmacological or surgical manipulation of a single component
inadequate for long-term resolution of obesity. That body fat content can be regulated is evident
from the responses of both lean and obese humans subjected to experimental manipulation of body
weight, making it unlikely that behavior alone is the sole determinant of obesity. It has been observed
that a decreased expenditure of energy and an increased propensity to store fat may precede the
development of obesity, which suggests that the extra body fat in the obese person in some way
corrects for low energy expenditure [8].
CIGARETTE SMOKING, APPETITE, AND ENERGY EXPENDITURE

Smoking is a behavior that is maintained by physical addiction, psychological dependence, and
habit and is associated with a wide variety of health problems relating to the cardiovascular,
neurological, and pulmonary systems. Nicotine, the addictive substance in cigarettes, has various
mood-altering effects that contribute to and reinforce the highly controlled or compulsive pattern
of drug use through smoking. The pharmacological and biochemical effects of nicotine are powerful,
with smokers reporting a mixture of relaxing, mood-lifting, and pleasurable effects. Smoking is
also associated with decreased food intake and lower body weight. Nicotine is considered the major
appetite-suppressing component of tobacco. Leptin and insulin are endogenous hormones that
decrease appetite and increase energy expenditure by affecting the neuropeptide levels in the
hypothalamus. Nicotine administration has been found to reduce food intake and body weight.
Acute (24-hr) administration of nicotine lowered the expression of orexigenic neuropeptides, such
as neuropeptide Y, Agouti-related protein, and melanin-concentrating hormone; however, 3 days
of nicotine treatment did not alter hypothalamic neuropeptide mRNA levels. Nicotine was not found
to affect the intracellular signaling of leptin and insulin in the hypothalamus. These data indicate
Cigarette Smoking, Inflammation, and Obesity 45
that the acute anorectic effect of smoking may be explained in part by the decreased levels of
orexigenic neuropeptides in the hypothalamus. This effect is not likely due to enhanced leptin or
insulin signal transduction in the hypothalamus; however, chronic cigarette smoking may have a
differential effect on leptin and insulin signaling.
Studies on the influence of cigarette smoking on resting energy expenditure (REE) in normal-
weight and obese smokers have indicated that REE increased in both obese and normal-weight
smokers after smoking, but the increase was greater for normal-weight participants [12]; however,
the reliability of the observed alterations is lower for both normal-weight and obese smokers.
Although smokers have lower mean BMIs compared with non-smokers, they have a more meta-
bolically adverse fat distribution profile, with higher central adiposity [13]. Just how smoking affects
fat distribution is not entirely clear. One theory is that smoking has some kind of antiestrogenic
effect. Another suggestion is that cigarette smoking may have an effect on the uptake and storage
of triglyceride fatty acids, increasing fat mass [13]. A precise explanation for the association may
help to identify the mechanisms underlying the adverse health consequences of cigarette smoking
and abdominal obesity. The strong negative correlation over time between smoking rates and obesity
have led some to suggest that reduced smoking leads to weight gain [14].
SMOKING AND HORMONAL MEDIATORS OF ENERGY HOMEOSTASIS

Cigarette smoke is an admixture of many potent oxidants, carcinogens, mutagens, and chemicals
that are major risk factors for the development of various metabolic disorders. Mainstream cigarette
smoke contains over 5000 chemical species, including high concentrations of oxidants (1017/puff)
[15]. The aqueous phase of cigarette smoke condensate may undergo redox recycling (due to the
presence of free iron) in the lungs of smokers [16]. The tar component of cigarette smoke contains
high levels of relatively stable radicals (e.g., semiquinone radicals). The tar component effectively
chelates metals and can bind iron (released from activated macrophages) to produce tar–semi-
quinone and tar–Fe2+ adducts, which can generate millimolar levels of hydrogen peroxide (H2O2)
over a prolonged period. Sidestream cigarette smoke contains more than 1015 reactive organic
compounds per puff, as well as carbon monoxide, ammonia, formaldehyde, N-nitrosamines,
benzo(a)pyrene, benzene, isoprene, ethane, pentane, nicotine, acrolein, acetaldehyde, and other
genotoxic and carcinogenic organic compounds.
Superoxide anion (O2•– ) and nitric oxide (NO) are the predominant free radicals of the gas
phase of cigarette smoke. NO and O2•– quickly react to form more toxic peroxynitrite (ONOO–).
The semiquinone radicals in the tar component of cigarette smoke can reduce oxygen to produce
so-called reactive oxygen species (ROS), including O2•– , •OH, and H2O2 [17]. Oxidants present
in cigarette smoke can stimulate alveolar macrophages to release a host of mediators, some of
which are chemotactic and recruit neutrophils and other inflammatory cells into the lungs. Both
neutrophils and macrophages can then generate ROS via activation of the NADPH oxidase
complex system [18].
Cigarette-smoke-derived oxidants (inhaled or endogenously produced by inflammatory cells)
may affect many obesity-related hormones such as leptin, adiponectin, and resistin that are produced
by the adipose tissue [18]. Whereas leptin, a satiety hormone, regulates appetite and energy balance,
adiponectin suppresses atherogenesis and fibrotic diseases and might play a role as an antiinflam-
matory hormone. Increased resistin, on the other hand, might cause insulin resistance and thus
could link obesity with type 2 diabetes [18]. Ghrelin, produced in the stomach, is involved in long-
term regulation of energy metabolism. All of these hormones play an important role in energy
homeostasis, glucose and lipid metabolism, reproduction, cardiovascular function, and immunity,
and they also influence other organ systems, including the brain, liver, and skeletal muscle. Impor-
tantly, the functions of these enzymes are influenced by the cellular oxidant/antioxidant balance.
In view of the local oxidative stress generated by adipocytes (discussed later) leading to activation
of macrophages, this is still further evidence to support a crucial role for oxidative stress in the
Brain
Neuropeptide Y Hormonal Effects

Metabolic Effects Leptin Leptin
-NPY Secretion Leptin Synthesis
-Food intake -Glucocorticoids -Catecholamines
-Body weight -Insulin -T3/T4
-Sympathetic tone -TNFα/IL-1 -cAMP
-Energy expenditure -Androgens
-Fertility
Glucose & Insulin Homeostasis
Adipose Tissue
Pancreas Liver Smooth Muscles

Insulin Synthesis Glycogenesis Glucose Uptake & Utilization
FIGURE 4.2 Effect of leptin on hypothalamus and peripheral organs such as liver, pancreas, and smooth
muscles. Leptin released from the adipocytes triggers the brain to regulate a host of responses such as food
intake, fertility, insulin secretion, and sympathetic tones and exerts peripheral responses on the liver, pancreas,
and smooth muscles.
complications related to obesity. Smoking, which is known to directly activate and recruit mac-
rophages and other leucocytes in various tissues, can thus further exaggerate the effect of oxidative
stress in obesity.
The adipocyte volume has been reported to be proportional to plasma insulin concentrations
[10]. Insulin is transported to the central nervous system by a saturable transport system where it
mediates reduction in food intake by inhibiting the expression of neuropeptide Y, enhancing the
anorectic effects of cholecystokinin and inhibiting neuronal norepinephrine reuptake [3,19]. It has
been recently shown that insulin reduces food intake through an effect on leptin-mediated signaling.
Cholecystokinin is a duodenal peptide secreted in the presence of food and is known to reduce
food intake [6].
OBESITY, METABOLISM, AND ENERGY EXPENDITURE: SIGNALING MOLECULES

Leptin is synthesized in and secreted from adipose tissue and is a potential afferent signal of fat
stores (Figure 4.2). In humans, the gene responsible for leptin expression is referred to as LEP. It
is anorectic and increases energy expenditure, resulting in reduced body fat and restoration of
insulin-sensitive glucose disposal in leptin-deficient (ob/ob) mice [20]. Plasma leptin concentrations
have been reported to be in direct proportion to body fat mass in obese human subjects [21]. Various
hormones influence the expression of leptin in adipose tissue [21–23]. Leptin probably contributes
to energy homeostasis in part by decreasing neuropeptide Y mRNA [20] or by blocking its action
as an appetite stimulant; however, transgenic mice lacking the neuropeptide Y gene still respond
to the anorexigenic effects of leptin, suggesting that it may also act via mechanisms that are
independent of neuropeptide Y [20]. Neuropeptide Y is a potent central appetite stimulant that links
afferent signals of the nutritional status of the organism from the endocrine, gastrointestinal, and
central and peripheral nervous systems to effectors of energy intake and expenditure (Figure 4.2).
Exogenous administration of neuropeptide Y has been reported to exert coordinated effects on
energy intake and output and favor weight gain.
Obesity • Adiponectin
• Adiponectin Normal
• Leptin • Leptin
• TNFα • TNFα
• Resistin • Resistin
• Free fatty acids • Free fatty acids
PPAR
Hypertrophy
Adipose tissue Adipose tissue

Insulin sensitive Insulin resistant
FIGURE 4.3 Adiponectin and related biochemical effects. Both cigarettes and adipocytes lead to inflammation
through PPARγ activation leading to obesity via elevations in resistin, free fatty acids, leptin, and TNFα and
decreased adiponectin. The adipocytes in turn become resistant to insulin.
Ghrelin, a 28-amino-acid peptide preprohormone, was discovered as an agent that stimulates

the release of growth hormone (GH) from the anterior pituitary. Studies established that ghrelin
stimulates food intake in rodents as well as in humans and is strongly involved in the regulation
of energy homeostasis. It was subsequently determined that ghrelin, along with several other
hormones, has significant effects on appetite and energy balance [24]. Ghrelin increases adipose
deposition by decreasing fat oxidation.
Adiponectin, also known as adipocyte-complement-related protein (adipoQ), is an adipocyte-
specific secreted protein with roles in glucose and lipid homeostasis. Adiponectin is induced during
adipocyte differentiation, and its secretion is stimulated by insulin. Administration of adiponectin
leads to an insulin-independent decrease in plasma glucose. This is likely attributable to insulin-
sensitizing effects involving adiponectin regulation of triglyceride metabolism (Figure 4.3). The
mechanism underlying the role of adiponectin in lipid oxidation may involve the regulation of
production or activity of proteins associated with triglyceride metabolism, including CD36, acyl
CoA oxidase, 5-activated protein kinase, and peroxisome proliferator-activated receptor γ (PPARγ)
[25]. Inhalation of cigarette smoke may be associated with abnormal triglyceride metabolism and
activation of PPARγ. A negative correlation between obesity and circulating adiponectin has been
well established, and adiponectin concentrations increase concomitantly with weight loss [26].
Decreased adiponectin concentrations are associated with insulin resistance and hyperinsulinemia,
and patients with type 2 diabetes are reported to have decreased circulating adiponectin.
CIGARETTE-SMOKE-MEDIATED
OXIDATIVE STRESS AND OBESITY
Oxidative stress due to increased ROS or reactive nitrogen species (RNS) plays a critical role in
the pathogenesis of various diseases and their complications. Activation of various inflammatory
cells consequent to smoking results in the release of a battery of cytokines, including proinflam-
matory tumor necrosis factor α (TNFα) and interleukin 1β (IL-1β), both of which cause upregu-
lation of adhesion proteins on the endothelium, increased permeability, and increased secretion of
chemokines such as IL-8, macrophage inflammatory protein 2, or monocyte chemotactic protein 1
(MCP1) [27]. Chemokines and cytokines then act in concert to further promote the extravasation
and accumulation or activation of leukocytes to produce ROS, such as superoxide anion and
hydrogen peroxide (H2O2). The release of ROS is largely believed to contribute to cell and tissue
damage associated with many chronic inflammatory diseases such as atherosclerosis, asthma, adult
respiratory distress syndrome (ARDS), and chronic obstructive pulmonary disease (COPD).
Chemokines released as a result of oxidative stress may in turn impinge on the fat cells and trigger
Obesity
NADPH Oxidase
Antioxidant Enzymes
ROS
Oxidative stress in Oxidative stress in

peripheral tissues white adipose tissues
Dysregulation of
adipocytokines
-PAI-1, TNFα, MCP-1
-Adiponectin
METABOLIC SYNDROME
FIGURE 4.4 Oxidative stress in the adipocytes, followed by inflammatory response, can lead to the devel-
opment of various metabolic alterations such as diabetes and atherosclerosis.
a series of reactions leading to obesity or secondary complications of obesity. Growing evidence

supports the notion that the condition of obesity may itself induce systemic oxidative stress, and
increased oxidative stress in accumulated fat cells in turn may lead to dysregulation of adipocy-
tokines and development of metabolic syndrome. Increased oxidative stress in accumulated fat,
therefore, is potentially an important target for the development of new therapies.
In studies involving obese mice, H2O2 production was found to be increased in adipose tissue
but not in other tissues. These results suggested that adipose tissue may be the major source of the
elevated plasma ROS in obese conditions (Figure 4.4). Oxidative stress is known to impair both
insulin secretion by pancreatic β-cells and glucose transport in muscle and adipose tissue. Increased
oxidative stress in vascular walls is involved in the pathogenesis of hypertension and atherosclerosis.
An association between smoking and increased risk of coronary heart disease was first reported in
1940 in an observational study by the Mayo Clinic [28]. Subsequently, numerous epidemiologic
studies have confirmed a strong and consistent association between cigarette smoking and morbidity
and mortality associated with coronary heart disease [29]. In general, the relative risk of death due
to coronary heart disease in smokers is two to four times greater than that in persons who have
never smoked; thus, oxidative stress locally produced and disseminated to tissues seems to be
involved in the pathogenesis and outcome of these diseases. Furthermore, increased ROS release
and the resultant appearance of lipid peroxidation end-products in peripheral blood from accumu-
lated fat in obesity may be involved in the induction of insulin resistance in skeletal muscle and
adipose tissue, impaired insulin secretion by β-cells, and pathogenesis of various vascular diseases
such as atherosclerosis and other cardiovascular disorders.
The other abundant source of O2•– and H2O2 is the professional phagocytes (i.e., neutrophils
and macrophages), which have long been known to express an NADPH oxidase that requires
stimulation for assembly of its cytosolic components with the two subunits of the membrane
flavocytochrome (gp91phox and p22phox) to generate high levels of O2•– upon activation of the
cell [30]. The recent recognition that many cells express homologs of the catalytic subunit of the
NADPH oxidase gp91phox (now collectively known as NOX for NADPH oxidase and DUOX for
dual oxidase) has raised questions about their mode of regulation to produce ROS either constitu-
tively or in response to cytokines, growth factors, and calcium signals. Why, therefore, is oxidative
stress only exhibited in accumulated fat and not more widespread in association with inflammatory
cells? The answer to this question probably lies in the fact that mRNA expression levels of NADPH
oxidase (NOX) subunits were increased only in white adipose tissue (WAT), and was associated
with decreased mRNA expression levels of various antioxidant enzymes. A parallel increase in the
expression of the transcription factor PU.1, which upregulates the transcription of the NADPH
oxidase gene [31], was also recorded in adipose tissue of obese mice. Recently, it was reported
that macrophages infiltrate the adipose tissues of obese individuals and are an important source of
inflammatory cytokines, indicative of their activation in this setting [32,33]. Because activated
macrophages are also known to produce ROS, it is possible that infiltrating macrophages are subject
to augmentation of NOX and, consequently, increased ROS production in the adipose tissue of
obese individuals. In this regard, a family of gp91phox homologs, termed NOX (NAD(P)H oxidase)
proteins, has been reported to be expressed in non-phagocytic cells, not in macrophages [34]. Recent
studies on adipocytes found that NOX4, a member of the NOX family, plays a role in the generation
of H2O2 [35]. The expression of NOX4 was not detected in macrophages [36,37]. In contrast,
expression of NOX4 in WAT, as well as gp91phox, and mRNA expression of NOX4 were signif-
icantly increased in the WAT of obese mice. These results suggest that adipose NOX is elevated
and contributes to ROS production in accumulated fat. These observations are also supported by
reports that ROS production was increased in 3T3-L1 adipocytes, in parallel with fat accumulation
and by incubation with linoleic acid, in a NOX-dependent manner. In accumulated fat, therefore,
elevated levels of fatty acids activate NADPH oxidase and hence induce ROS production, which
in turn upregulates mRNA expression of NADPH oxidase, establishing a vicious cycle that aug-
ments oxidative stress in WAT and blood. It has also been reported that ROS increases the expression
of monocyte chemotactic protein 1 (MCP1), a chemoattractant for monocytes and macrophages,
in adipocytes. Byproducts of lipid peroxidation by ROS, such as trans-4-hydroxy-2-nonenal and
malondialdehyde, are themselves potent chemoattractants [38]. Hence, it is possible that increased
ROS production and MCP1 secretion from accumulated fat may trigger macrophage recruitment
and inflammation of adipose tissue in obesity. Thus, oxidative stress (triggered endogenously by
cigarette smoking) in the adipocytes, followed by inflammatory response, can lead to the develop-
ment of various metabolic alterations such as diabetes, cancer, and atherosclerosis (Figure 4.4).
ROLE OF INOS IN OBESITY AND RELATION TO INFLAMMATION
Nitric oxide (NO) free radical is synthesized by three different isoforms of NO synthase (NOS)
and was originally discovered as an endothelium-derived relaxing factor (EDRF). Endothelial NOS
(eNOS) and neuronal NOS (nNOS) are constitutively expressed and synthesize low levels of NO
in response to a wide range of stimuli, including, in the case of eNOS, shear stress and insulin
[39]. In contrast, inducible NOS (iNOS) is expressed upon stimulation by inflammatory cytokines
and can produce up to 1000-fold more NO than eNOS [40], which, while important for the immune
response, can have detrimental effects on different cell types, including vascular smooth muscle
cells [41] and pancreatic β-cells [42].
Common vascular disease states including hypertension and atherosclerosis are associated with
endothelial dysfunction, characterized by reduced bioactivity of NO [43]. Loss of the vasculopro-
tective effects of NO contributes to disease progression, but the mechanisms underlying endothelial
dysfunction remain unclear. Increased superoxide production in animal models of vascular disease
contributes to reduced NO bioavailability and endothelial dysfunction. In human blood vessels, the
NAD(P)H oxidase system is an important source of superoxide anion under pathological conditions
and is functionally related to clinical risk factors and systemic endothelial dysfunction. Furthermore,
the C242T polymorphism in the NAD(P)H oxidase p22phox subunit is associated with significantly
reduced superoxide production in patients carrying the 242T allele, suggesting a role for genetic
variation in modulating vascular superoxide production. In vessels from patients with diabetes
mellitus, endothelial dysfunction, NAD(P)H oxidase activity, and protein subunits are significantly
increased compared with matched non-diabetic vessels [43]. Furthermore, the vascular endothelium
in diabetic vessels is a net source of superoxide rather than NO production, due to the dysfunction
of eNOS. This deficit is dependent on the eNOS cofactor, tetrahydrobiopterin, and is in part mediated
by protein kinase C signaling.
These studies suggest an important role for both the NAD(P)H oxidases and endothelial NOS
in the increased vascular superoxide production and endothelial dysfunction in human vascular
disease states. It is well established that obesity is associated with a chronic inflammatory response
characterized by abnormal cytokine production, increased acute phase reactants, and activation of
inflammatory signaling pathways [44,45]. Recent studies have demonstrated that murine models
of obesity are associated with infiltration of adipose tissue by macrophages and activation of several
inflammatory genes [46]. The expression of iNOS may be one aspect of such inflammatory
activation. iNOS expression is primarily regulated at a transcriptional level and, once expressed,
the enzyme may generate large amounts of NO over long periods of time. In other models of
increased iNOS-derived NO (e.g., sepsis), excessive NO may contribute to increased basal bioactive
NO and blunt classic, calcium-dependent vasodilation (e.g., in response to acetylcholine) [46–48].
Thus, iNOS expression induced by cigarette smoke could potentially contribute to several of the
obesity-associated abnormalities reported in this study.
Evidence of a significant increase rather than a reduction in basal NO in the early stages of
obesity has been found using several different approaches. Supporting these reports is the obser-
vation of an increased vasoconstrictor response to the nonselective NOS inhibitor L-NMMA, an
effect of obesity that was lost in iNOS knockout (KO) mice. A role for iNOS was further supported
by the effect of the specific iNOS inhibitor 1400W to increase tone in the aorta of obese mice,
whereas no effect was seen in lean mice. Evidence for an increase in whole-body NO production
was seen in the elevated plasma nitrite levels in obese mice, an effect that was significantly reduced
in iNOS KO mice. Finally, iNOS expression was found to be significantly increased in the aorta
of obese mice. Earlier studies in vessels exposed to inflammatory cytokines rendered the mice
septic by using injections of lipopolysaccharide [47], and iNOS gene transfer studies have all
supported a role for iNOS-derived NO in causing vascular dysfunction during obesity [48].
INFLAMMATION AND OBESITY

Advances in adipose tissue research over the past decade have led to a better understanding of the
mechanisms linking obesity with metabolic syndrome and related complications [49]. Biomarkers of
inflammation, such as leukocyte count, tumor necrosis factor α (TNFα), interleukin 6 (IL-6), and C-
reactive protein, are all increased in obesity and insulin resistance and are useful in predicting the
development of type 2 diabetes and cardiovascular disease. It is perhaps no coincidence that all of
the above cited biomarkers of inflammation are also hallmarks of smoking-induced oxidative stress.
Thus, it is reasonable to surmise that many of the detrimental effects of smoking and obesity are
mediated via a common pathway that is characterized by inflammation. This interaction could explain
the additive, if not synergistic, relationship between these factors in disease development and outcome.
Although it is now established that adipocytes are active participants in the generation of the
inflammatory state in obesity, the initiating steps in the pathway are not fully ascertained. Adipocytes
secrete a variety of cytokines, including IL-6 and TNFα, that promote inflammation. Moreover,
recent studies suggest that obesity is associated with an increased recruitment of macrophages in
adipose tissue, which also participate in the inflammatory process through the expression and release
of cytokines. An in-depth understanding of the role of adipose tissue in the activation of inflam-
matory pathways may identify novel treatment and prevention strategies aimed at reducing obesity-
associated morbidity and mortality.
Many questions still remain to be answered; for example, does obesity per se induce an
inflammatory response, or is inflammation initiated as a secondary event by hyperlipidemia or
hyperglycemia? Is inflammation the primary event linking obesity with insulin resistance, or does
the inflammatory response begin only after the onset of resistance to insulin? How and why does
the body initiate an inflammatory response to obesity? From the available reports, it is fairly clear
that obesity promotes states of both chronic low-grade inflammation and insulin resistance, but
how the inflammatory response begins is yet to be understood [50]. The answers to such questions
are unlikely to be straightforward, but it has been suggested that the inflammatory response is
initiated in the adipocytes, as they are the first cells affected by the development of obesity, or in
neighboring cells that may be affected by adipose hypertrophy.
Recent reports suggest that obesity may elicit inflammatory pathways by inducing oxidative
stress on the endoplasmic reticulum (ER) [50–53]. ROS are produced as inevitable byproducts of
energy production within mitochondria during the course of normal metabolism. The production of
O2•– by the mitochondrial respiratory chain occurs continuously during normal aerobic metabolism;
a small, but significant, percentage of all the electrons traveling down the mitochondrial respiratory
chain never make it to the end but instead form O2•– . The autoxidation of ubisemiquinone in
mitochondria as well as metal-catalyzed autoxidation of molecules generate O2•– through one-electron
O2 reduction. In addition to mitochondria, cytochrome P450s and their reductases, the xanthine–xan-
thine oxidase system, and NOS are all capable of ROS generation. Under normal metabolic condi-
tions, it has been estimated that each cell is exposed to ~1010 molecules of O2•– each day. This is
particularly relevant to the adipose tissue, which undergoes alterations in tissue architecture, protein
and lipid synthesis, and perturbations in intracellular nutrient and energy fluxes.
Studies involving both cultured cells and whole animals have revealed that ER stress leads to
activation of Janus kinase (JAK) and thus contributes to insulin resistance [51]. Interestingly, ER
stress is also known to activate I-kappaB kinase (IκBK, a cytosolic nuclear factor kappa-B [NF-
κB] modulator) and thus may represent a common mechanism for the activation of these important
signaling pathways [54]. Another mechanism that may play a role in the initiation of inflammation
in obesity is oxidative stress. Increased delivery of glucose to adipose tissue may increase glucose
uptake by endothelial cells in the fat pad, leading to excess production of ROS in mitochondria,
which inflicts oxidative damage and activates inflammatory signaling cascades inside endothelial
cells [55]. Endothelial injury in the adipose tissue is likely to attract inflammatory cells such as
monocytes and further exacerbate the local inflammation. Hyperglycemia has earlier been reported
to also stimulate ROS production in adipocytes, which leads to increased production of proinflam-
matory cytokines [56].
FACTORS OVERLAPPING INFLAMMATION

AND METABOLIC DISEASE
The first molecular link between inflammation and obesity — tTNFα —was established from the
discovery that this inflammatory cytokine is overexpressed in the adipose tissues of rodent models
of obesity [57]. TNFα was also found to be elevated in adipose tissue and muscle in obese humans
[44,58]. Furthermore, transcriptional profiling studies have revealed that inflammatory and stress-
response genes are among the most abundantly regulated gene sets in adipose tissue of obese
animals [59]. Finally, lipids themselves also participate in the coordinated regulation of inflamma-
tion and metabolism; elevated plasma lipid levels are characteristic of obesity, infection, and other
inflammatory states. It is interesting to note that metabolic changes characteristic of the acute-phase
response are also proatherogenic; thus, altered lipid metabolism that is beneficial in the short term
in fighting against infection is harmful if maintained chronically. The critical importance of bioactive
lipids is also evident in their regulation of lipid-targeted signaling pathways through fatty-acid-
binding proteins (FABPs) and nuclear receptors.
The coordination of inflammatory and metabolic pathways is highlighted by the overlapping
biochemical characteristics and function of macrophages and adipocytes in obesity. Both macroph-
ages and adipocytes can express similar sets of genes. Macrophages can express many of the
adipocyte genes, such as the adipocyte/macrophage FABP aP2 (also known as FABP4) and PPARγ,
and adipocytes can express many macrophage-derived proteins, such as TNFα, IL-6, and matrix
metalloproteinases (MMPs) [60,61]. There is, therefore, considerable overlap in the functional
capability of these two cell types. For example, macrophages can take up and store lipid to become
atherosclerotic foam cells. Preadipocytes under some conditions can exhibit phagocytic and anti-
microbial properties and may even differentiate into macrophages given the appropriate environ-
ment, suggesting a potentially immunological role for preadipocytes [62]. Furthermore, macroph-
ages and adipocytes colocalize in adipose tissue in obesity. Macrophages in adipose tissue are likely
to contribute to the production of inflammatory mediators either alone or in concert with adipocytes,
suggesting a potentially important influence of macrophages in promoting insulin resistance; how-
ever, no direct evidence has been offered to establish this connection to date. In terms of the immune
response, integration between macrophages and adipocytes appears interesting, given that both cell
types participate in innate immune responses. Although it is still to be confirmed that macrophages
are drawn to adipose tissue in other inflammatory conditions, it is conceivable that macrophage
accumulation in adipose tissue may be a feature not only of obesity but of other inflammatory
conditions as well.
OXIDATIVE/NITROSATIVE STRESS IN CARDIOVASCULAR

DISEASE: IMPACT ON DISEASE PROGRESSION AND
INFLUENCE OF OBESITY AND SMOKING AS RISK FACTORS
OXIDATIVE STRESS AND THE ENDOTHELIUM
The potential contribution of oxidative and nitrosative stress to the progression of cardiovascular
disease is well recognized but highly complex. The monolayer of endothelial cells that lines all
blood vessels is central to protection against cardiovascular diseases, including hypertension and
atherosclerosis. In healthy vessels, the endothelium secretes various antiatherogenic molecules,
including the powerful vasodilator NO, which help to control vascular tone, maintain the integrity
of the vessel wall, and resist the adhesion of leucocytes and platelets. It is now widely accepted
that a critical early event in atheroma formation is endothelial cell injury and damage, resulting in
endothelial dysfunction. This can occur by several mechanisms: Chemical injury can be caused by
oxidative stress, including the oxidation of low-density lipoproteins (LDLs) which results in the
formation of damaging oxidized low-density lipoproteins (ox-LDLs), which can themselves cause
further endothelial damage. Also, physical damage to the endothelium can occur from shear stress
within vessels, with plaques tending to form in regions of low shear stress or at sites usually
subjected to particularly turbulent blood flow, such as bifurcation points in the arterial tree [63].
The consequences of an insult to the endothelium are several fold: First, the endothelium becomes
dysfunctional, resulting in a decrease in the net production of NO by eNOS, thus promoting
vasoconstriction and allowing the adhesion of circulating inflammatory cells. A decrease in the
normal NO-producing capacity of the endothelium has been demonstrated in patients with risk
factors for atherosclerosis, such as hypercholesterolemia, who have impaired endothelium-depen-
dent vasodilatation of resistance vessels, which can be reversed by the delivery of exogenous NO
[64]. Additionally, the insult to the endothelium triggers an inflammatory response.
OXIDATIVE STRESS, HYPERTENSION, AND OBESITY

Hypertension, defined as chronically elevated blood pressure, is a complex clinical condition that
is recognized as an important risk factor for coronary artery disease. Many studies have indicated
that endothelial dysfunction is a feature of hypertension, but there is still some debate as to whether
it is a cause or an effect; however, there is an increasing body of evidence to support a role for
increased angiotensin II-dependent ROS production from NAD(P)H oxidases, with an associated
uncoupling of eNOS, leading to the generation of further ROS and formation of highly cytotoxic
peroxynitrite. Taken together, these events result not only in the loss of vasodilatory effects of NO
but also the perpetuation of further endothelial damage induced by oxidating and nitrosating species
[65], perhaps contributing to the predisposition of hypertensives to other vascular diseases.
Obesity, and particularly visceral obesity, is strongly associated with hypertension, mediated at
least in part through overactivity of the sympathetic nervous system, leading to an increase in
peripheral resistance and sodium and water retention [66]. It is understood that increased circulating
levels of leptin, free fatty acids, and perhaps insulin all act to increase sympathetic outflow from the
hypothalamus, particularly when associated with low levels of adiponectin and ghrelin, which nor-
mally act to suppress sympathetic activity and are antiinflammatory. An important impact of increased
renal sympathetic drive is activation of the renin–angiotensin system, with the associated increase in
oxidative stress and endothelial dysfunction [67] as discussed above. It is somewhat surprising and
disappointing, therefore, that clinical trials of dietary antioxidants in hypertension have proved incon-
clusive, and it remains to be seen whether any more success will be achieved with phytochemicals
in this arena, given their potential for a combined antioxidant/antiinflammatory effect.
OXIDATIVE STRESS, LIPID PEROXIDATION, AND INFLAMMATION IN ATHEROGENESIS

Atherosclerosis is characterized by the formation of lipid-rich plaques in the subendothelial space
of conduit blood vessels [63,68–71] and is the process that underpins coronary artery disease,
peripheral vascular disease, and some forms of stroke. The plaques consist of a necrotic core of
lipid-laden inflammatory cells encapsulated by a fibrous, collagen-rich cap made up of vascular
smooth muscle cells (VSMCs) and extracellular matrix [72]. It is generally accepted that endothelial
cell injury is a trigger for atherogenesis, leading to the expression of numerous inflammatory
cytokines together with cell-surface adhesion molecules specific for monocytes. Adherent mono-
cytes then translocate through the endothelial layer into the subendothelial space where they
differentiate into macrophages that express scavenger receptors and secrete inflammatory cytokines.
TNFα, for example, is essentially produced by monocytes and macrophages in response to oxidative
stress, and, in turn, it is the strongest known paracrine activator of monocytes and macrophages
[73]. Upon stimulation, these cells also secrete a variety of products including IL-6, stimulating
the liver to produce the acute-phase reactant C-reactive protein (CRP) [74]. TNFα and CRP are
both found in considerable quantities in atherosclerotic lesions, and they have also been associated
with increased cardiovascular risk in numerous large population-based studies.
Beside instigating endothelial injury, oxidative stress is an important mediator of lipid perox-
idation, which is essential for the accumulation of LDL-derived lipids in macrophages that have
infiltrated the blood vessel wall. Modification of LDL can occur by various means, including
acetylation, exposure to malondialdehyde (MDA), or ROS-mediated peroxidation that leads to
recognition by scavenger receptors and accumulation in macrophages [75]. Peroxynitrite (ONOO–),
formed by the rapid reaction of superoxide with NO, can also oxidize LDL [76–79] but might also
have proatherogenic effects through modification of the protein, lipid, and antioxidant composition
of LDL, most notably by depleting the antioxidant vitamin E content of the particle via the
conversion of α-tocopherol to α-tocopherol quinone [75]. The oxidative/nitrosative status of an
individual is, therefore, central to that individual’s risk of developing atheroma on a number of
levels. It follows that both smoking and obesity predispose to increased ROS and encourage
atherogenesis, and recent evidence suggests that the prevalence of ROS is likely to be enhanced in
atheroma not only through increased ROS generation but also reduced synthesis of the endogenous
antioxidant glutathione and concomitant depression of the activity of glutathione peroxidase [80].
In the case of obesity, oxidative stress acts in concert with other well-recognized risk factors
that are usually associated with the obese condition — namely, hypertension, type 2 diabetes
mellitus, and metabolic syndrome, which in turn have been linked to some extent to oxidative
stress. The net effect of increased oxidant load is raised levels of markers of oxidative stress [81]
with an associated reduction in plasma total antioxidant status and superoxide dismutase (SOD)
activity in blood [82]. Furthermore, there is now clear evidence that increased oxidative stress in
accumulated fat is important in the development of metabolic syndrome on account of NAD(P)H
oxidase activation in adipocytes [83]. The importance of ROS in mediating many of the secondary
pathologies that stem from obesity was further confirmed in this study by the benefit achieved
through antioxidant treatment with respect to dysregulation of the metabolic pathways relating to
glucose and lipids, as well as the genes associated with adipocytokines.
These are encouraging findings with respect to phytochemicals, which might prove even more
effective than conventional therapy. Hyperlipidemia is a critical risk factor for vascular disease that
one might intuitively believe to be raised in obese individuals, but a wealth of studies do not necessarily
show the expected correlation between body mass index and total cholesterol, LDL cholesterol, or
serum triglyceride, particularly in humans. Indeed, even though obesity is widely believed to be a
risk factor for development of atherosclerosis [84,85] a body of evidence suggests that no correlation
exists between obesity per se and plaque deposition in coronary arteries [86,87], although it clearly
predisposes to other risk factors, most notably hypertension, insulin resistance, and diabetes [84,88].
Smoking, on the other hand, is a very well-recognized risk factor for vascular disease, an effect that
is primarily mediated via its prooxidative [89,90] and proinflammatory effects [91].
IMPACT OF SMOKING AND OBESITY ON PLAQUE PROGRESSION

AND RUPTURE LEADING TO THROMBOTIC EVENTS
Atherosclerotic plaques evolve and grow as the ox-LDL accumulated in macrophage-derived foam
cells causes further endothelial damage and is a chemoattractant for additional macrophage recruit-
ment [92]; hence, a perpetual cycle of endothelial damage, monocyte recruitment, and accumulation
of ox-LDL is established. Activated macrophages resident in the early lesion secrete numerous
cytokines and growth factors, including platelet-derived growth factor (PDGF), basic fibroblast
growth factor (bFGF), interleukin 1 (IL-1), TNFα, and transforming growth factor β (TGF-β) [63].
All of these factors induce vascular smooth muscle cell (VSMC) hypertrophy and hyperplasia and
promote secretion of extracellular matrix and connective tissue to form a mesh over the fatty streak.
Eventually, calcification occurs and a fibrous cap forms over the top of the plaque, encapsulating
the highly thrombogenic lipid core and maintaining a barrier between the plaque contents and the
circulation [68–72]. Although atherosclerotic lesions can be widespread by middle age, the vast
majority remain subclinical with only a small minority of plaques becoming symptomatic. The
physical presence of a plaque within an arterial wall may impinge on the vessel lumen, causing
partial occlusion of the vessel which might be sufficient to cause substantial blood flow restriction
and tissue ischemia, resulting in chronic stable angina pectoris. A more serious situation arises if
the fibrous cap is subject to mechanical breakdown or erosion such that it is considered to be
unstable and liable to rupture, generating a thrombus and leading to the more serious acute
cardiovascular syndromes such as unstable angina, myocardial infarction, and stroke [93]. The
determinants of plaque vulnerability to rupture have yet to be fully identified, but a growing body
of evidence is emerging that points to a critical role for both the thickness of the VSMC layer
overlaying the core [94] and unresolved inflammation within the plaque [69,95,96].
The crucial role of unresolved inflammation in the progression of atherosclerosis and ultimately
to destabilization of the plaque is increasingly being identified as a potential target for therapeutic
intervention. It is entirely possible that cigarette smoking and obesity, through their proinflammatory
effects, might exacerbate these important phases of plaque development, with potentially fatal
consequences. Indeed, smoking is one of the most powerful risk factors for atherosclerotic disease,
but the relationships between smoking and cardiovascular disease result from multiple mechanisms
that interact to contribute to atherosclerosis, vascular injury, thrombosis, and vascular dysfunction
[97]. Several products of tobacco combustion, including nicotine, free radicals, and aromatic
compounds, have been shown to cause the release of catecholamines, endothelial injury, oxidation
of LDL, increased plasma fibrinogen, and alteration of platelet activity. All of these agents are
proatherogenic in nature [98].
Prospective cohort studies have consistently shown smoking to be one of the strongest risk factors
for development of peripheral vascular disease. Risk of progression of atherosclerotic peripheral
vascular disease is also increased among patients who continue to smoke compared with those who
quit [13,71]. The Atherosclerosis Risk in Communities study showed a substantial increase in athero-
sclerosis progression in patients who smoked compared with those who had never smoked and an
intermediate progression in former smokers. The progression of atherosclerosis attributable to smoking
was more substantial than that due to other cardiovascular risk factors. The risk of progression of
atherosclerosis was highest in smokers who had other risk factors, such as hypertension and diabetes
mellitus, smoking being one of the strongest cardiovascular risk factors for atherosclerotic diseases
[14]. Several studies have revealed increased plasma levels of TNFα and of CRP in smokers as
compared to nonsmokers [99,100], suggesting that part of the coronary risk associated with smoking
may relate to increased inflammatory activity; however, the prevalence of cardiovascular disease varies
substantially among smoking individuals [101]. This could indicate that genetic factors are important
determinants of the biological pathways linking smoking with cardiovascular disease risk [102].
The effects of nicotine are much less important than the prothrombotic effects of other products
of tobacco combustion, as there is no apparent dose–response relationship between nicotine and
cardiovascular events [98]. Nicotine and carbon monoxide produce acute cardiovascular conse-
quences, including altered myocardial performance, tachycardia, hypertension, and vasoconstric-
tion. Smoking a cigarette, in view of its composition consisting of a host of oxidants, releases an
array of signals that recruit and activate macrophages and other inflammatory cells. Persistent local
or systemic oxidative stress due to sustained smoking leads to expression of cytokines and lipid
peroxides which injure blood vessel walls by damaging endothelial cells, thus increasing perme-
ability to lipids and other blood components. Among the metabolic and biochemical changes
induced by smoking is a tendency for increased serum cholesterol, reduced high-density lipoprotein,
elevated plasma free fatty acids, elevated vasopressin, and a thrombogenic imbalance of prostacyclin
and thromboxane A2. In addition to rheologic and hematologic changes from increased erythrocytes,
leukocytes, and fibrinogen, smokers have alterations in platelet aggregation and survival that
predispose to thrombosis [12]. In fact, it has recently been shown that the CC polymorphism in
the promoter region of the CD14 gene (CD14-159C/T) is associated with common carotid artery
intima-media thickness in smokers but not in nonsmokers [103]. Furthermore, smoking is known
to reduce the activity of the endogenous fibrinolytic pathway that usually degrades thrombi in an
effort to restore blood flow through an occluded vessel, while both smoking and obesity are
prothrombotic through the activation of platelets. Once again, one could envisage the potential
benefits of phytochemicals not only in preventing the inflammatory events that might predispose
to plaque rupture but also by reducing the propensity for thrombus formation.
PHYTOCHEMICAL TREATMENT OF
OBESITY AND RELATED DISEASES
Smoking induces oxidative stress and depletes antioxidants by elevating oxidant levels, resulting in
depletion of the cellular antioxidants utilized to counter the effects of the oxidants. The downstream
effect of smoke-dependent induction of oxidative stress leads to local generation of inflammatory
cytokines such as TNFα, IL-1, and IL-8. The cytokines in turn activate and recruit more inflammatory
cells and may lead to systemic effects at various sites in the body. While oxidative injury to the lungs
can result in lung cancers, COPD, and ARDS, inflammatory responses in the blood vessel may lead
to various cardiovascular anomalies. In obese subjects, the risk of oxidative injury is heightened by
the fact that the fatty stores by themselves behave as seats of inflammatory reactions and, as discussed
earlier, may trigger oxidative stress and activation of local macrophages thus leading to metabolic
syndrome. This influence of obesity may augment consumption of the cellular antioxidant pools and
further add to oxidative imbalance. Oxidatively modified molecules, especially lipids, act as triggers
for expression of cell adhesion molecules in the vasculature. Circulating monocytes and platelets then
adhere to the intimal surfaces and extravasate to the subintimal space, leading to atherogenesis; hence,
antioxidant supplementation and therapies are logical, particularly via phytochemicals in addition to
exercise, obesity, and cardiovascular management via pharmacological means.
The regular consumption of fruits and vegetables is associated with a reduced risk of cancer,
cardiovascular disease, stroke, and many functional declines associated with aging, and it has been
estimated that one third of all cancer deaths in the United States could be avoided through dietary
modification to include an abundant intake of fruits and vegetables [104]. These foods contain
phytochemicals that have anticancer, antioxidant, and antiinflammatory properties that confer many
health benefits; for example, red foods (e.g., tomatoes) often contain lycopene, which is localized in
the prostate gland and may be involved in maintaining prostate health and which has also been linked
with a decreased risk of cardiovascular disease. Green foods, including broccoli, Brussels sprouts,
and kale, contain glucosinolates, which have also been associated with a decreased risk of cancer.
Garlic and other white-green foods in the onion family contain allyl sulfides, which may inhibit cancer
cell growth. Other bioactive substances in green tea and soybeans provide health benefits, as well.
Plant-based diets have a lower calorie density and increased nutrient density, which are impor-
tant factors in curbing the obesity epidemic. Several studies have suggested a strong link between
dietary phytochemical intake and a reduced risk for cardiovascular disease. Dietary flavonoids have
been inversely correlated with mortality from coronary artery disease, plasma total cholesterol, and
low-density lipoprotein. Oxidized LDL has been proposed as an atherogenic factor in heart disease
as it promotes cholesterol ester accumulation and foam cell formation [105]. Dietary antioxidants
from fruits and vegetables can be incorporated into LDL and become oxidized in preference to
polyunsaturated fatty acids. Phytochemicals also reduce platelet aggregation, modulate cholesterol
synthesis and absorption, and reduce blood pressure [106]. Systemic inflammation may also be a
critical factor in cardiovascular disease; indeed, the inflammatory marker C-reactive protein might
be a stronger predictor of cardiovascular disease than LDL cholesterol [107]. The antiinflammatory
activity of phytochemicals, then, may play an important role in cardiovascular health.
Phytochemicals found in fruits and vegetables can affect the above processes by several
mechanisms. The chemical species involved in oxidative stress can cause DNA damage, in the
form of base mutation, DNA cross-linking, and chromosomal breakage and rearrangement. This
damage may be limited by the dietary antioxidants in fruits and vegetables through modulation of
detoxifying enzymes, scavenging of oxidative agents, stimulation of the immune system, hormone
metabolism, and regulation of gene expression in cell proliferation and apoptosis [108]. Whole
plant extracts may induce these protective effects via more than one mechanism; for example,
curcumin, a well-recognized phytochemical found in the spice turmeric, has been found to have
several antimetastatic mechanisms in hepatocellular carcinoma cells [109]. Tomato products, includ-
ing ketchup, tomato juice, and pizza sauce, are the richest sources of lycopene in the American
diet and account for more than three quarters of the total lycopene intake of Americans [110].
Several studies have linked the consumption of tomatoes and tomato products with a decreased
risk of cancer and cardiovascular disease. The health benefits of lycopene have been attributed to
its antioxidant properties, although other mechanisms of lycopene action are possible, including
the modulation of intercellular communication, hormonal and immune system changes, and
enhancement of gap junctional communication [111]. In breast cancer cells, lycopene can interfere
with insulin-like growth factor 1 (IGF-1)-stimulated tumor cell proliferation [112]. The relationship
between lycopene intake and prostate cancer risk has been reported and is supported by studies
linking low plasma levels of lycopene with an increased risk [113]. Lycopene administration may
reduce proliferation and increase apoptosis in human prostate tissue where lycopene is the pre-
dominant carotenoid [114].
CONCLUSIONS
Smoking, oxidative stress, inflammation, and obesity are intricately associated phenomena. While
many sociopsychological factors influence both smoking and feeding habits, the emerging physi-
ological factors consequent to smoking and eating abuse lead to a variety of metabolic disorders,
including diabetes mellitus, and can independently or in conjunction with metabolic disorders lead
to cardiovascular diseases, including hypertension and atherosclerosis. Hormones synthesized by
the adipocytes such as leptin, adiponectin, hormones of the intestinal tract such as cholecystokine,
and brain-related peptides such as neuropeptide Y and ghrelin undergo a complex interplay of
regulatory cascades that modulate hunger, insulin secretion, and a wide variety of other metabolic
effects. Interestingly, adipocytes laden with fats can themselves generate free radicals, which in
turn can initiate cytokine-dependent signals to activate and recruit macrophages and other inflam-
matory cells that may lead to the development of various metabolic disorders and more complex
vascular diseases. Cigarette smoke, which itself consists of an array of oxidizing species, can elicit
similar inflammatory responses and can either initiate obesity-dependent inflammatory processes
or direct obese conditions to a particular disease; therefore, the obesity–oxidative stress–cigarette
smoking triad appears to be a multifactorial complication, and several focal points may be available
for therapeutic targeting. Decoding the exact mechanisms involved in the etiopathogenesis of
complications of obesity and smoking will reveal newer strategies of therapy for the amelioration
of such complications. Phytochemicals from various plant sources may specifically interfere with
particular focal points of the etiopathogenesis of obesity and thus serve as better, cost-effective,
and less toxic therapeutic alternatives for the treatment of obesity and related pathologies.
ACKNOWLEDGMENT
Irfan Rahman is supported by the Environmental Health Sciences Center grant no. ES01247.
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5 Disordered Eating
as a Correlate in the
Development of Obesity
Gwendolyn W. Pla
CONTENTS
Introduction ......................................................................................................................................63
Description of the Disorders............................................................................................................64
Anorexia Nervosa .....................................................................................................................64
Bulimia Nervosa .......................................................................................................................64
Eating Disorders Not Otherwise Specified ..............................................................................64
Binge Eating Disorder .......................................................................................................64
Bulimic Behaviors Associated with Fasting .....................................................................65
Night Eating Syndrome ............................................................................................................65
Food Choices and Preferences.........................................................................................................65
Prevalence of Eating Disorders and Associated Obesity ................................................................66
Health Effects and Risks of Eating Disorders and Obesity............................................................66
Lois............................................................................................................................................67
Roseanne ...................................................................................................................................67
Ben ............................................................................................................................................68
Functional Foods and Phytochemicals ............................................................................................68
Medications in Eating Disorder Treatment .....................................................................................68
Conclusion........................................................................................................................................69
References ........................................................................................................................................69
INTRODUCTION
Reports of disordered eating practices involving starvation related to asceticism date back to the
1600s, but descriptions found in early religious literature did not include treatment. Cases of
starvation reported in the 1600s and 1700s included various treatment modalities, some of which
were successful and some not. Anorexia nervosa was recognized as an emotional illness in the
1600s and received its current name in 1873. In the 19th century, weight concerns were known to
be the motivating factor behind disordered eating practices [1]. A review by Russell [2] on bulimia
nervosa, which received its name in 1979, shows a clear connection, historically, with anorexia.
As he pointed out, bulimia is defined as overeating; however, bulimia nervosa involves overeating
with the addition of compensatory behaviors (e.g., vomiting or laxative abuse) and concerns about
weight and body image. This chapter provides a review of disordered eating as it relates to obesity.
It includes a brief description of eating disorders, as well as discussion regarding the prevalence
of eating disorders; their associated eating patterns, health risks, and comorbidities; and the rela-
tionship of eating disorders to the development of obesity. Three relevant case reports are presented,
and phytochemicals and psychotropic medications are discussed.
63
DESCRIPTION OF THE DISORDERS

The American Psychiatric Association (APA) has classified disordered eating practices as three
diseases: anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified. The third
category includes binge eating disorder and other practices that do not specifically fit the criteria
for anorexia nervosa or bulimia nervosa. Additionally, another disordered eating pattern that is not
specifically included by the APA is night eating syndrome. All can compromise nutritional status
and health. Just as for anorexia nervosa and bulimia nervosa, emotional comorbidities are associated
with both binge eating disorder and night-eating syndrome.
ANOREXIA NERVOSA
Anorexia nervosa involves severe undereating. An individual with this disorder refuses to maintain
a body weight that is even minimally normal. He or she is intensely afraid of gaining weight or
becoming fat and has a disturbed sense of the way his or her body is perceived (e.g., seeing fat
where there is none, even when very emaciated). Females suffering from anorexia nervosa after
the age of menarche become amenorrheic. The two types of anorexia nervosa are the restricting
type and the binge eating/purging type, the latter of which involves self-induced vomiting or the
abuse of laxatives, diuretics, or enemas [3].
BULIMIA NERVOSA
Bulimia nervosa is characterized by binge eating followed by the use of inappropriate compensatory
methods to avoid weight gain. Body shape and weight excessively influence how such patients
view themselves. A binge has been defined as eating, in a discrete period of time, an amount of
food that is definitely larger than most people would eat under similar circumstances. Those so
affected experience a lack of control, a feeling that they cannot stop or control the amount eaten.
These practices are accompanied by compensatory behaviors to prevent weight gain such as self-
induced vomiting; the misuse of laxatives, diuretics, enemas, or other medications; and fasting or
excessive exercise. To qualify for the diagnosis, the binge eating practices and compensatory
mechanisms must occur at least twice a week for 3 months’ duration [3]. Despite their excessive
concern about weight, bulimics are usually of normal weight.
EATING DISORDERS NOT OTHERWISE SPECIFIED

The “eating disorders not otherwise specified” category includes eating disorders that do not meet
the criteria for any specific eating disorder [3]. Examples include: (1) a disorder for which all
criteria for anorexia nervosa are met except that, despite significant weight loss, the individual’s
current weight is in the normal range; (2) a disorder in females for which all the criteria for anorexia
nervosa are met except that the individual has regular menses; and (3) a disorder in which all of
the criteria for bulimia nervosa are met except that the binge eating and inappropriate compensatory
mechanisms occur at a lesser frequency than for bulimia nervosa. Some additional disorders of
eating that fit this category include the use of inappropriate compensatory behavior by an individual
of normal body weight after eating small amounts of food (e.g., self-induced vomiting after the
consumption of two cookies); repeatedly chewing and spitting out, but not swallowing, large
amounts of food; and binge eating disorder, which features recurrent episodes of binge eating in
the absence of regular use of inappropriate compensatory behaviors characteristic of bulimia nervosa
(e.g., purging, fasting, excessive exercise) [3].
Binge Eating Disorder

Persons with binge eating disorder have recurrent episodes of binge eating. In a discrete period of
time (e.g., within any 2-hour period), they eat an amount of food that is definitely larger than most
people would eat in a similar period of time under similar circumstances. They also experience a
Disordered Eating as a Correlate in the Development of Obesity 65
sense of lack of control over eating during the episode (e.g., a feeling that they cannot stop eating
or control what or how much they are eating). The binge eating episodes are associated with eating
much more rapidly than normal or eating until feeling uncomfortably full. Those suffering from
binge eating disorder may eat large amounts of food when they are not feeling physically hungry,
or they may eat alone because of feeling embarrassed by how much they are eating. Other indicators
are feeling disgusted with oneself, depressed, or very guilty after overeating. Binge eaters experience
marked distress regarding the binge, and the binge eating occurs, on average, at least 2 days a week
for 6 months [3].
Bulimic Behaviors Associated with Fasting
It has been observed that extreme restriction may lead to binging and purging. Russell [2] noted
in his historical review that two saints who lived between 1566 and 1727 exhibited bulimic behaviors
associated with fasting. They ate very little for long periods of time but then were observed to
binge on everything in sight. Purging was done to make reparations for their sins. In modern times,
it has been observed that for some individuals anorexia nervosa, bulimia nervosa, and binge eating
disorder exist on a continuum; that is, extreme restriction may lead to binging and purging and,
for some individuals, obesity. Persons with binge eating disorder generally overeat in comparison
to those with bulimia nervosa who generally restrict [4]. Restriction can also lead to food cravings
and contribute to the continuum. In their discussion of the literature on cravings, Weingarten and
Elston [5] noted that a craving is a desire to eat a certain food. They suggested that cravings result
from not consuming a desired substance (in this context, food) followed by exposure to stimuli
associated with that substance; thus, cravings may be the antecedents of binges. According to
Weingarten and Elston [5], abstaining from an appropriate level of food intake triggers cravings
for food.
NIGHT EATING SYNDROME

Although not specifically identified by the APA as an eating disorder, night eating syndrome is
another disordered eating practice that has been described by Stunkard [4]. It involves morning
anorexia and evening hyperphagia. It is also characterized by awakening at night to consume high-
calorie snacks. Depression is a comorbid feature. The pattern occurs for a period of at least 3
months, and subjects do not meet the criteria for any other eating disorder. Binge eating and night
eating syndrome can both lead to a positive energy balance and excess weight. Emotional distress
is a feature of both.
FOOD CHOICES AND PREFERENCES

Anorectics lose weight by reducing their total food intake. Although they may begin by excluding
foods that they believe are high in calories, the end result is a very restricted diet that is limited to
just a few foods [3]. Reports on the food choices of eating-disordered subjects have revealed some
differences among the various eating disorders. Some patients with bulimia nervosa were found to
focus more on dessert and snack foods as compared to weight-matched controls, and those with
binge eating disorder ate more fat and less protein. Also, subjects with binge eating disorder
consumed more calories than obese subjects who were not binge eaters [6]. Excessive calorie
consumption and underactivity are important factors in the development of obesity. Wurtman [7]
suggested that, of the macronutrients, excessive consumption of carbohydrate-rich foods is a major
factor in the development of obesity. In a later review, however, Wurtman and Wurtman [8] noted
that patients often consume such foods as pastries and chips, which are high in both fat and
carbohydrates, to try to make themselves feel better. In still other studies, dietary fat has been
proposed to be the major factor in obesity, as obese women who consumed a lot of calories as fat
were found to have higher levels of body fat [9]. It is significant that many foods that are high in
carbohydrates may also be high in fats, the converse of which is also true; for example, pastries,
gravies, and chips have both fat and carbohydrates.
Binge eaters have been shown to have a fondness for carbohydrates. Also, depression has been
shown to occur at a greater rate in binge eaters than in obese persons who are not bingers [10].
Wurtman [11] suggested the existence of a relationship between depression and carbohydrate
cravings, such that depression brings about carbohydrate cravings and carbohydrate intake
relieves depression. This suggestion was based on the observation of depression in individuals
consuming low amounts of carbohydrates and relief of the depression upon the intake of carbo-
hydrates. Drewnowski et al. [9] pointed out, however, that food preference data can be misleading
(e.g., people may have misconceptions about the macronutrient contributions of certain foods).
Foods that people might consider to be carbohydrates because of their sugar content often have
fat as the predominant energy source; examples of such foods are doughnuts, ice cream, and
chips. Because of the food choices in dieting and binge eating, many important foods containing
fiber and phytochemicals may not be present in the diet. For severe restrictors, such as subjects
with anorexia nervosa who avoid carbohydrates and fats, other important constituents will be
absent, as well.
PREVALENCE OF EATING DISORDERS

AND ASSOCIATED OBESITY
Data from the National Center for Health Statistics show that 65% of adults over the age of 20 are
overweight or obese and 30% are obese. Among children, the rate has more than doubled in the
past 25 years; 16% of children between the ages of 6 and 11 are overweight compared with 7%
in 1980.12 The National Eating Disorders Association estimates that 5 to 10 million women and
girls and 1 million men are affected with eating disorders, including anorexia nervosa, bulimia
nervosa, and binge eating disorder [13], but prevalence estimates for binge eating disorder range
from 2% in community studies to more than 25% in severely obese, treatment-seeking populations
[14]. A significant number, but not all, of obese subjects are binge eaters [6]. Dieting has been
observed to be a risk factor for binge eating and for hyperphagia. Bulik et al. [15] reported the
results of a study conducted to determined whether dieting was an antecedent of binging. They
assessed 100 overweight women and determined that, of the women who reported binging behav-
iors, 80.5% reported dieting prior to binging; only 16.7% reported that binge eating preceded dieting
or vomiting. Additionally, they concluded that, although dieting is not always a precursor to binging,
it is a precursor to the development of bulimia nervosa. A positive relationship between binge eating
and obesity has been reported by Lamerz et al. [16], Siqueira et al. [17], and Morgan et al. [18].
HEALTH EFFECTS AND RISKS OF EATING

DISORDERS AND OBESITY
Disordered eating can take a serious toll on health and the quality of life. The consequences of
those disordered eating practices that lead to obesity include those same risks that are generally
associated with excess weight and obesity. They are hypertension, dyslipidemia, type 2 diabetes,
coronary heart disease, stroke, gallbladder disease, osteoarthritis, and sleep disturbances, as well
as endometrial, breast, and colon cancers. An exception, however, is that obese persons with binge
eating disorders have more psychological stress and a more greatly impaired quality of life than
those obese who are not binge eaters [19]. It is important to note that, because of the limited food
intake and choices characteristic of anorexia nervosa, patients with this disorder are likely to be
missing important nutrients, including fat, fiber, phytoestrogens, and carotenoids — those dietary
components associated with gonadal hormone status [20]. Comorbid features of anorexia nervosa,
bulimia nervosa, and eating disorders not otherwise specified include anxiety disorders, obsessive–
compulsive disorders, body dysmorphic disorders, and depression. Devlin et al. [21] noted high rates
of depression and anxiety among obese patients, particularly those with binge eating disorder. These
findings were consistent with those of Yanovski et al. [22], who reported that major depression,
panic disorder, borderline personality disorder, and avoidant personality disorder were significantly
higher in persons with binge eating disorder. Fahy et al. [23] discussed the relationship between
obsessive–compulsive disorder and patients with anorexia nervosa. The following are composites of
case reports that demonstrate the limited food choices, disordered eating practices, and emotional
components that lead to obesity.
LOIS
Lois recalls being a chubby little girl. Her mother put her on a lettuce and carrot diet when she
was 8 years old but spent very little time with her, lavishing attention instead on her sisters and
her brother. Lois recalls being too hungry to fall asleep at night and stealing cheese and crackers
to satisfy this hunger. She didn’t want to eat with the family because of the constant criticism that
she received from her mother. She is a 54-year-old, single, white female who has experienced
ongoing difficulties controlling her weight. Lois weighs 260 lb and is 5'5''; she is hypertensive.
When she was at 200 lb, her doctor gave her a 1200-kcal diet and told her that she needed to get
busy losing weight now; however, instead of losing weight, Lois continued to gain weight. She
tried to eat less than the diet her doctor provided but found herself more and more hungry. She
talked about how much she missed “good” food. She now stays home every evening and eats
several bags of cookies and corn chips while watching news and game shows on television, but
she does not really pay much attention to them. Sometimes she orders in a double order of fried
chicken wings from a local restaurant that delivers, but she rarely goes out for food. She eats until
her stomach hurts and then feels disgusted with herself, but she is unable to stop once she starts
eating. She does not eat breakfast because she gets up too late, and she never eats lunch at work
because she does not want to eat around other people. Lois’ case provides a good example of how
extreme dietary restriction and emotional factors can lead to binge eating disorder and obesity. The
characteristics of binge eating disorder that Lois displays include eating until uncomfortably full,
eating larger quantities than most people would eat in a finite period of time, feeling disgusted
with oneself, and avoiding eating around other people.
ROSEANNE
Two years ago Roseanne went on a diet that cut out all fat, fruit, and starchy vegetables; she ate
only cucumbers, lettuce, and tomatoes. Her roommate’s boyfriend often sends boxes of chocolates,
which her roommate offers freely. Roseanne loves chocolate but resists the offers to share. She lost
about 100 pounds but had no energy and found herself having insatiable cravings for the chocolates.
Roseanne is a 24-year-old African-American female who had been diagnosed with type 2 diabetes
mellitus and complains of pain in her knees. Her weight is 290 lb, and her height is 5'4''. She has
gained weight steadily over the last 5 years and acknowledges that she often binges on chocolate
bars, eating them very quickly, especially when she feels sad or anxious; she feels unable to stop
herself and is disgusted with herself when the binge ends. Her doctor referred her to a nutritionist,
who suggested a 2000-kcal diet with liberal amounts of fruit and vegetables, told her to stop eating
candy, explained the benefits of exercise, and, because of the pain in her knees, suggested that she
swim every day. She cries a lot, fights with her roommates, and is angry with both her doctor and
the nutritionist. Roseanne’s case illustrates some of the components of binge eating disorder: a lack
of control during the binge, feeling disgusted with oneself, and eating much more rapidly than
normal. It also illustrates the role of cravings in binge eating disorder.
BEN
Before Ben began his current job 5 years ago, his weight was just under 200 lb. He played tennis
several times a week, ate regular meals with lots of vegetables, had a girlfriend, and played
saxophone in a small volunteer community band. Ben is a 35-year-old white male who now weighs
300 lb and is 6' tall. He works in a mid-level management position, puts in long hours, and usually
does not eat until he gets home at around 9 p.m. He eats a light dinner and usually falls asleep at
about 11 p.m. He wakes up several times during the night and eats a couple of hot dogs or a large
bag of potato chips or corn chips, cookies, and peanuts. Sometimes he will drink a couple of beers
or a shot or two of Kentucky bourbon. His day starts again at 7 a.m. He always feels very tired
upon arising but never hungry. Ben meets the criteria for night eating syndrome, morning anorexia,
evening hyperphagia, and depression.
FUNCTIONAL FOODS AND PHYTOCHEMICALS

Although the benefits of foods containing fiber and phytochemicals have been documented, many
common popular weight-loss diets promote foods that are essentially devoid of or, at best, low in
fiber and phytochemicals. Additionally, because of limited food choices, persons who have disor-
dered eating patterns will not have the advantage of important nutrients and phytochemicals. Several
functional foods, those that provide health benefits in addition to providing basic nutrition, have
been promoted for their various benefits in combating disease. These include unchanged whole
fruits, such as fruits and vegetables, as well as foods that have been fortified with nutrients or
enhanced by the addition of phytochemicals. These may include, but are not limited to, fortified
margarines, garlic, green tea, grape juice or red wine, whole oats, cranberry juice, and fermented
dairy products. Although no well-designed clinical trials on functional foods have been conducted,
some anecdotal evidence links such foods to health benefits [24].
MEDICATIONS IN EATING DISORDER TREATMENT

Only very limited data, if any, are available regarding the use of phytopharmaceuticals in the
treatment of eating disorders. Psychotropic medications have sometimes been used in the treatment
of eating disorders [25]. These have included antidepressants, mood stabilizers, anxiolytics, opiate
antagonists, and fenfluramine for bulimia nervosa. Antipsychotics, antidepressants, anxiolytics,
appetite-enhancing agents, and prokinetic agents have been used in the treatment of anorexia nervosa
[25]. Selective serotonin reuptake inhibitors (SSRIs) and imipramine have been used for the
treatment of binge eating disorder, and topiramate, an antiepileptic drug, has been reported to be
effective in reducing the frequency and duration of binges and reducing obsessive–compulsive
behaviors [26]. Shapira et al. [27] and Vaswami et al. [28] reported short-term benefits of SSRIs
in the treatment of anorexia nervosa.
Wong et al. [29] conducted a literature review of herbal remedies that are used to treat psychiatric
symptoms; they reported that for many of the herbal medications the quality and quantity of data
were insufficient to determine their safety and efficacy. They did conclude, however, that good
evidence suggests the efficacy of St. John’s wort in treating depression. This is consistent with a
report by Fugh-Berman [30], who conducted a meta-analysis of 23 studies and concluded that
sufficient data support the effectiveness of St. John’s wort in the treatment of mild to moderate
depression. It is important to note, however, that the depression associated with anorexia is most
effectively treated with refeeding and psychotherapy. The classic semi-starvation study of Keys et
al. [32] found that depression lessened with refeeding; they reported that changes in the depression
score during the period of nutritional rehabilitation were substantially in direct proportion to the
level of supplementation.
Lake [33] provided an extensive review of natural sources of psychotropic medications. A

number of them are being investigated for their antidepressant activity and anxiolytic activity and
include the vitamins folic acid, vitamin B-12, vitamin C, and pyridoxine, as well as the amino
acids S-adenosyl methionine, L-tryptophan, L-tyrosine, and D,L-phenylalanine and the mineral mag-
nesium. These findings underscore the value of a balanced and varied mixed diet for the improve-
ment of health, both physical and mental.
CONCLUSION
Disordered eating plays a role in the development of obesity. Progress on its prevention and
treatment has been insufficient, and the public is vulnerable to promises of quick weight loss. More
research is needed with regard to effective and safe treatment modalities for those disordered eating
practices that lead to obesity. This would include effective and safe phytopharmaceuticals to improve
mental health.
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[2] Russell, G.F.M., The history of bulimia nervosa, in Handbook of Treatment for Eating Disorders,
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[5] Weingarten, H.P. and Elston, D., The phenomenology of food cravings, Appetite, 15, 231, 1990.
[6] Cooke, E.A. et al., Patterns of food selection during binges in women with binge eating disorder, Int.
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12, 999, 2004.
[20] Rock, C.L. et al., Nutritional characteristics, eating pathology, and hormonal status in young women,
Am. J. Clin. Nutr., 64, 566, 1996.
[21] Devlin, M.J., Yanovski, S.Z., and Wilson, G.T., Obesity: what mental health professionals need to
know, Am. J. Psychiatry, 157, 854, 2000.
[22] Yanovski, S.Z. et al., Association of binge eating disorder and psychiatric comorbidity in obese
subjects, Am. J. Psychiatry, 150, 1472, 1993.
[23] Fahy, T.A., Osacar, A., and Marks L., History of eating disorders in female patients with obsessive–
compulsive disorder, Int. J. Eat. Disord., 14, 439, 1993.
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6 Role of Neurotransmitters
in Obesity Regulation
Sunny E. Ohia and Catherine A. Opere
CONTENTS
Introduction ......................................................................................................................................71
Neurotransmitters and Relevant Pharmacological Receptors .........................................................72
5-Hydroxytryptamine................................................................................................................72
Catecholamines .........................................................................................................................73
Histamine ..................................................................................................................................74
Neuropeptides and Relevant Pharmacological Receptors ...............................................................75
Neuropeptide Y .........................................................................................................................75
Galanin ......................................................................................................................................76
Corticotropin-Releasing Factor.................................................................................................76
Orexins ......................................................................................................................................77
Melanocortin .............................................................................................................................78
Other Chemicals and Relevant Pharmacological Receptors ...........................................................79
Endocannabinoids .....................................................................................................................79
Summary and Conclusions ..............................................................................................................80
Bibliography.....................................................................................................................................80
INTRODUCTION
The main goal of this chapter is to provide a comprehensive review of neurotransmitters, neuropep-
tides, and other chemicals that have been reported to be involved in obesity regulation based on
data obtained from animal and human studies. These substances affect obesity via several mecha-
nisms: a decrease in food intake through satiety and non-satiety pathways or an effect on energy
expenditure through hyperactivity and thermogenesis. An induction of weight loss is a resultant
action of the ingestion of compounds that mimic or alter the action of neurotransmitters and
neuropeptides, as described in this chapter. The neurotransmitters discussed in this chapter include
5-hydroxytryptamine (5-HT), or serotonin; the catecholamines norepinephrine (NE) and dopamine
(DA); and histamine. For neuropeptides, the focus is on neuropeptide Y (NPY), galanin, corticotro-
pin-releasing factor (CRF), orexin, and melanocortin. For both neurotransmitters and neuropeptides,
an additional review of pharmacological receptors associated with their actions is provided. For
brevity, only in highly relevant cases is a discussion of signal transduction pathways for neurotrans-
mitters and neuropeptides included. We also discuss the role of other chemicals such as endocan-
nabinoids and their respective receptors in the regulation of obesity. The reader is also provided
with a bibliography of critical references for more information about the neurotransmitters and
neuropeptides discussed in this chapter.
71
NEUROTRANSMITTERS AND RELEVANT

PHARMACOLOGICAL RECEPTORS
5-HYDROXYTRYPTAMINE
In addition to its well-known actions on the gastrointestinal tract and cardiovascular system,
5-hydroxytryptamine (5-HT; serotonin) plays an important role as a neurotransmitter in the central
nervous system (CNS). 5-HT is biosynthesized from the essential amino acid tryptophan by two
enzymes: tryptophan hydroxylase and aromatic L-amino acid decarboxylase. Dietary tryptophan is
converted into 5-hydroxytryptophan (5-HTP) by tryptophan hydroxylase. At the nerve terminal, 5-
HTP is rapidly converted into 5-HT by the enzyme aromatic L-amino acid decarboxylase. Newly
synthesized 5-HT is stored in vesicles at serotonergic neurons and is released by exocytosis
following a nerve action potential. In the nervous system, the effect of released 5-HT is terminated
by a reuptake process into neurons by a specific transporter. The localization of 5-HT transporters
on membranes of serotonergic axon terminals facilitates the reuptake process. It is pertinent to note
that the 5-HT transporter plays an important role in the action of this neurotransmitter in the
regulation of obesity. Drugs that inhibit the activity of this transporter (such as d-norfenfluramine
and fluoxetine) increase the concentration of 5-HT at synaptic sites and have been reported to have
a suppressive action on food intake.
Further evidence for the role of 5-HT in the regulation of feeding behavior is derived from
both animal and human studies. For example, when 5-HT or its precursors, tryptophan and 5-HTP,
are administered to experimental animals, a significant decrease in food intake, eating rate, and
meal size results. Baseline levels of 5-HT and its metabolite, 5-hydroxyindoleacetic acid, are lower
in the hypothalamus of obese Zucker rats when compared to their lean counterparts. Similarly, in
obese humans, plasma concentrations of tryptophan and brain 5-HT levels are low, indicating a
role for this monoamine in the individual’s ability to control caloric intake.
In general, compounds that increase the concentration of 5-HT (whether through inhibition of
the transporter or via direct administration into the brain or periphery) have been shown to have a
preferential suppressant action on carbohydrate and fat consumption with little or no effect on
protein ingestion. In addition to the well-known selective serotonin reuptake inhibitors (SSRIs)
such as fluoxetine and fenfluramine, hydroxycitric acid has been reported to initiate its anti-obesity
action through an action on the 5-HT metabolic pathway. Hydroxycitric acid increased brain
concentrations of 5-HT in experimental animals and plasma 5-HT levels in humans. Although 5-HT
appears to possess a selective action on carbohydrate and fat ingestion in animal studies, it is
unclear whether these findings are relevant to humans. Be that as it may, an increase in 5-HT
concentrations at synaptic and other sites produces a general inhibitory action on the pattern of
food intake by modulating hunger and satiety.
The pharmacological actions of 5-HT are mediated by specific receptors of seven different
families (5-HT1 to 5-HT7). Of all the 5-HT receptors described, 5-HT1A, 5-HT1B, and 5-HT2C
subtypes have been implicated in the regulation of feeding behavior. For example, activation of
5-HT1A receptors can lead to increased food intake, whereas stimulation of 5-HT1B and 5-HT2C
receptors will cause a decrease in food consumption. 5-HT1A receptors are localized on nerve
terminals, and both 5-HT1B and 5-HT2C receptors are found on postsynaptic sites. Evidence linking
the action of 5-HT on food intake and feeding behavior with specific receptor subtypes was based
on animal studies in which selective antagonists of 5-HT1B and 5-HT2C receptors were found to
block the anorectic actions of serotonergic drugs such as fenfluramine and fluoxetine. Further
evidence is derived from studies using knockout mice that possess no functional 5-HT2C receptors.
5-HT2C receptor knockout mice demonstrate marked hyperphagia and late-onset obesity and exhibit
metabolic hormone changes such as hyperleptinemia and hyperinsulinemia. Likewise, 5-HT1B
receptor knockout mice gained more weight than the corresponding wild-type, indicating a higher
degree of food intake. The observations made in the knockout mice provide strong evidence that
Role of Neurotransmitters in Obesity Regulation 73
these genetically altered obese animals possess a deficient endogenous 5-HT satiety system. Animals
deprived of food demonstrate intense food-seeking behavior and increased food intake when food
is provided, a response that is linked to turnover of 5-HT and a differential expression of 5-HT2C
receptor subtypes in the hypothalamus.
In summary, studies on food intake and feeding behavior confirm a significant role for 5-HT
(and its possible action on 5-HT1B and 5-HT2C receptors) in mediation of the hypophagic response
induced by this monoamine. Attention is now being focused on producing receptor-selective 5-HT1B
and 5-HT2C agonists that can serve as novel molecules for the treatment of obesity. Indeed, weight
loss induced by fenfluramine is now ascribed to a direct stimulant action of its desmethyl metabolite,
norfenfluramine, on 5-HT2C receptors. The effectiveness of 5-HT2C receptor agonists in regulating
appetite and food intake in humans shows significant promise for the serotonergic system in the
development of new anti-obesity drugs.
The ability of 5-HT to cause hypophagia may involve the interaction of this monoamine with
other neurotransmitter and neuropeptide pathways; for example, neuropeptide Y (NPY)-induced
hyperphagia can be blocked by fenfluramine. Treatment of animals with 5-HT has been reported
to decrease hypothalamic NPY concentrations. Anorectic 5-HT drugs such as fenfluramine activate
proopiomelanocortin neurons in the arcuate nucleus (ARC), thus indicating a role for downstream
melanocortin pathways in the regulation of food intake and body weight. Orexin can stimulate
5-HT release in the hypothalamus, suggesting that serotonergic pathways are involved in the
anorectic action of this neuropeptide.
It is clear from the discussion above that, as a neurotransmitter, 5-HT plays a crucial role in
satiety response and may serve as a template for future anti-obesity therapy. Compounds that
increase its concentrations at synaptic sites or activate 5-HT1B or 5-HT2C receptors will continue
to represent compelling therapeutic targets in the quest to develop highly selective pharmacological
entities for the regulation of food intake and feeding behavior.
CATECHOLAMINES
Of the three major catecholamines, dopamine and norepinephrine have been linked to the regulation
of appetite and feeding behavior. Dopamine, an immediate precursor of norepinephrine and epi-
nephrine, is a neurotransmitter in the CNS. It is synthesized from the amino acid tyrosine by two
enzymes: tyrosine hydroxylase and aromatic L-amino acid decarboxylase. Tyrosine is converted to
dihydroxyphenylalanine (DOPA) by tyrosine hydroxylase, which is subsequently metabolized to
dopamine by aromatic L-amino acid decarboxylase. Dopamine is presumed to be one of the target
neurotransmitters linking the genetic and environmental factors that contribute to obesity. It has a
site-specific action on the regulation of food intake. The reinforcing action of dopamine on food
intake is associated with the release of this neurotransmitter in the brain nucleus accumbens. The
duration of meal consumption is ascribed to dopamine release in the hypothalamus. It appears that
dopamine is required to initiate each meal and is also responsible for the number of meals and
duration of feeding. Dopamine knockout mice do not express tyrosine hydroxylase activity; these
animals do not lack the motor capabilities for feeding but cannot initiate this process. Evidence
from biomedical literature supports the fact that dopamine is essential for feeding.
Dopamine exerts its pharmacological actions via activity on five receptor subtypes classified
into D1-like (D1 and D5) and D2-like (D2, D3, and D4) families. Both subtypes of dopamine receptors
are found on hypothalamic neurons, thus supporting their role in the regulation of feeding behavior.
Data from studies in animals show that chronic activation of D1 or D2 receptors results in a decrease
in food consumption with concomitant body weight reduction. In humans, there is evidence that
striatal D2 receptor activity is significantly lower in obese individuals than in controls, a finding
that was hypothesized to be due to the action of dopamine on motivation and reward circuits. In
general, an effect of dopamine on D1 receptors is presumed to be regulation of satiety signals, thus
leading to a decrease in meal size and duration of feeding. Activation of D2 receptors leads to a
reduction in the rate of feeding. Drugs that activate or block dopamine receptors can affect appetite
and feeding behavior; for example, the D1/D2 receptor agonist apomorphine has been shown to
decrease both the rate and duration of feeding. On the other hand, behavioral studies in animals
have revealed that antagonists of D2 receptors can increase meal size and the duration of feeding.
In humans, patients treated with antipsychotics that block D2 receptors show an increase in body
weight as a side effect. Clearly, both dopamine receptors play a very important role in the regulation
of appetite and feeding behavior in both animals and humans.
Norepinephrine is a neurotransmitter that is released from sympathetic nerves. It is a metabolic
product of the action of dopamine β-hydroxylase on dopamine. Compounds that produce effects
that resemble sympathetic nerve stimulation (i.e., sympathomimetics) such as amphetamine, phen-
termine, and sibutramine have been employed as anti-obesity drugs. The mechanism of action of
these anti-obesity compounds is complex with a diverse activity spectrum, such as a reduction in
food intake or increase in energy expenditure (through hyperactivity or thermogenesis). Amphet-
amine was the first compound mimicking the action of sympathetic nerve stimulation that was
employed for the treatment of obesity. Amphetamine reduces hunger, food intake, and the number
of meals while increasing feeding latency and feeding rate. Due to its deleterious side effect on
the cardiovascular system and high rate of abuse potential, this drug is no longer in use for the
treatment of obesity. Sibutramine, a potent inhibitor of norepinephrine and serotonin reuptake, has
anti-obesity actions through an inhibitory action on food intake.
Norepinephrine produces its physiological and pharmacological actions via activation of three
major receptor classes: α1-, α2-, and β-adrenoceptors. All three receptor classes have been implicated
in the regulation of appetite and feeding behavior. In the brain, α1- and α2-adrenoceptors present
in the paraventricular hypothalamus have been linked to the regulation of feeding behavior. In
animal studies, stimulation of α1-adrenoceptors suppresses food intake, whereas activation of
α2-adrenoceptors increases food intake. It appears that the observed anti-obesity action of sympatho-
mimetics could be related to the degree to which they act on α1- and α2-adrenoceptors; for example,
sibutramine is presumed to decrease appetite via an inhibitory action on α2-adrenoceptors.
α-Adrenoceptors mediate glucose homeostasis through an effect on insulin and glucagon secretion,
liver glucose production, and glucose uptake into muscle. Production of heat by the body (thermo-
genesis) can increase energy expenditure leading to weight loss. The adipose tissue serves both as
a depot for fat storage and also as a dynamic endocrine organ involved in the control of energy
balance. β3-Adrenoceptors present in adipose tissue are involved in catecholamine-stimulated lipol-
ysis and thermogenesis. The discovery that mutation of a gene encoding β3-adrenoceptors is linked
with the propensity to gain weight coupled with the observation that these receptors mediate
thermogenesis in adipose tissue led to the search for anti-obesity drugs that act via this pathway.
It remains to be determined whether β3-adrenoceptors present on adipose tissues could serve as a
useful target for the treatment of obesity.
HISTAMINE
Histamine is a neurotransmitter in the central nervous system that has also been linked to the
regulation of feeding behavior. Apart from the CNS, histamine is found in abundance in mast cells,
especially in skin, lungs, and the gastrointestinal tract. In the brain, histamine is synthesized in
tuberomamillary nucleus hypothalamic neurons from the amino acid histidine. Histidine is decar-
boxylated to form histamine, a reaction that is catalyzed by the enzyme L-histidine decarboxylase.
Unlike the catecholamines whose effect is terminated by reuptake mechanisms in synapses, hista-
mine diffuses from synapses, where its action is terminated by degradative enzymes. Nerves
containing histamine project throughout the brain to areas such as the thalamus and cerebral cortex.
In animal studies, histamine has been shown to suppress food intake, and there is evidence that
this neurotransmitter may regulate body weight and adiposity by an action on peripheral energy
metabolism. Histamine-containing neurons have been linked to the rate of feeding and intake volume
of meals. Histamine produces its pharmacological actions via effects on four different receptor
subtypes: H1, H2, H3, and H4. Of these receptor subtypes, both H1 and H3 receptors have been
associated with the regulation of appetite and feeding behavior. In animal studies, injection of H1
receptor agonists or peripheral administration of the histamine precursor histidine suppressed food
intake in rats and mice. Furthermore, H1-receptor-deficient mice demonstrated an increase in food
intake when compared to their normal counterparts. Taken together, data from animal studies reveal
a role for H1 receptors in the regulation of food intake and feeding behavior. Administration of the
H3 receptor antagonist thioperamide into the brain has been reported to suppress food intake in
rats. Presumably, by blocking inhibitory H3 receptors present on histamine-containing nerve ter-
minals, thioperamide indirectly causes an increase in the release and availability of this amine,
leading to enhanced stimulation of postsynaptic H1 receptors and the suppression of food intake.
Based on this observation, several new compounds with antagonistic activity at H3 receptors have
been developed by pharmaceutical companies for potential use as anti-obesity drugs. In spite of
the evidence from preclinical studies that implicates histamine in the regulation of food intake, it
remains to be determined whether compounds that interact with H1 and H3 receptors will be of
therapeutic importance in the treatment of obesity in humans.
NEUROPEPTIDES AND RELEVANT

NEUROPEPTIDE Y
Neuropeptide Y (NPY), a 36-amino-acid neurotransmitter that was discovered in 1982, is one of
the most abundant and widely distributed neuropeptides in mammalian central nervous systems. It
belongs to a family of pancreatic polypeptides with similar structural homology known as the NPY
family. Other members of this family include peptide YY, pancreatic polypeptide, and polypeptide
Y. NPY, which is also one of the most studied neuropeptides, is highly conserved across species
from Drosophila to humans. Biosynthesis of NPY involves posttranslational enzymatic cleavage
of the 98-amino-acid preproNPY to the 69-amino-acid prohormone proNPY, which is further
cleaved to NPY by the prohormone convertases PC1/3 and PC2. It is often colocalized and
coreleased with norepinephrine neurotransmitter in both the central and autonomic nervous system,
where it is believed to modulate catecholamine release and activity. In addition to its regulatory
role in the cardiovascular, reproductive, bone mass, and psychomotor systems, among others, NPY
is a potent orexigenic neuropeptide that plays a central role in the regulation of appetite in the
central nervous system. In the central nervous system, NPY is most abundant in the hypothalamic
nuclei, such as the arcuate nucleus (ARC) and paraventricular nucleus (PVN), both key areas in
the regulation of feeding. Indeed, several studies have shown that injection of NPY into the
paraventricular nucleus stimulates hyperphagia, reduced energy expenditure, and the induction of
obesity in the long run.
Neuropeptide Y mediates its pharmacological actions by activating six Gi/Go-protein-coupled
NPY receptor subtypes (Y1 to Y6), all of which have been cloned and have been shown to be
expressed in both central nervous system and peripheral tissues. Three of these receptor subtypes
(Y1, Y2, and Y5) have been implicated in the regulation of food intake; for example, evidence
suggests that Y1 receptors are involved in selective stimulation of carbohydrate intake and meal
size. Several studies utilizing receptor NPY agonists and receptor subtype antagonists have dem-
onstrated that both Y1 and Y5 receptors independently and synergistically interact with each other
to mediate NPY hyperphagic response. In contrast, the Y2 receptor subtype, which is located
presynaptically (with postsynaptic expression in some brain regions) on neurons, suppresses car-
bohydrate intake. Other studies report that Y2 receptors have no effect in satiated animals but
suppresses food intake in fasted animals. It appears that, under fasted conditions, Y2 receptor
activity attenuates the release of PVN NPY and eliminates tonic inhibition of γ-aminobutyric acid
(GABA) on proopiomelanocortin (POMC) neurons, thereby stimulating release of α-melanocyte-

stimulating hormone (α-MSH) with the net effect of decreased food intake. It has been hypothesized
that, in satiated animals, the Y2-sensitive NPY and GABA are rendered inactive, while the activity
of α-MSH and POMC neurons predominates to reduce food intake.
In general, Y2 receptors regulate the transport, synthesis, and release of NPY and other central
mediators, in addition to playing a significant role in the NPY-mediated effects of leptin. Although
the central orexinogenic effect of NPY has been established in several studies, the use of transgenic
mice has surprisingly revealed that neither overexpression nor deletion of NPY receptors interferes
with normal weight and appetite. It appears that, although NPY is central to the regulation of food
intake and energy balance, the body can adjust other orexigenic and anorexigenic signals to
compensate for its receptor deletion or overexpression. The normal transgenic phenotype of both
transgenic models thus reflects the rich functional redundancy of the system regulating food intake
and energy balance. Based on studies utilizing transgenic models, it is not surprising that a Y5
antagonist was unsuccessful in clinical trials with human subjects. Although these observations
suggest that NPY is not involved in morbid obesity, NPY analogs may still find clinical application
as appetite suppressants and anti-obesity drugs.
GALANIN
Galanin is a 29-amino-acid (30 in humans) peptide that is widely expressed in mammalian central,
peripheral nervous, and endocrine systems; it was originally identified in porcine intestines in 1983.
It is colocalized with and regulates the release of several neurotransmitters and has been implicated
in high-order physiological functions such as learning and memory, nociception, epileptic activity,
spinal reflexes, sexual activity, mood changes, and food intake. The pharmacological effects of galanin
are mediated through three G-protein-coupled receptors: GalR1, GalR2, and GalR3. It is unclear
which of these receptors mediate the effects of galanin on the regulation of food intake. Injection of
galanin into the brain stem stimulates food consumption. On the other hand, administration of galanin
antagonists such as M40 decreases food intake. Evidence suggests that in the PVN of the hypothal-
amus, endogenous galanin selectively stimulates the intake of lipids and alcohol, and its production
is stimulated by the same dietary components. Interestingly, consumption of a high-carbohydrate diet
does not regulate endogenous galanin levels. Transgenic mice overexpressing galanin mRNA in the
hypothalamus exhibit a higher preference for a lipid diet. It is therefore conceivable that a potent
galanin antagonist may have potential clinical application as an anti-obesity drug.
CORTICOTROPIN-RELEASING FACTOR
Corticotropin-releasing factor (CRF), also known as corticotropin-releasing hormone (CRH), is a
41-amino-acid neuropeptide that belongs to the CRH family of peptides. Other members of this
family include urocortin I, II, and III. In addition to being one of the major physiologic secretagogs
of adrenocorticotropic hormone (ACTH), CRF regulates the hypothalamic–pituitary axis; auto-
nomic and behavioral responses to stress; cardiovascular, inflammatory, and gastrointestinal func-
tion; and food intake. CRF is synthesized by hypothalamic paraventricular neurons and is distributed
throughout the brain and spinal cord. Biosynthesis of CRF involves cleavage of flanking amino
acid base pairs from a 191-amino-acid precursor. CRF activates two seven-transmembrane-domain-
spanning, G-protein-coupled receptors: CRF type 1 (CRF1) and CRF type 2 (CRF2). CRF1, which
exhibits a higher affinity for CRF, is expressed in cortical, hypothalamic, limbic, cerebellar, and
pituitary regions of the brain and in the gastrointestinal tract. In contrast, CRF2 exhibits a lower
affinity for CRF and is distributed mainly in peripheral systems such as the gut and in more limited
areas of brain compared to CRF1. Both receptors are positively coupled to adenylyl cyclase enzyme.
In humans, CRF2(a) is localized in hypothalamic areas that control appetite such as the PVN, in
the gastrointestinal tract, and on vagal afferent nerves, suggesting their role in the regulation of
food intake.
Chronic intracerebroventricular (i.c.v.) administration of exogenous CRF in rats elicits a potent

anorexic effect via stimulation of synthesis and secretion of POMC-related peptides leading to
suppression of food intake and a decrease in body weight. The discovery of endogenous-selective
CRF2 receptor agonists (type 2 urocortins Ucn-II and Ucn-III) and the synthesis of more selective
ligands continue to delineate the functional significance of the CRF systems in brain and gut. Using
some of the newly found ligands, it has been shown that agonists with higher affinity for CRF2
exhibit a high potency of hypophagic response; for example, Ucn-I, which has a higher affinity for
CRF2, is more potent at suppressing food intake and less potent at modulating stress compared
with CRF1, which has a moderate affinity for this receptor subtype. In contrast, the selective CRF2
receptor antagonist antisauvagine-30 attenuates CRF-induced anorexia, unlike the CRF1 receptor
antagonist counterpart. In support of this premise, deletion, reduction, or inhibition of the CRF2
receptor subtype attenuates the hypophagic effect caused by i.c.v. injection of Ucn-I and CRF.
Other studies indicate that, in rats, CRF1 receptors mediate abbreviated, short-onset anorexia, while
CRF2 elicits delayed-onset anorexia. Furthermore, activation of both CRF1 and CRF2 receptor
subtypes using nonselective agonists provokes both prolonged and short-onset anorexia. Clearly,
the exact mechanisms by which the CRF receptor system regulates appetite suppression remain to
be fully elucidated. It is conceivable that CRF antagonists may find therapeutic application in the
treatment of overweight, obesity, and associated morbidities.
OREXINS
Orexins (previously known as hypocretins) A and B are neuropeptides that were initially identified
in rat hypothalamus in 1998. These novel neuropeptides have been shown to be involved in the
regulation of food intake, in addition to sleep/wakefulness and energy homeostasis. Orexin A (33-
amino-acid residues) and orexin B (28-amino-acid residues) are proteolytically derived from
130–131 preproorexin. Orexins interact with two seven-transmembrane-domain-spanning, G-pro-
tein-coupled receptors: orexin receptor 1 (OX1R), which selectively binds orexin A, and orexin
receptor 2 (OX2R), which has the same affinity for both orexin A and B. Originally localized in
the lateral and posterior hypothalamus, orexin neurons project diffusely into brain regions, including
areas involved in the regulation of energy homeostasis such as the arcuate nuclei, paraventricular
hypothalamus, and ventromedial hypothalamus. Interestingly, these hypothalamic regions also
express orexin receptors, suggesting involvement of the orexin system in the regulation of food
intake. In the lateral hypothalamus, orexin neurons are coexpressed with the hyperphagic endoge-
nous opioid dynorphin. Both orexins and their receptors are now known to be expressed in the
gastrointestinal system, as well.
Administration of orexin A elicits an OX1R-receptor-sensitive hyperphagic response that is less
potent than that of NPY but comparable to that of melanin-concentrating hormone (MCH). In rodents,
acute administration of orexin A induces a transient orexinogenic effect that is preceded by anorexia
with no net increase in food intake over a 24-hour period. It is therefore not surprising that chronic
administration of orexin A does not induce obesity, unlike the orexigenic neuropeptides, NPY, and
Agouti-related protein (AGRP). OX1R antagonists such as SB-334867 not only reverse orexin-A-
induced hyperphagia but may also induce satiety when administered alone. Interestingly, orexin-A-
induced feeding can also be blocked by nonselective opioid antagonist and partially reversed by
NPY Y1 receptor antagonist, suggesting that the control of food intake involves an integration of
various pathways. The hyperphagic effect of orexin A is supported by the observation that mice
lacking preproorexin are hypophagic with normal body weight. Hypophagia is also observed in the
selective deletion of orexin neurons using ataxin-3 in mice. Ataxin-3-treated mice develop late-onset
obesity, an effect that can be ascribed to an orexin-induced increase in thermogenesis. In contrast,
orexin B induces little or no hyperphagic response and promotes grooming and searching activities.
Although these observations indicate that the orexin system does play the main regulatory role in
food intake, OX1R antagonists have the potential to reduce food intake and reduce body weight.
MELANOCORTIN
The melanocortin (MC) system consists of a group of four peptides: α-, β-, and γ-melanocyte-
stimulating hormones and ACTH, which are derived from posttranslational cleavage of the precursor
molecule proopiomelanocortin. Other members of the system include two endogenous antagonists
(Agouti and AGRP) and five melanocortin receptor subtypes (MC1R to MC5R). Although the
behavioral effects of ACTH and α-MSH have been known since 1955, it was not until the 1980s
that the regulatory effect of MC peptides on food intake was illustrated. So far, two receptor
subtypes, MC4R and, to a lesser extent, MC3R (also known as the central receptors), have been
implicated in the regulation of food intake. MC3R is highly expressed in hypothalamic nuclei that
control feeding such as ventromedial hypothalamus, arcuate nucleus, lateral hypothalamus, and
preoptic nucleus. MC4R is more widely expressed in multiple parts of the brain, including hypo-
thalamic dorsal medial nucleus and PVN, which receive projections from ARC. Interestingly, MC3R
and MC4R receptors are activated by all of the four MC peptides, with α-MSH exhibiting the
highest selectivity for MC3R. In general, MC peptides suppress food intake and reverse a positive
energy balance, while MCR antagonists increase food intake and body weight. For example, the
endogenous antagonists Agouti and AGRP are competitive antagonists at MC4R that elicit a
hyperphagic response. Similarly, synthetic selective MC4R inhibitors such as HS024, HS028, and
SHU9119 induce hyperphagia in both normal and satiated mice. Targeted gene deletion of central
MC receptors (MC4R and NC3R) and precursor molecules (POMC) can result in obese mice. Mice
deficient in MC4R are hyperphagic and exhibit an obese phenotype. Additionally, evidence suggests
that the MC system interacts with other systems to regulate food intake; for example, in mice,
centrally administered MCR agonists attenuate fasting or NPY-induced hyperphagia. On the other
hand, NPY1 receptor inhibitors attenuate hyperphagia induced by selective MC4R antagonists.
MC4R antagonists also attenuate the effects of leptin on food intake and body weight, suggesting
the involvement of the MC system in the effects of leptin. In support of this hypothesis, leptin has
been reported to stimulate hypothalamic POMC mRNA. Furthermore, administration of peripheral
and central leptin to obese MC4R knockout mice does not alter food intake, thus implicating MC4R
in the regulation of food intake by leptin. The effects of individual MC peptides on food intake
are summarized below:
• α-MSH — α-MSH is a 13-amino-acid MC receptor agonist that appears to be the primary

endogenous agonist for central MC receptors mediating suppression of food intake. It is
expressed in both central (highest levels in the hypothalamus) and peripheral tissues.
Central administration of α-MSH has been shown to induce suppression of food intake
in experimental animals such as the rat. Injection of α-MSH into the ventricles of fasted
rats has been shown to attenuate food intake. It also reverses NPY-mediated or dark-
phase-mediated feeding following administration into the paraventricular nucleus. In
addition to its central effects, α-MSH exhibits peripheral effects on weight gain; for
example, it elicits weight loss in POMC-deficient and diet-induced obese mice. Taken
together, these data suggest that α-MSH plays a vital role in MC-mediated inhibition of
food intake.
• β-MSH — β-MSH is a 22-amino-acid peptide derived from the C-terminus fragment of
POMC that exhibits a higher affinity for MC4R than α-MSH or γ-MSH in humans and
rats. Findings regarding its effect on the regulation of food intake are conflicting. Whereas
it has been reported to be equivalent to α-MSH in attenuating food intake in rats fasted
for 24 hours, other studies indicate it failed to reduce the food intake of rats fasted for
48 hours. Evidence from other studies suggests a dose-dependent attenuation of food
intake in freely feeding rats after i.c.v. administration of β-MSH. Although some data
suggest that β-MSH is involved in the regulation of food intake, the exact nature of its
involvement remains to be fully elucidated.
• ACTH — ACTH is a 39-amino-acid peptide formed by the action of PC1 on POMC in

anterior pituitary corticotrophs; it plays a significant role in the regulation of appetite.
Cleavage of ACTH by PC2 yields α-MSH. Other fragments of ACTH include
ACTH(1–16), ACTH(4–16) and ACTH(7–16). Interestingly, ACTH is the only endoge-
nous MC that activates all five MCRs. The anorectic effects of ACTH are mediated by
ACTH(1–24), whose activity is protected by ACTH(25–39). Central administration of
ACTH(1–24) attenuates feeding in both fasted and freely feeding rat. Furthermore,
ACTH(1–24) was found to inhibit the hyperphagic effect of intraperitoneally adminis-
tered kappa opiate agonists. Neither adrenalectomy nor subcutaneous administration
(dose up to 200 µg/kg in rats) of ACTH(1–24) was found to suppress food intake,
suggesting that the anorectic effects of ACTH are not linked to adrenal steroids nor are
they mediated by interaction with peripheral feeding regulatory pathways but via sites
in the central nervous system.
In summary, evidence from studies using experimental animals clearly demonstrates a role for
several neuropeptides in the regulation of appetite and feeding behavior. The wide array of neu-
ropeptides involved offers great potential for the identification of several classes of these agents
that could ultimately be employed in the treatment of obesity in humans.
OTHER CHEMICALS AND RELEVANT

ENDOCANNABINOIDS
It is well known that the cannabis plant (Cannabis sativa) and its extract have an appetite-stimulating
action due to the presence of the psychoactive compound ∆9-tetrahydrocannabinol (THC). The
discovery of endogenous ligands for plant-derived cannabinoids (endocannabinoids) has led to the
description of a physiological basis for the efficacy of these compounds in experimental animals
and humans. Endocannabinoids are derived from arachidonic acid, and they include substances
such as anandamide and 2-arachidonoylglycerol (2-AG). In low doses, centrally or systemically
administered THC has been shown to stimulate feeding in a variety of animal models. In high
doses, THC can decrease feeding due to its potent sedative actions. In humans, THC has also been
reported to increase food intake, a factor that has been found to be beneficial in the treatment of
conditions involving appetite loss such as AIDS and cancer. It is important to note that the
hyperphagic effects of THC can be mimicked by endocannabinoids, anandamide, and 2-AG.
Endocannabinoids have been linked with a physiological process involved in the regulation of
feeding behavior. Increased concentrations of anandamide and 2-AG have been found in the nucleus
accumbens during fasting. A decline in the 2-AG level was found during the feeding state, suggesting
that the endocannabinoids play an important role in the motivation to obtain food.
Both exogenous cannabinoids and endocannabinoids increase food intake and promote weight
gain by stimulating two subtypes of receptors: CB1 and CB2. CB1 receptors are found in the central
nervous system and some peripheral tissues, whereas CB2 receptors are localized in peripheral
immune cells. CB1 receptors are linked to the regulation of appetite and feeding behavior. Evidence
suggests that the pharmacological blockade of CB1 receptors with drugs such as rimonabant
(SR141716) produces a reduction of food intake and body weight. Indeed, CB1 gene-deficient mice
are found to be lean and resistant to diet-induced obesity.
In summary, it appears that endocannabinoids, acting on brain CB1 receptors, can stimulate
appetite and feeding behavior in both experimental animals and humans. The discovery of the link
between endocannabinoids and their potential to regulate feeding behavior provides immense
opportunities for the treatment of diseases or conditions that require either an increase or decrease
in appetite.
SUMMARY AND CONCLUSIONS

A wide variety of neurotransmitters and neuropeptides are involved in the regulation of appetite
and feeding behavior in both experimental animals and humans. Receptors for classical neurotrans-
mitters (5-hydroxytryptamine, norepinephrine, and histamine) are well known and appear to be
ready targets for the development of compounds with therapeutic potential as anti-obesity drugs.
The neuropeptides NPY, galanin, corticotropin-releasing factor, orexin, and melanocortin are a
diverse group with the potential to interact with classical neurotransmitters in the pathways involved
in appetite and food regulation. The discovery of endocannabinoids and their receptors has revealed
additional targets for the manipulation of pathways that control food intake in experimental animals
and humans. In conclusion, concerted efforts should be focused on the effects of the neurotrans-
mitters and neuropeptides that are important in the regulation of food intake and energy metabolism
in humans. It may well be that formulations that contain more than one neurotransmitter or
neuropeptide could produce the optimum action in terms of controlling food intake and energy
metabolism.
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7 Neurobiology of Obesity
Nina Eikelis
CONTENTS
Introduction ......................................................................................................................................81
Obesity Epidemic.............................................................................................................................82
Regulation of Body Weight .............................................................................................................82
Leptin ...............................................................................................................................................83
The ob Gene..............................................................................................................................83
The Leptin Protein ....................................................................................................................83
Leptin Receptors (Ob-R) ..........................................................................................................84
Transport of Leptin into the CNS....................................................................................................85
Leptin and Eating Disorders ............................................................................................................86
Mechanisms of Leptin Action in the Brain.....................................................................................86
Leptin Resistance in Obesity ...........................................................................................................87
Leptin Signaling Pathways ..............................................................................................................88
Role of Neuropeptide Y in the Control of Food Intake...........................................................88
Central Melanocortin System in the Regulation of Food Intake.............................................89
Ghrelin Effects in the Hypothalamus .......................................................................................90
Conclusions ......................................................................................................................................90
References ........................................................................................................................................91
INTRODUCTION
Food is a necessity of life, like sleep. It is also one of the pleasures of life. We may eat when we
are not hungry just because it tastes, looks, or smells good! In fact, a lot of people will eat much
more than their bodies actually need for fuel. Not surprisingly, the obesity epidemic is sweeping
the world. Obese people go to extreme measures in hopes of gaining control over their body weight,
but why is it so difficult to control our body weight? In recent years, remarkable progress has been
made in our understanding of the molecular basis of obesity. The mammalian energy balance is
controlled by complex networks between brain structures, such as the hypothalamus, brainstem,
and higher brain centers, and in the periphery between the stomach, gut, liver, thyroid, and adipose
tissue. Advances in molecular techniques have resulted in major advances being made in the
understanding of hypothalamic circuits involved in body weight regulation. More than ten years
ago scientists discovered a gene (ob gene), a mutation of which causes severe obesity in a strain
of laboratory mice. This gene encodes a hormone, leptin, which is mainly secreted by fat cells and
acts within the hypothalamus to reduce appetite and increase energy expenditure. When mice are
injected with leptin, they lose weight dramatically. Overweight people have elevated leptin levels
due to increased adipose tissue mass; however, they seem to be leptin resistant when it comes to
its anorexigenic effects — despite high levels of leptin levels, they continue to overeat. Several
mechanisms have been suggested to explain leptin resistance in humans, such as impaired leptin
transport in the brain, where it informs the central nervous system about the state of body fat,
defects in leptin receptor, or altered leptin downstream signaling.
81
OBESITY EPIDEMIC
The Western world is experiencing an epidemic. Although people should be aware of this epidemic,
as the evidence is literally under our noses, the rise in obesity prevalence continues to sweep the
world unabated. Globally, more than 1 billion adults are overweight, and at least 300 million of
these are obese. Often coexisting in developing countries with undernutrition, obesity is a multi-
dimensional condition affecting virtually all ages and socioeconomic groups. Alarmingly, this trend
is even greater in young children, suggesting that this problem will escalate in the foreseeable future.
Why is this happening? A decade or two ago it was common to blame the individual for being
overweight. While there is no doubt that the rising epidemic to a great extent reflects changes in
lifestyle due to a simultaneous decrease in activity and increase in caloric intake, today a different
approach is being taken to address the problem of weight control that considers the strong and
complex factors involved in the tendency to increase body weight. Twin and adoption studies, as
well as experimental models of obesity, now indicate that obesity results from both genetic and
environmental factors.
The health, economic, and psychosocial consequences of obesity are substantial. The health
consequences of obesity range from a number of nonfatal complaints that impact on the quality of
life, such as skin problems (particularly infections in flexural creases), respiratory difficulties, and
infertility, to complaints that reflect an increased risk of premature death, including diabetes, gall-
bladder disease, and cardiovascular problems (hypertension, stroke, and heart disease). Hyperten-
sion and diabetes, for example, are between two and six times more prevalent among heavier people.
From a social perspective, being overweight may have deleterious effects on a person’s self-
esteem, social and economic characteristics, and physical health. In our culture, being thin means
more than just good health; it symbolizes self-control, hard work, ambition, and success in life.
Positive attributes are assigned to thin people, whereas those with less than perfect bodies are often
thought to be lazy and self-indulgent.
REGULATION OF BODY WEIGHT

The regulation of body weight may be considered a homeostatic process, directed at conserving
an energy balance, seeking food in times of need and storing energy in times of plenty; however,
the homeostatic system in humans is strongly biased toward weight gain and storage of fat, with
only a few mechanisms that encourage weight loss. This biased homeostatic system is probably
due to little evolutionary pressure to decrease food intake once energy stores are full [1].
Regulation of body weight in humans involves genetic, environmental, and psychosocial factors
that affect the physiological regulators of food intake and energy expenditure [2]. Most animals,
including humans, can maintain constant body weight over prolonged periods of time. This means
that energy intake (derived from ingested foods) must equal energy expenditure over a long term
to maintain a stable body weight. Although the equation seems pretty straightforward, regulation
of body weight is actually a far more complex interplay of energy intake and expenditure, satiety
factors, and other controls of appetite.
Food intake elicits sensory inputs — nutrient and gastrointestinal signals mediated by distension
of the stomach or local hormones, which together modulate appetite. The mechanisms involve
various neurotransmitters, such as norepinephrine, dopamine, serotonin, orexins, melanocortins,
and neuropeptide Y (NPY), to name just a few [3]. All of these signals produce neural and humoral
outputs that cause appropriate adjustments in nutrient intake and metabolism [4].
Many of the hormones that are involved in the regulation of body weight via appetite and
satiety are released from the gastrointestinal tract after a meal. Some of these are cholecystokinin,
glucagon, and gastrin-releasing peptide, which act by reducing food intake after a meal. Nutrients
such as glucose and fatty acids provide another signal that regulates food intake. Long-term
regulators of food intake include insulin, ghrelin, corticosteroids, and leptin.
Neurobiology of Obesity 83
In addition to appetite, thermogenesis is another mechanism involved in body weight regulation.

Several prospective studies have shown that a relatively low energy expenditure predicts body
weight gain [5–7]. Results from most overfeeding studies indicate that short-term, diet-induced
weight gain is associated with an increase in energy expenditure [8,9]. Similarly, underfeeding is
accompanied by a decrease in energy expenditure beyond the predicted values [10–12]. Such
overcompensatory metabolic changes are presumably acting to oppose any further weight gain.
It is currently assumed that the major factors involved in obesity include the genetic back-
ground of an individual and the individual’s dietary and physical activity habits. The role of
inheritance in human obesity has been extensively studied over the last decade, with adoption
and twin studies showing that obesity has a genetic component. More recently, the studies have
shown that both body fat mass and partitioning between central and peripheral fat depots are
influenced by genetics [13]. It is likely, therefore, that genes involved in weight gain increase
the susceptibility of an individual to develop obesity when exposed to an environment that favors
positive energy balance.
The discovery and cloning of specific genes involved in fat accumulation have led to a renewed
interest in genetic factors responsible for the development of human obesity. The relatively recent
isolation of the ob gene, which encodes leptin, has attracted particular attention. Other genetic
mutations that lead to the excessive accumulation of fat in animal models have also been identified,
and some of them involve the leptin receptor, melanocortin-4 receptor, and proopiomelanocortin
(POMC).
Body weight is regulated by the central nervous system, which can sense the body’s metabolic
status from a wide range of humoral and neural signals. The integration of the signals takes place
largely, but not solely, in the hypothalamus. The hypothalamus is the structure that is generally
considered to be the most sensitive to manipulations that modulate appetite and eating behaviors.
Hypothalamic amines, hormones, and neurotransmitters participate in a complex network of systems
that influence eating behavior and the metabolism of specific nutrients. Stimulation of some systems
results in an increase in food consumption, while stimulation of other systems results in a reduction
in food intake and storage; therefore, it is likely that disturbances in one or many of these systems
may underlie body weight changes.
LEPTIN
THE Ob GENE
The ob gene was first discovered in adipose tissue of the obese mouse through positional cloning
[14]. The full coding sequence contains 167 amino acids and represents a 21-amino-acid signal
peptide and 146-amino-acid circulating bioactive hormone [14]. In both human and mouse, the
leptin gene is composed of three exons and two introns. Interestingly, the leptin peptide has
structural similarities to members of the cytokine family [15]. In mammals, leptin is predominantly
produced in adipose tissue and secreted into the bloodstream; however, non-adipocyte leptin
production has been also documented in the stomach [16], placenta [17], and brain [18,19]. Non-
adipose sources of leptin production may perhaps suggest a far more complex role for leptin than
originally thought.
THE LEPTIN PROTEIN

The ob gene codes for a protein secreted by fat cells. This protein is hypothesized to regulate fat
storage by signaling the brain to suppress appetite when the body’s fat stores are full. When mutated
in mice, the ob gene is no longer able to express leptin and therefore can no longer deliver its
appetite-suppressing message. The mice consequently develop a syndrome that resembles extreme
obesity and type 2 diabetes in humans. Human leptin is 84% homologous to mouse and 83%
Leptin
Leptin binding
to its receptor
Ob-Rb
Jak Jak plasma membrane

Jak Jak
Tyr Tyr
P P
STAT phosphorylation
STAT STAT
STAT
STAT
P P
nuclear membrane
STAT
STAT
transcription
P P
FIGURE 7.1 Schematic representation of leptin signaling cascade. Leptin–Ob-Rb complex formation leads
to the induction of tyrosine phosphorylation through its association with JAK2, which leads to the activation
of STAT proteins.
homologous to rat leptin. Leptin consists of four antiparallel α-helices (A, B, C, and D), connected
by two long crossover links (AB and CD) and one short loop (BC), arranged in a left-handed
twisted helical bundle. The four-helix bundle is folded as packing of antiparallel helix pairs A and
D against B and C; a disulfide bond between the C-terminus of the protein and the beginning of
the CD loop is important for stability and biological activity [20].
LEPTIN RECEPTORS (OB-R)

Leptin is predominantly produced by adipocytes, but leptin receptors are located in many tissues.
The leptin receptor is encoded by the diabetes (db) gene. Tartaglia et al. [21] were the first to isolate
and describe the leptin receptor (Ob-R) in a mouse. To date, at least six leptin receptor isoforms
have been described [22]. Alternative gene splicing explains the number of leptin receptors. All
isoforms share the same extracellular domain; however, only one of them, the long form, has all
of the intracellular motifs required for signal transduction via the JAK/STAT pathway (Figure 7.1).
Based on sequence homology, the Ob-R belongs to the class I cytokine receptor family, which
includes receptors for interleukin 6, leukocyte inhibitory factor, and granulocyte-colony-stimulating
factor [23]. Leptin–Ob-Rb complex formation leads to the induction of tyrosine phosphorylation
through its association with JAK2 (Figure 7.1). The activated JAK2 phosphorylates a distal tyrosine
(Tyr-1138) on the receptor, similar to STAT proteins. Although leptin can activate STAT1, STAT3,
STAT5, and STAT6, it only activates STAT3 in the rodent hypothalamus.
Mutations in the functional leptin receptor result in an obese phenotype identical to that of ob
mice. In fatty Zucker rats, a point mutation in the extracellular domain inhibits signal transduction.
On the other hand, db/db mice predominantly express the short form of leptin receptor, which
leaves these mice with a nonsignaling leptin receptor system. Ob-Rb is highly expressed in the
hypothalamus. Experimental studies have identified the hypothalamic arcuate nucleus (ARC),
dorsomedial nucleus of the hypothalamus (DMH), paraventricular nucleus (PVN), ventromedial

nucleus of the hypothalamus (VMH), and lateral hypothalamic nucleus as the principal sites of
leptin receptor expression in the central nervous system [24,25]. Each of these nuclei is important
in regulating body weight.
A soluble form of leptin receptor consisting of an extracellular domain only also exists. It binds
leptin with an affinity similar to that of membrane receptors. Results from animal experiments have
demonstrated that the soluble form of leptin receptor may modulate leptin levels in plasma by
delaying its clearance and it may determine the amount of free vs. bound leptin [26]. In obese
subjects, a considerable greater proportion of leptin circulates in the free form compared to lean
individuals, and the amount of free leptin increases with increasing body mass index (BMI),
suggesting that the soluble form of this receptor is saturated in the state of obesity [27]. In addition,
short-term fasting results in a decrease of total leptin levels, which is mostly attributable to the
decrease in free leptin.
Mutations in the db gene are extremely rare in humans. The first case of leptin receptor mutation
was first described by Clement [22]. In these patients, a single G–A substitution in the splice donor
site of exon 16 resulted in a nonfunctional leptin receptor lacking both transmembrane and intra-
cellular domain. As a result of that mutation, the truncated leptin receptor is unable to activate the
STAT signal transduction pathway. Similar to the ob gene mutation in humans, human db mutation
results in hyperphagia and early-onset obesity, with BMIs reaching as high as 70 kg/m2.
TRANSPORT OF LEPTIN INTO THE CNS

Leptin is primarily secreted by adipocytes, circulates in blood (in part while linked to binding
proteins), and exerts its effects in specific regions of the brain. The delivery of leptin into the brain
represents a crucial step toward the regulation of body weight and energy balance. How leptin
gains access to specific regions in the brain is still a controversial issue. Different studies have
demonstrated the presence of leptin receptors in the brain capillaries as well as the binding of leptin
to human and mouse brain capillaries [28,29]. Potentially, the presence of leptin receptors in the
brain capillaries would allow leptin access through the capillary wall to specific regions (such as
hypothalamic nuclei) to exert its effects.
In rodents, leptin enters the brain via saturable transport mechanisms across the blood–brain
barrier. Results from the previous studies demonstrated that brain microvessels express the short
form of the leptin receptor (Ob-Ra) at a high rate. It has been suggested that the same short form
of leptin receptor, which is highly expressed in the choroid plexus (the site of cerebrospinal fluid
[CSF] production), mediates blood-to-CSF leptin transport. In fact, the experiments conducted by
Hileman and coworkers [30] on Madin–Darby canine kidney showed that the short form of leptin
receptor is capable of mediating transcellular transport of leptin. These data further suggest that
the short form of the leptin receptor expressed at the blood–brain barrier is capable of transporting
leptin from the circulation into the brain. It is also of interest to note that the receptor is preferentially
expressed on the apical membrane, which faces the bloodstream; therefore, the Ob-Ra is well
positioned to mediate the transport of leptin from the circulation into the brain. Once in the brain,
leptin can reach the neurons containing the long form signaling leptin receptor (Ob-Rb) to activate
the signal transduction pathway [30]. These data are supportive of the concept that Ob-Ra mediates
the passage of leptin across the cerebral microvessels that constitute the blood–brain barrier. Fur-
thermore, deficits in Ob-Ra function at this site could result in leptin resistance. On the other hand,
leptin is present in the CSF of Koletsky rats, which lack leptin receptors altogether, thereby
suggesting that leptin receptors are perhaps not essential for leptin receptor transport into CSF. In
addition, recent evidence from our laboratory also suggests that leptin is actually synthesized by
the human brain itself, as evident from the net leptin efflux into the internal jugular vein [19,31,32],
as well as leptin mRNA expression in human cadaver hypothalami [33,34].
Human obesity is characterized by a state of leptin resistance, which is likely caused by a

combination of resistance at the receptor and post-receptor levels, as well as reduced transport of
circulating leptin across the blood–brain barrier. A few lines of evidence have suggested impaired
leptin transport across the blood–brain barrier; for example, it has been demonstrated that obese
humans have a reduced CSF-to-serum ratio for leptin. Experimental evidence also supports the
idea of impaired leptin transport across the brain in obesity by showing that some obese animal
models that no longer respond to peripherally administered leptin can still respond to leptin given
centrally.
LEPTIN AND EATING DISORDERS

Because eating disorders such as anorexia nervosa and bulimia nervosa are characterized by
abnormal eating behaviors, dysregulation of endogenous endocrine axes, alterations of reproductive
and immune functions, and increased physical activity, extensive research has been carried out in
the last decade to ascertain a role of leptin in the pathophysiology of eating disorders. It has been
reported that plasma leptin levels are dramatically reduced in underweight anorectic patients as
compared to healthy age-matched people [35]; however, although markedly reduced, circulating
leptin is significantly and positively correlated with the person’s BMI, indicating that even at
extremely low body weight and fat circulating leptin still functions as a signal of energy stores.
Longitudinal studies have shown that, in anorexia nervosa patients undergoing refeeding during
recovery, circulating leptin levels increase progressively and reach values disproportionately higher
than compared to stable-weight healthy people [35]. It has even been suggested that hyperleptinemia
in these patients during refeeding treatment may be one of the factors making it difficult for patients
to reach and maintain their target weights. In fact, it has been demonstrated that, in patients
undergoing refeeding treatment, too rapid of a weight gain followed by hyperleptinemia is associ-
ated with poor prognosis [36].
In normal-weight patients with bulimia nervosa, plasma leptin levels have been reported to be
increased, decreased, or normal [37–39]. The reason for such a discrepancy among the results may
be due to the heterogeneous composition of the patient groups. It seems that a group of bulimic
patients hyposecreted leptin despite their body weights being similar to otherwise healthy people
[37]; therefore, even if body weight is a major determinant of circulating leptin levels, other factors
are likely to be involved in suppressing leptin production in these patients. It has been proposed
that the chronicity and severity of the illness could be determinants of the leptin hyposecretion
[37]. Although leptin does not seem to be directly involved in the pathogenesis of eating disorders,
derangements in its physiology may contribute to some clinical alterations occurring in the course
of these disorders.
MECHANISMS OF LEPTIN ACTION IN THE BRAIN

The brain has been hypothesized to be the primary site of leptin action, as peripherally administered
leptin has been shown to rapidly induce the hypothalamic signal transduction pathway. In situ
hybridization studies have shown that the Ob-Rb is predominantly expressed in hypothalamic nuclei
such as the arcuate nucleus (ARC), the dorsomedial nucleus of the hypothalamus (DMH), the
paraventricular nucleus (PVN), the ventromedial nucleus of the hypothalamus (VMH), and lateral
hypothalamus (LH). Early experimental work demonstrated that destruction of the PVN and VMH
produced hyperphagia and obesity, while lesions to the LH caused anorexia. Leptin-sensitive
neurons in the hypothalamus are known to express neuropeptides and neurotransmitters involved
in the central regulation of appetite. The long-form leptin receptor has been shown to be coexpressed
with neuropeptide Y (NPY), Agouti-related peptide (AGRP), proopiomelanocortin (POMC), and
cocaine- and amphetamine-regulated transcript (CART) in the arcuate nucleus; therefore, leptin-
sensitive neurons in the arcuate nucleus may influence other peptides involved in the regulation of
appetite. In addition, leptin is known to modulate the effects of the orexigenic peptides in the brain
by inhibiting their synthesis, such as in the case of NPY [40,41].
LEPTIN RESISTANCE IN OBESITY

The observation that high leptin levels in overweight and obese individuals fail to induce weight
loss has given rise to the notion of “leptin resistance.” Although the mechanisms underlying leptin
resistance are still a matter of considerable research, a number of biological processes hypothesized
to be involved include leptin binding to bloodborne proteins (one of which is the soluble leptin
receptor), active and passive transport of leptin into the brain, leptin receptor expression levels, and
alterations of leptin receptor second-messenger responsiveness [22]. The failure of leptin to reach
its target in the brain, in particular the hypothalamus, has received much attention. Experimental
studies provided some evidence of leptin-impaired transport across the blood–brain barrier in animal
models of diet-induced obesity [42]. Moreover, in some animal models, the delivery of leptin into
the central nervous system seems to be a crucial step toward the regulation of food intake and
energy balance. Different studies have shown the presence of specific leptin receptors in the brain
capillaries as well as the binding of leptin to brain capillaries [28,43]. Thus, the presence of the
leptin receptors on endothelial cells would suggest that leptin can gain access to the specific
hypothalamic nuclei to initiate the signaling cascade. Leptin has also been shown to be transported
by a saturable transport system, the activity of which is impaired in obesity [44].
When first discovered, leptin was thought to be secreted exclusively by adipocytes into the
bloodstream [14]. Later evidence, however, suggests that adipose tissue may not be the only site
of leptin production due to the demonstration of leptin gene expression in other tissues, such as
stomach [16], placenta [45], and skeletal muscles [46]. The results of previous studies from our
laboratory demonstrated a net efflux of leptin from the brain into the internal jugular veins [19,32].
This observation suggests that perhaps the brain itself produces leptin, which is subsequently
released into the circulation and contributes to the total leptin plasma pool [32]. In fact, leptin
mRNA expression has been shown in the rat pituitary and the brain [18].
Another possible mechanism in leptin resistance could involve defects in the leptin receptor.
A few isoforms of the leptin receptor are spliced abnormally and therefore do not result in the
appropriate signal transduction. The mutation of the db gene generates a truncated version of the
leptin receptor that lacks most of the intracellular domain. In fa/fa Zucker rats, a missense mutation
occurs in the leptin receptor. This mutation causes obesity, despite the fact that the expression of
the leptin gene is significantly augmented. These examples demonstrate that the defects in the leptin
receptor may result in leptin resistance.
An extensive search has been conducted in the human hypothalamic leptin receptors for possible
variations that would explain the leptin resistance in human obesity. The full-length functional
receptor, Ob-Rb, was found to be expressed in the human hypothalamus. In addition, no abnormal
splicing of the human leptin receptor was observed, and no difference was found in leptin receptor
mRNA expression between lean and obese individuals. Some sequence variations have been
detected in the human leptin receptor, with most variations being the single-base substitutions that
did not result in a change in the amino acid. A single-base substitution was detected in the leptin
receptor gene that results in the change of the amino acid from glutamine to arginine; however,
this substitution was detected in both lean and obese individuals, thus making it unlikely that this
polymorphism is the basis for leptin resistance in humans. A few mutations in the human leptin
receptor gene result in the truncated receptor being unable to activate the signal transduction
pathway. These mutations result in early-onset obesity, highlighting the importance of leptin in
body weight regulation in humans. Mutations in the leptin receptor gene are very rare in humans,
however.
BMI
ladder
30 19 28 25 28 38
439 bp
FIGURE 7.2 Leptin receptor (Ob-Rb) expression in the human hypothalamus of six donors of different body
mass index (BMI). No association was found between adiposity and Ob-Rb expression.
We have examined full-length leptin receptor expression (Ob-Rb) in the human hypothalamus
in males and females across a broad range of BMIs (Figure 7.2); however, we have not found any
relation between the level of its expression and adiposity, suggesting that other factors must operate
that regulate Ob-Rb levels. So, it would seem that leptin resistance cannot simply be explained on
the basis of mutations in the leptin receptor.
Because most cases of human obesity are not associated with inappropriate leptin levels or
mutated leptin receptor, a defect could lie in the signaling cascade. Suppressor of cytokine signaling
3 (SOCS-3) has been demonstrated to play a role in leptin resistance [47]. SOCS proteins are
negative regulators of the JAK/STAT signaling pathways. It has been shown experimentally that
injection of leptin stimulates the production of SOCS-3. The signaling cascade induced by leptin
binding to its receptor is blocked due to SOCS-3 binding to leptin. Although several biological
mechanisms that may participate in leptin resistance have been identified, the sequence of events
that initiate this state, as well as treatment possibilities, still remain to be determined.
LEPTIN SIGNALING PATHWAYS

It is clear that leptin and its receptors are only one of many maybe important determinants in the
control of body weight and the pathogenesis of obesity (Table 7.1). It has been proposed that two
classes of neurons account for the actions of leptin in the central nervous system: NPY- and POMC-
containing neurons (Figure 7.3).
ROLE OF NEUROPEPTIDE Y IN THE CONTROL OF FOOD INTAKE

Neuropeptide Y (NPY), a 36-amino-acid protein, is synthesized as a long precursor molecule with
the active portion at the amino end of the polypeptide. It is expressed in many areas of the brain
and acts as a transmitter in the nervous system. It selectively binds to Y1 and Y5 receptors in the
hypothalamus and is a potent stimulator of feeding. Most attention given to the role of NPY in
feeding behavior has focused on its central action in the hypothalamus, where a single injection
of NPY stimulates overeating, and its repeated administration results in obesity. NPY seems to be
a partner of leptin in the regulation of body fat through its participation in the energy balance and
neuroendocrine signaling. Leptin appears to inhibit feeding partly by suppressing the synthesis of
NPY. Not surprisingly, leptin deficiency results in elevation of the central NPY levels. To examine
the role that NPY plays in feeding behavior, scientists have examined NPY gene knockout mutants.
Because knockout NPY mutant mice birth rates follow mathematical probability calculations and
these mice have normal lives and fertility, it can be concluded that the presence of NPY is not vital
to maintain a seemingly normal feeding and body weight regulation. Although NPY is clearly
involved in the control of feeding behavior, leptin effects on body weight are only partly mediated
by its effects on NPY expression. No doubt other overlapping systems are involved in the control
of food intake and energy homeostasis.
TABLE 7.1
Neuropeptide Systems Involved in the Control of Food Intake
Orexigenic (Increase Energy Intake) Anorexigenic (Decrease Energy Intake)
Agouti-related peptide (AGRP) Leptin
Neuropeptide Y (NPY) α-Melanocyte-stimulating hormone (α-MSH)
Melanin-concentrating hormone Cholecystokinin (CCK)
Ghrelin Corticotropin-releasing factor (CRF)
Orexin Glucagon
Opioid Neurotensin
CENTRAL MELANOCORTIN SYSTEM IN THE REGULATION OF FOOD INTAKE

One of the central systems activated by leptin is the melanocortin system. The melanocortin system
refers to a family of peptide hormones and hormone receptors that controls a number of functions
in our bodies such as energy metabolism, sexual functions, and skin pigmentation. Bioactive
peptides, generated from the prohormone proopiomelanocortin (POMC), are key regulators of
appetite control and energy homeostasis. It is therefore important to understand many aspects of
POMC gene regulation, particularly in the brain, as pharmacological manipulations of POMC
expression and processing could be a potential strategy to combat obesity.
Proteolytic processing of POMC results in a number of different hormones and neuropeptides
that are mainly divided into two classes: melanocortins and endorphins. Melanocortin peptides
include adrenocorticotropin and α-, β-, γ-melanocyte-stimulating hormones (MSHs), which exert
their effects via G-protein-coupled melanocortin receptors (MC1 through to MC5). Agouti-related
peptide (AGRP) is a naturally occurring antagonist of melanocortin action. It is a neuropeptide
expressed in the arcuate nucleus of the hypothalamus that increases appetite and decreases metab-
olism. It is one of the most potent and longest lasting appetite stimulators. AGRP levels are elevated
in obese males [48]. AGRP is an endogenous antagonist at the MC3 and MC4 receptors, whereas
POMC products, such as α-MSH, act as agonists [49].
Leptin has been shown to activate AGRP-containing neurons and POMC/CART-containing
neurons in the hypothalamus via activation of the long-form leptin receptor coexpressed in these
neurons. Central infusion of leptin stimulates expression of the POMC gene while reducing expres-
sion of the AGRP gene in the arcuate nucleus of the hypothalamus. Not surprisingly, animals deficient
in either leptin or leptin-signaling pathways have increased levels of AGRP but reduced POMC levels.
Potential signaling pathways in the regulation of food intake
Fasting Overeating
Stomach ghrelin release Leptin levels Stomach ghrelin release Leptin levels
Hypothalamic NPY/AGRP -MSH Hypothalamic NPY/AGRP -MSH
Energy expenditure Food intake Energy expenditure Food intake
FIGURE 7.3 Schematic representation of the potential signaling pathways in the regulation of food intake.
The melanocortin system plays a key role in the central control of appetite and energy expen-
diture, which is highlighted by the studies showing that mice deficient in MC4 receptors, as well
as mice with increased levels of AGRP, are obese. In humans, mutations in the α-MSH gene also
lead to obesity. Abnormalities in the melanocortin system produce obesity through changes in
appetite and food intake; moreover, melanocortin agonists have been shown to suppress appetite.
Animals and humans with defects in the central melanocortin system display a characteristic
melanocortin obesity phenotype typified by increased adiposity, hyperphagia, metabolic defects,
and increased linear growth.
GHRELIN EFFECTS IN THE HYPOTHALAMUS

The hormone ghrelin is expressed mainly in the stomach. It was initially discovered as the endog-
enous ligand of the growth hormone secretagogue receptor type 1a [50]. Now it is also known to
participate in the regulation of energy homeostasis. It is the only known systemic signal to date to
promote a positive energy balance by stimulating food intake and decreasing fat oxidation [51].
During fasting, ghrelin levels are increased; however, they fall after meals. As such, this hormone
plays a critical role in signaling the brain when we are hungry or full and has become an important
focus of obesity research.
In both rodents and humans, ghrelin acts to increase hunger through its actions on the hypo-
thalamic feeding centers. It has been shown that ghrelin-dependent food intake is at least partially
mediated by its action in the arcuate nucleus [52]. The neurons of the arcuate nucleus are also
known to express NPY and AGRP. In fact, it has been demonstrated that ghrelin increases the
expression of these two orexigenic peptides [52], which perhaps suggests indirect action of ghrelin
on food intake via the NPY/AGRP signaling pathway.
Evidence has been found that ghrelin administration in humans leads to reported sensations of
hunger. Ghrelin administration in the experimental setting leads to increased AGRP and NPY mRNA
levels in the arcuate nucleus of the hypothalamus [52]. This perhaps indicates that AGRP/NPY
neurons are the primary target of the orexigenic effects of ghrelin in the hypothalamus.
In a recent elegant study, Theander-Carrillo et al. [53] reported that, apart from ghrelin’s
stimulation of appetite, it also has an effect on adipocyte metabolism. In white adipocytes, ghrelin
caused glucose and triglyceride uptake, increased lypogenesis, and inhibited lipid oxidation; in
brown adipose tissue, ghrelin inhibited the expression of uncoupling proteins, which usually
contribute to energy expenditure [53].
Ghrelin can also regulate feeding through the inhibition of leptin. Leptin receptors are found
in the hypothalamus, including the arcuate nucleus, and hypothalamic NPY-positive neurons are
the target of leptin action. Leptin suppresses arcuate NPY mRNA expression, and ghrelin can
reverse leptin-induced downregulation of NPY expression, thereby inhibiting leptin effects. It would
seem, then, that leptin and ghrelin share the hypothalamic NPY/AGRP signaling pathway.
CONCLUSIONS
Nothing seems simpler or more natural than eating; yet, every article on feeding behavior empha-
sizes how complex it is. Feeding behavior has intrigued scientists for centuries, but it was not until
the late 1990s that the most amazing discoveries were made. The discovery of the fat-derived
peptide leptin set in motion an intense research effort to better understand the genetic, hormonal,
and neurochemical basis of obesity. No other hormone has drawn more attention than leptin in
studies on the control of body weight and appetite. Several neuropeptides and transmitters have
been identified and shown to be mediators of the central actions of leptin, with POMC and NPY
having opposing effects. It is unlikely that leptin has evolved to prevent obesity, because high
circulating leptin does not prevent the development of obesity.
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8 Leptin as a Vasoactive
Adipokine: Link Between
Metabolism and Vasculature
Anne Bouloumié, Cyrile Anne Curat, Alexandra Miranville,
Karine Lolmède, and Coralie Sengenès
CONTENTS
Introduction ......................................................................................................................................93
Central Effects of Leptin .................................................................................................................94
Energy Homeostasis..................................................................................................................94
Blood Pressure ..........................................................................................................................95
Peripheral Effects of Leptin.............................................................................................................96
Fatty Acid Metabolism .............................................................................................................96
Vascular Wall Homeostasis.......................................................................................................96
Vascular Tone.....................................................................................................................97
Vascular Wall Remodeling ................................................................................................97
Conclusion........................................................................................................................................99
References ......................................................................................................................................100
INTRODUCTION
The discovery of leptin has opened up new perspectives and introduced new concepts regarding
our understanding of the regulation of the body weight. With recognition of its important endocrine
activity, adipose tissue has acquired a central role in the regulation of energy homeostasis but also
in the immune function and reproductive capacity. Obesity is frequently clustered with a number
of cardiovascular risk factors such as insulin resistance, diabetes mellitus, hyperlipidemia, and
arterial hypertension, commonly referred to as the metabolic syndrome. Although each component
of the metabolic syndrome may contribute to the increased risk of cardiovascular disease observed
in obesity, the adipose tissue may also directly influence the pathogenesis of hypertension and
atherosclerosis by the secretion of adipocytokines and more particularly leptin. Leptin is an adi-
pocyte-derived hormone [1–3] that exhibits structural similarities with the cytokine family. Other
tissues also express leptin, although at lower levels, including placenta, ovaries, skeletal muscle,
stomach, pituitary, and liver [4]. Leptin gene expression in adipocyte is regulated in the context of
hormonal and nutritional status (Table 8.1) [5].
93
TABLE 8.1
Regulation of Leptin Expression
Upregulation Downregulation
Refeeding Fasting/dieting
Insulin/glucose β-Adrenoceptor agonists
Oestrogens Androgens
Glucocorticoids PPARγ agonists (thiazolidinediones)
TNFα/IL-1 Cigarette smoking
Acute inflammation
CENTRAL EFFECTS OF LEPTIN

The interest in leptin focused initially on appetite and body weight regulation (Figure 8.1).
ENERGY HOMEOSTASIS
Leptin acts as an afferent satiety signal influencing the central regulation of food intake and energy
expenditure via central leptin receptors. Fasting and dieting induce a fall in leptin, thus signaling
the brain to initiate adaptive responses, such as suppression of reproductive and thyroid function
and stimulation of the hypothalamic–pituitary–adrenal axis.
Two genetic obese animal models, the ob/ob and db/db mouse, have been extensively investigated,
the former being defective in leptin synthesis and the latter in leptin receptor function. Several isoforms
(a through f) of the leptin receptor (Ob-R) exist as a result of alternative mRNA splicing [6]. Db/db
mice lack the llong isoform of the Ob-R (Ob-Rb) that has a cytoplasmic domain required for activation
of signal transducers and activators of transcription (STATs) but still express the four other isoforms
of the leptin receptor (the lshort isoforms: Ob-Ra, Ob-Rc, Ob-Rd, and Ob-Re). The short isoforms
exhibits abbreviated intracellular amino acid sequences and have little intracellular signaling capacity
[6]. Their physiological role is less clear. The short isoforms Ob-Ra and Ob-Rc seem to be important
for blood–brain barrier function [7], whereas the circulating Ob-Re isoform might play a role in
preventing the hormone from degradation and clearance. The long form leptin receptor belongs to
the cytokine receptor superfamily coupled to the Janus kinase (JAK)/STAT pathway. This pathway
is essential for the regulation of energy homeostasis by leptin but not for the leptin-dependent control
of reproductive function and glucose homeostasis [8]. Activation of the phosphoinositol 3-kinase-
dependent pathways [9] as well as inhibition of AMP-activated protein kinase (AMPK)-dependent
pathways [10] are also involved in the control of appetite and weight loss by leptin.
Hypothalamus
Decreases food intake
Increases energy expenditure
LEPTIN
Skeletal muscle, liver, adipose tissue Pancreas

Increases FA oxidation Modulates insulin secretion
Increases lipolysis
Decreases lipogenesis
FIGURE 8.1 Central and peripheral effects of leptin on energy homeostasis.

Leptin as a Vasoactive Adipokine: Link Between Metabolism and Vasculature 95
Hypothalamus
Increases
sympathetic nerve activity
Blood vessel LEPTIN Kidney

Balance Sodium and
Endothelin-1/nitric oxyde water retention
FIGURE 8.2 Central and peripheral effects of leptin on blood pressure
Although some cases of leptin deficiency in humans have been reported, most obese subjects
and animals with diet-induced obesity are characterized by elevated systemic leptin concentra-
tions. Those observations have led to the concept of a hypothalamic leptin-resistant state that is
associated with obesity due to the action of leptin on body weight and appetite [11]. Suppressor
of cytokine signaling (SOCS) proteins have emerged recently as a potential mechanism of leptin
resistance. In the hypothalamus, SOCS-3 is thought to participate in the physiologically negative
feedback of leptin signaling by its inhibition of JAK activity once activated by STAT-3 [12].
SOCS-3 haploinsufficiency or brain SOCS-3 deficiency increases leptin sensitivity and protects
mice against the development of high-fat, diet-induced obesity [13,14]. Thus, SOCS-3 appears
to be an important mechanism of leptin resistance, suggesting that targeting SOCS-3 may be an
interesting therapeutic approach for the treatment of obesity and associated diseases. Protein
tyrosine phosphatase 1B (PTP1B) is another negative regulator of leptin signaling that might
contribute to leptin resistance. Mice lacking PTP1B exhibit enhanced leptin sensitivity and are
protected from diet-induced obesity [15,16]. Inhibition of this pathway is also considered as a
potential target for anti-obesity drugs.
BLOOD PRESSURE
In addition to its effect on appetite and energy homeostasis, leptin also affects blood pressure
(Figure 8.2). A positive correlation has been found between mean blood pressure and leptin
serum levels in lean subjects with essential hypertension [17]. Leptin acts in the hypothalamus
to increase blood pressure through activation of the sympathetic nervous system [18]. Adminis-
tration of leptin to ob/ob mice increases arterial pressure, despite a reduction in food intake and
body weight, as well as urinary catecholamine. Because blood pressure normalized after acute
alpha adrenergic or ganglionic blockade, it appears that leptin exerts a sympathetically mediated
pressor response [19]. Long-term sympathoactivation could raise arterial pressure by causing
peripheral vasoconstriction and by increasing renal tubular sodium reabsorption (Figure 8.2).
Leptin was shown to increase sympathetic activity to the kidney and extremities [20]; in humans,
obesity is associated with increased sympathetic activity to the kidney [21]. Leptin may thus
represent a link between excess adiposity and increased cardiovascular sympathetic activity in
human obesity leading to hypertension [22].
The observation that in Agouti mice (a genetically induced obesity rodent model characterized
by a resistance to the anorexic and weight-reducing effect of leptin) the renal sympathoactivation
of leptin is preserved [23] has led to the concept of a selective hypothalamic leptin resistance.
The mechanisms underlying the selective hypothalamic leptin resistance are not well defined.
Several hypotheses have been suggested. In diet-induced obese mice, the inability of leptin to
activate leptin signaling pathways such as STAT3 proteins has been shown to be restricted to the
arcuate nucleus, where a specific upregulation of SOCS-3 was found [24]. Because leptin-induced
increases in renal sympathetic activity and blood pressure are mediated by the ventromedial and
dorsomedial hypothalamus [25], it has been suggested that the leptin resistance associated with
obesity is restricted to a specific hypothalamic area such as the arcuate nucleus. The selectivity
in leptin resistance may also relate to the divergent signaling pathways downstream from the
leptin receptor, depending on the physiological processes [26].
PERIPHERAL EFFECTS OF LEPTIN

The signaling form of the leptin receptor, initially described as being expressed only in the
hypothalamus, is also found in peripheral tissues.
FATTY ACID METABOLISM

The Ob-Rb is expressed on the major tissues involved in the regulation of glucose and fatty acid
metabolism, pancreas, adipose tissue, muscle, and liver (Figure 8.1). The presence of Ob-Rb in
pancreatic islets [27] indicates that leptin can directly regulate the secretion of insulin in rodents,
although inconsistent findings have been reported [28,29]. In other metabolically active tissues, a
clear effect of leptin is the promotion of energy dissipation through the stimulation of fatty acid
(FA) oxidation and prevention of ectopic lipid deposition [30]. In adipocytes, leptin directly
decreases lipogenesis [31], increases the enzymes involved in FA oxidation, and stimulates a novel
form of lipolysis in which glycerol is released without a proportional release of free fatty acids
[32]. In liver and muscle, leptin also inhibits lipogenesis and stimulates FA oxidation [33]. The
mechanisms underlying these actions of leptin may be the leptin binding to its receptor with
succeeding activation of the JAK/STAT pathway; the direct stimulation of the AMPK [34], which
will phosphorylate and thereby inhibit acetyl-CoA carboxylase activity and lipogenesis; and inhi-
bition of expression of the sterol regulatory element-binding protein 1c (SREBP-1c) [35].
The lack of adipose tissue and thus leptin, as observed in lipodystrophy or incorrect leptin
action, is associated with ectopic fat deposition in liver, pancreas, and muscle [33]. Administration
of leptin to lipodystrophic patients [36] or to rodent models of leptin deficiency [37] reverses many
lipotoxic effects, in part due to the direct effects of leptin on lipid metabolism; however, the impact
of hyperleptinemia in the peripheral regulation of metabolic fluxes under the background of insulin
resistance remains to be determined in obese people.
VASCULAR WALL HOMEOSTASIS

The blood vessel wall is composed of three different layers: intima, media, and adventitia. The
intima is a monolayer of endothelial cells that separates circulating blood from the underlying
media. The media consists of concentric layers of smooth muscle cells and elastic lamella. The
outer layer of the vessel, the tunica adventitia, is formed of collagen and elastic fibers, fibroblasts,
and vasa vasorum. With the discovery of nitric oxide (NO) as an endothelium-derived relaxing
factor in the 1980s, the endothelial layer has acquired the status of a paracrine tissue, the integrity
of which is necessary for vascular homeostasis. Through its production of contractile and relaxant
factors, the endothelium regulates the medial function but also a wide range of proatherogenic and
inflammatory processes such as platelet activation and aggregation, proliferation and migration of
smooth muscle cells, and infiltration of inflammatory cells within the vessel wall [38]. Endothelial
dysfunction mainly characterized by an impaired NO production or bioavailability is observed in
obesity [39] and is considered as one of the primary event in the genesis of cardiovascular diseases.
Although mechanisms linking obesity with endothelial dysfunction have not yet been fully clarified,
several observations suggest that hyperleptinemia might contribute to endothelial dysfunction.
Indeed, in obese women leptin was positively correlated with plasma levels of soluble thrombo-
modulin (sTM) and vascular cell adhesion molecule 1 (VCAM-1), two markers of endothelial
activation [40]. This relationship was independent of body mass index (BMI), waist-to-hip ratio
(WHR), C-reactive protein (CRP), and insulin sensitivity. Many blood vessels are surrounded by
adipose tissue in variable amounts. Several works [41,42] support the hypothesis of a paracrine
role of white adipose tissue in the regulation of vascular function. An increasing number of reports
suggests that the periadventitial adipose tissue has a pathophysiological role in the vascular dys-
function associated with obesity [43–45].
We and others have described the expression of Ob-Rb in human endothelial cells [46,47].
Later, Ob-Rb was also found in smooth muscle cells [48] as well as in platelets [49] and inflam-
matory cells [50].
Vascular Tone
Vascular tone is regulated through the actions of locally produced factors. NO is a critical modulator
of blood flow and is released by the endothelium in response to shear stress, thereby playing an
important role in flow-mediated vasodilation. Endothelial release of NO opposes the vasoconstrictor
effects of norepinephrine, endothelin-1, and angiotensin II. Endothelin-1 is one of the most potent
vasoconstrictor factors produced in the arterial wall. Vascular tone in health reflects the balance of
these opposing factors. Several observations suggest that hyperleptinemia may contribute to the
alteration of endothelial-dependent dilation in the obese. For example, plasma leptin correlates
inversely with the extent of NO-dependent coronary vasodilation in healthy obese males [51], and
obese-related concentrations of leptin infused to anesthetized dogs induce impairment of acetyl-
choline-induced dilations of the coronary arteries, suggesting that hyperleptinemia produces sig-
nificant coronary endothelial dysfunction [52]. In contrast, however, no relationship between plasma
leptin and flow-mediated dilatation of the brachial artery was found in healthy adolescents [53] or
in normolipidemic healthy obese women [54]. Those observations suggest that the hyperleptinemia-
dependent effect on vascular tone is dependent on the vascular bed location.
Nitric Oxide Production
Direct vasodilatory actions of leptin have been inconsistently reported. It appears that any direct
effects of leptin on the endothelial-dependent production of NO may be restricted to some vascular
beds and that they are generally insufficient to oppose sympathetically mediated vasoconstriction
[55,56]. Fruhbeck [57] reported that acute administration of leptin increases endothelial NO release
and decreases blood pressure in anesthetized Wistar rats. Such an effect is only observed in
sympathectomized rats, suggesting that leptin-dependent activation of the sympathetic nervous
system offsets the vasodilatory effect of leptin [58]. The mechanism by which leptin induces NO
production in some vascular beds is in part related to activation of the Akt–endothelial nitric oxide
synthase phosphorylation pathway [59].
Endothelin-1 Production
Leptin at high concentrations upregulates endothelin-1 production in vitro in human umbilical vein
endothelial cells (HUVECs) [60]. Because endothelin-1 exerts a potent direct vasoconstrictive effect
but also may itself reduce bioavailable NO, increased vascular production of endothelin-1 has been
suggested as a potential mechanism for endothelial dysfunction associated with obesity [39,61].
Consistent with such a hypothesis, blockade of endothelin-A (ETA) receptors induces significant
vasodilation in overweight and obese patients but not in lean hypertensive subjects [62].
Vascular Wall Remodeling
After the West of Scotland Coronary Prevention Study (WOSCOPS) demonstrated that hyperlep-
tinemia is an independent risk factor for coronary heart disease [63], recent studies have confirmed
a role for increased leptin concentration in cardiovascular disease [64–66]. Reilly et al. [67] reported
an association between plasma leptin levels and the degree of coronary artery calcification in type
2 diabetic patients after controlling for traditional indices such as obesity and C-reactive protein.
Leptin levels are increased in non-diabetic patients with restenosis after stenting, whereas no
differences were demonstrated in patients without restenosis and in control subjects [68]. Finally,
leptin impairs vascular compliance [53]. An increase in vascular stiffness has long-term adverse
effects on the cardiovascular system by increasing impedance to blood flow and thereby increasing
cardiovascular work and contributing to the development of left ventricular hypertrophy [69]. In
animal models, neointimal formation after endovascular arterial injury is markedly attenuated in
db/db mice [70], whereas it is promoted by leptin in normal strains [71]. The pathobiology of
restenosis in stented arteries is linked to neointimal hyperplasia. Atherosclerotic lesions are the
result of an excessive proliferative and inflammatory response that involves several cellular events,
including smooth muscle cell migration and proliferation, inflammatory cell infiltration, neovascu-
larization, production of extracellular matrix, and accumulation of lipids [72]. Leptin signaling has
been implicated in the promotion of atherosclerosis [73]. Indeed, in vivo, the expression of leptin
receptors are increased in atherosclerotic lesions [74,75], and leptin signaling promotes atheroscle-
rosis in mice models [76,77]. In vitro proatherogenic effects of leptin include endothelial cell
activation, migration, and proliferation; smooth muscle cell proliferation, migration, hypertrophy,
and calcification; activation of monocytes; and modulation of the immune response as well as
platelet aggregation.
Leptin and Endothelial Cells
Neovascularization within the plaque is known to be essential in the atheromatous plaque formation
[78,79]. Atherosclerotic aortic plaques have demonstrated a marked increase in Ob-Rb immunore-
activity, predominantly in foam cells, vascular smooth muscle cells, and the vascular endothelial
lining of intimal neovessels [80]. Bouloumié et al. [46] and others [47] showed that leptin increases
in vitro the proliferation and migration of endothelial cells and promotes the formation of new
blood vessels in vivo on various angiogenic models. Such a proangiogenic effect of leptin has been
suggested to contribute to the growth of the fat mass itself, as the development of the adipose tissue
is dependent on its own vasculature [81], as well as to the progression of atheromatous plaques
[80] and neointimal hyperplasia after endothelial damage.
Endothelial cells play an important role in the initiation and maintenance of inflammatory
processes and acute tissue injuries. Indeed, activation of the endothelial cell surface leads to the
expression of several adhesion molecules as well as chemokines that promote the adhesion and
transmigration of circulatory inflammatory cells into the vascular wall (Figure 8.3). The adhesion
of bloodborne monocytes and migration through the endothelial surface is a prerequisite for the
monocyte–macrophage conversion. Curat et al. [82] recently demonstrated that in vitro leptin at
high concentration promotes the adhesion as well as the transmigration of human blood monocytes
through the endothelial cell layer. Moreover, Bouloumié et al. [83] and others have shown that
leptin leads to the increased endothelial expression of monocyte chemotactic protein 1 (MCP1).
Furthermore, this effect is dependent on the leptin-induced production of reactive oxygen species
[83,84]. It is thus tempting to speculate that the intracellular accumulation of oxidant radicals
stimulated by high leptin concentrations and the consecutive expression of MCP1 in endothelial
cells might play a key role in the infiltration of inflammatory cells within the vessel wall. In addition,
chronic endothelial oxidative stress under hyperleptinemia, as in human obesity, might be involved
in the genesis of endothelial dysfunction linked to atherosclerosis through a direct interaction with
NO to form a more harmful oxygen radical compound, the peroxynitrite, thus leading to a decreased
NO bioavailability (Figure 8.3).
Leptin and Smooth Muscle Cells
High leptin concentrations stimulate the proliferation and migration of smooth muscle cells [85]
as well as smooth muscle cell hypertrophy through the p38 MAP kinase pathway [86]. Moreover,
leptin at obese-relevant concentrations promotes the accumulation of reactive oxygen species in
human smooth muscle cells [87]. Finally, Parhami et al. [75] demonstrated that leptin enhances the
calcification of vascular cells.
Blood monocyte
Rolling
Adhesion adhesion
Chemokines molecules Transmigration
Endothelial
cell Oxidative stress
LEPTIN Macrophage
NO oxLDL
Foam cell
FIGURE 8.3 Hyperleptinemia and endothelial dysfunction.
Leptin and Inflammation

Inflammatory reactions in the vascular wall play an important role in the development of athe-
rosclerosis and in plaque destabilization and rupture; consequently, systemic markers of inflamma-
tion (in particular, CRP) are independent risk factors of cardiovascular events [88]. CRP exerts
many proatherogenic effects, including impairment of endothelial NO production, activation of
vascular smooth muscle cells, and stimulation of monocyte adhesion to endothelial surfaces [89].
Leptin exerts strong proinflammatory and immunostimulatory effects [90]. Leptin, per se, acts on
monocytes and macrophages by inducing their release of proinflammatory cytokines, oxygen
radicals, and eicosanoids [91–93]. Leptin also affects natural killer (NK)-cell development and
activation both in vitro and in vivo [94]; moreover, leptin has been demonstrated to also modulate
adaptive immune response [95]. In addition, inflammatory stimuli have previously been shown to
induce elevated systemic leptin concentrations [96], suggesting that leptin induction is part of the
ubiquitous acute-phase reaction. In agreement with this notion, plasma leptin has been demonstrated
to correlate with acute-phase reactants, such as CRP, in both normal weight and obese subjects
[97–99]. Taken together, these data suggest that leptin might contribute to the proinflammatory
state associated with obesity.
Leptin and Platelets
Human obesity is associated with an elevated risk for arterial and venous thrombosis [100], and
hyperleptinemia has been suggested to play a role in the development of atherothrombotic disease
in obesity [101,102]. Platelets express the leptin receptor, and leptin potentiates platelet aggregation
through a leptin-receptor-dependent mechanism [49,103]. Leptin-deficient ob/ob mice have delayed
and unstable thrombus formation after arterial injury, and leptin normalizes this phenotype [104],
whereas inhibition of endogenous leptin protects mice from arterial and venous thrombosis [105].
CONCLUSION
Leptin is now well recognized as an adipose-tissue-originating signal that informs the hypothalamus
about the amount of energy stored, resulting in modulation of metabolic fluxes, energy intake, and
energy expenditure, as well as reproductive capacity and immune functions. Leptin-dependent
regulation of vascular tone according to the vessel bed location certainly plays an important role
in the efficiency of oxygen and nutrient delivery to tissues and the subsequent effectiveness of
metabolic activities. Such effects on vascular reactivity are similar to those of insulin [106]. Despite
this acute action of leptin, the majority of studies performed to date indicate that chronic hyper-
leptinemia is atherogenic. Although it is not clear whether or not hyperleptinemia is associated
with the development of a peripheral leptin resistance, high concentrations of leptin are known to
increase oxidative stress in endothelial cells. The long-term consequences of oxidative stress may
include reductions in NO bioavailability and increases in the expression of adhesion molecules and
chemokines that mediate vascular inflammation and atherogenesis. Furthermore, the associated
metabolic changes that occur in the insulin-resistant state (e.g., increased levels of plasma fatty
acids) associated with obesity are also known to impair endothelial function. Thus, hyperleptinemia
together with insulin resistance might exert powerful detrimental effects on the vascular wall,
leading to the genesis of vascular pathologies associated with obesity [107,108].
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9 Overview of Ghrelin,
Appetite, and Energy Balance
Rafael Fernández-Fernández and Manuel Tena-Sempere
CONTENTS
Introduction ....................................................................................................................................105
Discovery of Ghrelin......................................................................................................................106
Structure of Ghrelin and Its Functional Receptor, GHS-R...........................................................106
Distribution and Biological Functions of Ghrelin: An Overview.................................................107
Ghrelin and the Control of Appetite: Major Effects and Mechanisms of Action ........................108
Regulation of Ghrelin Levels and Interaction with Leptin System ..............................................109
Ghrelin as a Neuroendocrine Integrator Linking Energy Status and Other Key Functions ........111
Major Conclusions and Future Perspectives .................................................................................111
Acknowledgments ..........................................................................................................................112
References ......................................................................................................................................112
INTRODUCTION
Homeostatic control of energy balance is a key biological function essential for the survival of
individuals and species. Maintenance of the energy status of an organism critically relies on the
dynamic balance between energy expenditure and food intake. In this equation, expression of
appetite (defined as the motivational drive toward an energy source) appears as a pivotal, highly
regulated phenomenon, based on the complex physiological interaction of afferent signals (which
promote or inhibit appetite) and effector mechanisms (which restrain or get into motion the drive
toward food intake). Among the former, multiple peripheral factors, arising mostly from the adipose
tissue, pancreas, and gastrointestinal tract, have been identified in the last decades as powerful
regulators of central circuits at the hypothalamus, as well as in the brainstem and limbic system.
At those sites, such factors actively modulate neuropeptide release and, thereby, participate in the
control of food intake and energy expenditure [1,2].
In this context, leptin is probably the most illustrative paradigm of a peripheral regulator of
energy balance. Leptin was originally identified in 1994 as a secreted hormone, primarily produced
in the white adipose tissue and displaying a very potent satiating activity. Interestingly, circulating
leptin levels were demonstrated to directly correlate with the amount of adiposity; therefore, leptin
appeared to serve an essential function in signaling the amount of body energy stores to the
hypothalamic centers controlling food intake, thus contributing to body weight homeostasis [3,4].
Indeed, a wealth of experimental and epidemiological evidence gathered in the last decade has
fully confirmed the crucial role of leptin in the control of metabolism and energy balance. Moreover,
identification of leptin in the mid-1990s, coinciding with the exponential increase in the prevalence
of obesity and other weight disorders, boosted an extraordinary activity in terms of basic and clinical
research aimed at identifying the molecular and physiological basis for the dynamic regulation of
body weight. This research activity has not only helped to characterize the physiology of leptin
105
but has also significantly contributed to expanding our knowledge on the molecules and networks
involved in the dynamic control of food intake. One of these molecules turned out to be the gut-
derived hormone ghrelin.
DISCOVERY OF GHRELIN
The gastric hormone ghrelin was originally identified by Kangawa et al. in late 1999 (at the National
Cardiovascular Center Research Institute in Osaka, Japan) during their search for an endogenous
ligand of the growth hormone secretagogue receptor (GHS-R) [5,6]. Cloning of ghrelin was the
endpoint of a long search for the endogenous counterpart of a large family of peptidyl and non-
peptidyl synthetic compounds, globally termed growth hormone secretagogues (GHSs), with the
ability to elicit the release of growth hormone in vivo and in vitro in a wide spectrum of species,
including humans [7,8]. Synthesis of the first GHSs dates back to the late 1970s, when Bowers
and coworkers [9] reported that some synthetic peptide analogs of metenkephalin, although devoid
of any opioid activity, specifically induced GH secretion. Although early GHSs showed very weak
activity, further development of many peptide- and non-peptide-related molecules led to the gen-
eration of much more potent GH secretagogues; thus, GHRP-6 was the first hexapeptide shown to
actively release GH in vivo [10], and it is still considered the gold standard for peptidergic GHSs.
Among non-peptidyl members of the family, MK-0677 is probably the most representative GHS,
showing a potent GH-releasing effect even after oral administration [11].
A major breakthrough in the course of identification of ghrelin was the cloning in 1996 of the
GHS receptor (GHS-R), distinct from that of the major elicitor of GH release, the GH-releasing
hormone receptor (GHRH-R) [12]. This provided conclusive evidence for the existence of a natural
counterpart of GHSs: the endogenous ligand of GHS-R. Moreover, discovery of GHS-R allowed
the implementation of routines for identification of its ligand using an orphan receptor strategy.
Given the prominent expression of GHS-R reported at the pituitary and hypothalamus (among other
central areas), its potential ligand was expected to exist also in the brain [13]. The weak activation
of GHS-R reporter systems by brain extracts, however, suggested that such a ligand might be present
only at low levels at this site. Instead, a very prominent expression of this molecule was finally
demonstrated by Kojima and coworkers [5] in rat stomach extracts. This molecule turned out to be
a 28-amino-acid peptide, highly conserved between rat and human species, harboring an essential
n-octanoyl modification at Ser3. This molecule was named “ghrelin” from the Proto-Indo-European
root ghre, which means growth, and the suffix relin, for its reported GH-releasing activity [5].
STRUCTURE OF GHRELIN AND ITS

FUNCTIONAL RECEPTOR, GHS-R
The functional ghrelin peptide results from the cleavage of a precursor form, the preproghrelin,
which is composed of 117 amino acids. In the human and rat, the mature ghrelin peptide consists
of 28 amino acids, with divergence in 2 residues only [5]. Even in non-mammalian species, such
as chicken, the sequence homology is rather high (54% identity with human ghrelin) [14]. In the
rat, a second form of the peptide, termed des-Gln(14)-ghrelin, has been described. Its biological
activity and sequence are identical to ghrelin, except for the lack of one glutamine in position 14
[15]; however, this variant is present only in low amounts in the stomach, indicating that 28-amino-
acid ghrelin is the main active form of the molecule [16]. Interestingly, although no obvious
structural homology between ghrelin and peptidyl GHSs was found, the gastric peptide motilin
was shown to share 36% structural homology with ghrelin [17]. In fact, after the discovery of
ghrelin, Tomasetto et al. [18] reported the identification of a gastric peptide called motilin-related
peptide (MTLRP) [18], whose amino acid sequence was identical to preproghrelin, except for the
lack of Ser26 [18]. In terms of its structure–function relationship, the N-terminal seven-amino-acid
Overview of Ghrelin, Appetite, and Energy Balance 107
stretch of ghrelin is very well conserved across vertebrate species [19], suggesting that this region
is relevant for its biological functions.
Another highly conserved (and rather unique) feature of ghrelin molecule is the addition of an
n-octanoyl group at Ser3, which appears essential for most of its biological activities [5]. Such a
posttranslational modification (acylation) is the first reported in a secreted protein [20]; yet, acyl
modifications had been previously observed in G proteins and membrane-bound receptors. The
enzymatic system responsible for acylation of ghrelin is yet to be identified, while the biological
roles, if any, of unacylated ghrelin (whose concentration in plasma largely exceeds that of mature
ghrelin) have remained largely neglected. Nonetheless, compelling evidence has been recently
presented demonstrating that des-acyl ghrelin is not merely an inert form of the molecule [21,22].
The biological actions of ghrelin are mostly conducted through interaction with its specific cell
surface receptor, namely the GHS-R. The cognate ghrelin receptor belongs to the large family of
G-protein-coupled, seven-transmembrane-domain-spanning receptors [12,23]. This receptor is
highly expressed at central neuroendocrine tissues such as the pituitary and hypothalamus [13].
Two GHS-R subtypes, generated by alternative splicing of a single gene, have been described: the
full-length type-1a receptor and the truncated type-1b receptor [12,23]. The GHS-R1a is the
functionally active, signal-transducing form of the receptor. In contrast, the GHS-R1b lacks the
transmembrane domains 6 and 7, and it is apparently devoid of high-affinity ligand-binding and
signal-transduction capacity [26]. Thus, its functional role, if any, remains unclear. In addition,
evidence for GHS-R1a-independent biological actions of ghrelin, as well as of synthetic GHSs,
has been presented recently [21,23]. These seem to include (at least some of) the potential weight
gain-promoting effects of ghrelin [24]; however, the search for ghrelin receptors other than GHS-R
has not yet provided conclusive evidence.
DISTRIBUTION AND BIOLOGICAL FUNCTIONS

OF GHRELIN: AN OVERVIEW
Despite its identification in the context of GH control, in recent years it has become evident that
the biological actions of ghrelin are much wider than those originally anticipated. Indeed, a striking
feature of ghrelin is its widespread pattern of distribution [21,22]. Thus, while the peptide was
initially isolated from the stomach (which is undoubtedly the major source of circulating ghrelin),
ghrelin expression has been also demonstrated in an array of tissues and cell types, including small
intestine, pancreas, lymphocytes, placenta, kidney, lung, pituitary, brain, and the gonads [21,22,
25,26]. Overall, such a ubiquitous pattern of expression strongly suggests that, in addition to
systemic actions of the gut-derived peptide, locally produced ghrelin might be provided with
paracrine/autocrine regulatory effects in different tissues, the physiological relevance of which
awaits to be completely defined.
In terms of endocrine function, the first biological effect assigned to ghrelin was the ability to
elicit GH secretion, as predicted by its capacity to activate GHS-R1a in cell reporter systems. This
GH secretagogue action is conducted both at the pituitary and the hypothalamus, where ghrelin
has been proven to regulate GH-releasing hormone and somatostatin systems [27]. Yet, the impor-
tance of gut-derived ghrelin in the control of GH secretion remains controversial. In addition, a
wealth of data has now demonstrated that ghrelin may serve additional central neuroendocrine
functions, such as modulation of lactotropic, corticotropic, and gonadotropic axes [25,26]. Indeed,
ghrelin has been proposed to be a putative neuroendocrine integrator linking the function of several
endocrine systems essential for survival. These likely include the neuroendocrine networks respon-
sible for the control of body weight and energy balance, as reviewed in detail later in this chapter.
Finally, in addition to the endocrine actions of ghrelin summarized above, solid evidence has
been presented recently showing that ghrelin is also involved in the regulation of quite diverse
peripheral non-endocrine functions. These include regulation of gastric motility and acid secretion,
various effects upon the cardiovascular system, and modulation of glucose metabolism (and pan-
creatic insulin secretion), as well as control of adipogenesis and cell proliferation. Detailed descrip-
tions of these functional properties of ghrelin exceed the goals of this chapter and have been recently
provided elsewhere [20–22].
GHRELIN AND THE CONTROL OF APPETITE:

MAJOR EFFECTS AND MECHANISMS OF ACTION
Undoubtedly, the facet of ghrelin physiology that has attracted the most attention is its ability to
promote food intake. Considered in retrospect, the fact that ghrelin has been shown to enhance
body weight should not be considered totally unexpected, given previous reports of the ability of
GHSs to stimulate food intake. Nonetheless, these effects of GHSs had remained largely neglected
[21]. Thus, the demonstration in 2000 that administration of ghrelin efficiently induced body weight
gain [28] opened up a new dimension of ghrelin biology focused on characterization of the effects
and mechanisms of action of this gut-derived hormone in the control of appetite and energy balance.
Undisputed evidence indicates that the administration of ghrelin to rodents stimulates food
intake [28], an effect that is far more potent after intracerebral delivery of the peptide, which
suggests a primary central site of action. The relevance of central vs. peripheral ghrelin in the
control of food intake remains controversial, mainly due to conflicting data on the expression of
only minute amounts of ghrelin at the hypothalamus. Nonetheless, the importance of ghrelin/GHS-R
signaling in the homeostatic control of body weight is supported by the observed decrease in food
intake after antisense disruption of GHS-R at the hypothalamus [29] and the effects of centrally
and peripherally injected ghrelin on body weight [21]. Although the potency of systemically derived
ghrelin in terms of food intake induction is somewhat modest, the latter is a rather unusual feature,
as virtually all of the orexigens known to date are only effective when acting centrally. This has
led to the conclusion that ghrelin is the most important, if not the only one, appetite stimulant in
the bloodstream [30], and that it may serve an important role as a meal-initiating signal as well as
in the long-term regulation of body weight in combination with leptin.
The central circuitries whereby ghrelin conducts its modulatory actions upon food intake have
been exhaustively explored in the last years. Assuming a bipartite model of food intake control at
the hypothalamus, with neuropeptide Y (NPY) and Agouti-related peptide (AGRP) neurons as major
orexigenic effectors and proopiomelanocortin (POMC) and cocaine- and amphetamine-regulated
transcript (CART) neurons as major anorexigenic effectors, ghrelin has been demonstrated to
modulate expression of some (if not all) of the elements of this network. Thus, ghrelin appears to
enhance AGRP and NPY after acute and chronic administration — actions that might contribute
to the observed short- and long-term effects of ghrelin on body weight gain [21]. In addition, ghrelin
has been shown to target POMC and CART neurons at the hypothalamus. Moreover, orexins and
other neuropeptides with roles in the central control of appetite are apparently modulated by ghrelin.
This complex mode of action of ghrelin upon the hypothalamic centers controlling energy balance
and food intake is illustrated in Figure 9.1.
Some of the reported effects of ghrelin on food intake might not derive from direct central
actions of the gut-derived peptide but instead might be mediated by peripheral activation of afferent
activity of the vagal nerve [31]. Indeed, blockade of gastric vagal inputs has been shown to blunt
ghrelin effects in terms of food intake and hypothalamic NPY expression [32], and vagal resection
associated with gastroplastic surgery has been implicated in the lowering of ghrelin levels following
some of these surgical procedures [33], although the latter is still a matter of debate. Additional
contributors to the observed effects of ghrelin upon body weight likely include its direct actions
upon the adipose tissue, where it primarily promotes adipogenesis and antagonizes lipolysis, as well
as its ability to reduce cellular fat utilization and decrease locomotor activity. These, together with
is potent orexigenic action, drive the energy equation toward a state of positive energy balance [21].
Hypothalamus
Neurons
+
-
Food Energy
intake expenditure
NPY/
- AGRP
-
-
+ POMC/
CART
-
- +
Leptin
GHRELIN
PYY3-36 Insulin
WAT
Stomach
Pancreas
Ghrelin:
• Produced by the stomach
• Only known circulating orexigen
Intestinal
Tract • Levels inverse to BMI
• Stimulates appetite
• Reduces fat utilization
• Reciprocal interplaywith leptin
FIGURE 9.1 Illustration of the major biological actions of ghrelin in the control of appetite. Produced by
the stomach under the regulation of metabolic cues (putative regulators: prepradial state, caloric meal intake,
body mass index, leptin, insulin), ghrelin primarily operates at central levels by modulating the function of
leptin-responsive circuits, such as NPY/AGRP neurons. Other hypothalamic targets of ghrelin (such as
PMOC/CART neurons) have also been suggested. In addition, some of the orexigenic actions of ghrelin might
be conducted via modulation of vagal afferents (not shown). Importantly, the function of ghrelin in the control
of appetite and energy balance is counterbalanced by the concerted action of a set of peripheral signals, of
adipose (leptin and other adipocytokines), pancreatic (insulin), and gastrointestinal (PYY3-36 and other gut-
hormone) origin. Among these, the most prominent functional opponent for ghrelin actions appears to be
leptin, which dynamically interplays with ghrelin in the long-term control of energy homeostasis.
REGULATION OF GHRELIN LEVELS

AND INTERACTION WITH LEPTIN SYSTEM
Although pharmacological evidence for the appetite-promoting effects of ghrelin is unquestioned,
its physiological relevance in the dynamic regulation of body weight and energy homeostasis was
initially the subject of an intense debate. Several observations seemed to cast doubts on the
importance of ghrelin in this function, including: (1) the low to negligible expression of ghrelin at
the hypothalamus, (2) the limited passage of circulating ghrelin through the blood–brain barrier,
and (3) the modest orexigenic effects of ghrelin after its systemic administration [21]. In addition,
initial studies on mouse models of the genetic inactivation of ghrelin and its functional receptor
revealed rather mild metabolic phenotypes, without a clear-cut effect of the absence of ghrelin
signaling upon body weight [34,35]. Nonetheless, recent experimental observations appeared to
dissipate those concerns, as expression of ghrelin has been demonstrated in discrete neuronal
populations at the hypothalamus [36], ghrelin or GHSs have been proven to act at hypothalamic
regions (such as certain areas of the arcuate nucleus) where the permeability of the blood–brain
barrier is significantly enhanced [21], and, albeit less potent, consistent orexigenic responses to
peripheral ghrelin delivery have been obtained in different experimental models, in contrast to other
well-known orexigens devoid of systemic activity [21]. Moreover, detailed metabolic analyses of
GHS-R knockout animals have recently shown that mice lacking ghrelin signaling are resistant to
developing diet-induced obesity [37].
One of the hallmarks of gut-derived ghrelin is that its circulating levels appear to be regulated
by a number of metabolic factors. Strikingly, ghrelin concentrations have been reported to increase
preprandially, thus suggesting a role in meal initiation [38]. Moreover, circulating ghrelin levels
decrease after meal intake, the magnitude of such a drop being proportional to the ingested
caloric load [39]. In addition, ghrelin concentrations seem to be inversely correlated with the
body mass index (BMI), and ghrelin levels have been reported to increase in fasting conditions
or persistent undernutrition in a wide array of species [21]. Taken together, these observations
support the contention that ghrelin may play complementary roles in the short-term regulation
of pre-meal hunger and the duration of episodes of ingestion, as well as in the long-term control
of energy homeostasis, acting as a signal for energy insufficiency [40]. In keeping with the
proposed metabolic control of ghrelin, as the ultimate afferent signaling an energy deficit, changes
in glucose homeostasis, insulin, and leptin have been demonstrated, among others, as putative
regulators of ghrelin secretion [21].
From a homeostatic perspective, the functions and regulation of ghrelin cannot be indepen-
dently considered but rather integrated in the context of a complex network of peripheral
modulators of energy balance and food intake. Within this system, ghrelin possesses quite unique
features, as it is the only known circulating orexigen, and may serve both short- and long-term
regulatory functions [21,22]. The major functional opponent of ghrelin appears to be leptin [40].
Indeed, leptin and ghrelin show remarkable opposite characteristics in terms of their effects on
food intake and energy balance, as well as in their correlation with the nutritional state and body
mass index. Thus, although an excess of body weight and adiposity is associated with elevated
leptin levels, situations of negative energy balances and low BMIs are generally linked to
persistently elevated ghrelin levels. This inverse relationship has led to the proposal that leptin
(as the signal for energy abundance) and ghrelin (as the signal for energy insufficiency) are the
two major peripheral players in the maintenance of appropriate food intake and energy stores
[40]. The neuroendocrine substrate for such a reciprocal interaction appears to involve the
convergent actions of these hormones onto similar central pathways [40], as ghrelin has been
shown to regulate leptin-responsive neurons in specific hypothalamic areas [21,40]. Additional
levels of interplay between leptin and ghrelin are found at the periphery, where leptin has been
suggested to modulate ghrelin expression [21]. Overall, although it is probably a simplification
of a complex regulatory system, this “yin/yang” model of the regulation of appetite and energy
homeostasis by orexigenic (ghrelin) and anorexigenic (leptin) signals is tremendously illustrative
of the basic mechanisms governing energy homeostasis, the deregulation of which may lead or
contribute to alterations in body weight such as obesity, anorexia, or cachexia [40]. Obviously,
other peripheral factors, such as insulin and other gastrointestinal hormones (e.g., PYY3-36) and
adipocytokines, likely contribute, together with ghrelin and leptin, to the dynamic control of
appetite, metabolism, and energy balance, as shown in Figure 9.1.
GHRELIN AS A NEUROENDOCRINE INTEGRATOR LINKING

ENERGY STATUS AND OTHER KEY FUNCTIONS
The pleiotropic nature of ghrelin and the diversity of its biological functions clearly demonstrate
that ghrelin is much more than a simple regulator of appetite. Instead, ghrelin appears to play a
fundamental role in several key endocrine and non-endocrine systems, suggesting that ghrelin is
an important member of the survival kit of nature [40]. Interestingly, the concurrent actions of
ghrelin upon different neuroendocrine axes make it a suitable candidate for the integrated control
of energy balance and other essential endocrine functions, such as growth and reproduction. The
former has been assumed on the basis of the ability of ghrelin to elicit GH secretion; yet, its
physiological relevance remains to be fully defined. Indeed, from a teleological point of view, the
proposed role of ghrelin as a signal for energy insufficiency is difficult to reconcile with a supposed
action of this molecule as a major elicitor of GH secretion and growth.
In contrast, although the potential link between ghrelin and reproduction has received limited
attention to date, some fragmentary data strongly suggest that ghrelin may operate as putative
modulator (mostly inhibitor) of the reproductive axis in different mammalian species, including
primates, sheep, and rats [25,26,41]. As evidences for the reproductive aspect of ghrelin, its
expression has been demonstrated in human and rodent placenta, and ghrelin has been reported to
inhibit early embryo development in vitro and pregnancy outcome in vivo [25,26]. In addition,
ghrelin has been shown to suppress luteinizing hormone (LH) secretion in vivo and to decrease
LH responsiveness to gonadotropin-releasing hormone (GnRH) in vitro. Moreover, repeated admin-
istration of ghrelin induced a partial delay in the timing of puberty in male rats [42,43]. Finally,
transcripts of ghrelin and its cognate receptor have also been identified in rat and human gonads,
and ghrelin has been reported to inhibit stimulated testicular testosterone secretion [25,26]. Given
its proposed role as a peripheral signal for energy insufficiency [40], the above data suggest that
ghrelin exerts a negative influence on the gonadotropic axis, contributing to the complex neuroen-
docrine network linking energy status and fertility. From a general perspective, ghrelin appears to
operate as a neuroendocrine integrator involved in the coordinated control of several functions
essential for the survival of organisms or species, such as food intake and energy homeostasis,
growth, and reproduction.
MAJOR CONCLUSIONS AND FUTURE PERSPECTIVES

Despite the astonishing amount of studies published on ghrelin during the last 5 years (more than
1450 scientific papers registered in PubMed database), controversies and open questions still exist
regarding ghrelin physiology that await to be elucidated, as exhaustively reviewed elsewhere [30].
In the context of appetite control, a key issue to be defined is the contribution of central vs. peripheral
ghrelin in the control of food intake and the relevance of centrally produced ghrelin, if any, in the
neuronal networks involved in such function. Other important aspects to be fully characterized are
the mechanisms (neuronal targets and central effectors) by which ghrelin conducts its orexigenic
actions and whether some of the body-weight-gain-promoting effects of ghrelin might be mediated
via GHS-R1a-independent mechanisms, as recently suggested by pharmacological studies [24].
From a metabolic perspective, the reciprocal interplay between leptin and ghrelin and, more
importantly, between ghrelin and insulin remains to be fully clarified, as conflicting data on the
ability of ghrelin to modulate insulin secretion have been presented [30].
Finally, a contentious issue is whether unacylated ghrelin has specific or common physiologic
functions. In this sense, original reports firmly demonstrated that octanoylation of ghrelin at Ser3
is mandatory for GHS-R1a binding and stimulation of GH secretion [5,6]. Although this finding
remains undisputed, the wealth of data presented over the last several years strongly suggests that
unacylated ghrelin is not merely an inert form of the molecule. In contrast, several non-endocrine
actions of octanoylated ghrelin can be mimicked by its desacyl counterpart [21,22], including
cardiovascular, adipogenic, and (anti)proliferative effects. More important for the purposes of this
chapter, evidence for the central and peripheral neuroendocrine and metabolic effects of ghrelin
independent of GHS-R1a has also been recently reported [24,43,44]. These studies included dem-
onstration of the ability of desacyl ghrelin to modulate hypothalamic expression of neuropeptides
relevant for food intake control, such as CART, and to induce significant decreases in body weight
and food intake in mice. These observations suggest that, in rodents, unacylated ghrelin might
operate as a counterbalancing signal for ghrelin in some of its metabolic responses, in line with
recent reports in humans [45].
In summary, ghrelin has recently emerged as a key metabolic regulator playing an essential
role in the control of food intake and energy balance. Among other unique features, ghrelin appears
as the only known circulating orexigenic factor, whose serum profile (with preprandial elevation
and postprandial decrease) is highly suggestive of a major function of ghrelin as a pre-meal hunger
signal. In addition, circulating ghrelin levels seem to be negatively correlated with body mass index,
leading to the hypothesis that ghrelin operates as a peripheral signal for energy insufficiency. Indeed,
on the basis of their biological properties and their reciprocal fluctuation, it has been proposed that
leptin and ghrelin are the most prominent antagonic afferents of a dynamic (yin/yang) regulatory
system that allows precise tuning of the long-term control of body weight and energy balance.
Importantly, the biological roles of ghrelin clearly exceed those related with its metabolic aspect,
as ghrelin has been shown to be involved in a wide diversity of functions, from cell proliferation
to reproduction. Complete elucidation of ghrelin biology promises to be an active field in endocrine
research in the coming years.
ACKNOWLEDGMENTS
The authors are indebted to C. Dieguez, E. Aguilar, L. Pinilla, and other members of the research
team at the Physiology Section of the University of Cordoba for their continuous collaboration and
support in their studies on neuroendocrine aspects of ghrelin physiology, as well as for their helpful
discussions during preparation of this manuscript. The work from the authors’ laboratory described
herein was funded by grants BFI 2000-0419-CO3-03 and BFI 2002-00176 from DGESIC (Minis-
terio de Ciencia y Tecnología, Spain), funds from Instituto de Salud Carlos III (Red de Centros
RCMN C03/08 and Project PI042082), and EU research contract EDEN QLK4-CT-2002-00603.
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10 Molecular Genetics of
Obesity Syndrome:
Role of DNA Methylation
Rama S. Dwivedi, Atul Sahai, and Bernard L. Mirkin
CONTENTS
Introduction ....................................................................................................................................115
Molecular Genetics of Obesity ......................................................................................................116
Clinical Syndromes of Obesity......................................................................................................117
Prader–Willi Syndrome: A Clinical Description...........................................................................117
Role of DNA Methylation .............................................................................................................117
Conclusions ....................................................................................................................................118
References ......................................................................................................................................119
INTRODUCTION
The prevalence of obesity in developed and industrialized countries has reached alarming levels.
Worldwide, almost 1 billion adults are overweight, with a body mass index (BMI) of 25.0 kg/m2,
and more than 300 million individuals are obese, with a BMI of 30.0 kg/m2, at 20 years of age
and older. The incidence of obesity in adults has increased by approximately 50% over the past 7
years in the United States [1]. Based on data from the 1999–2002 National Health and Nutrition
Examination Survey, the percentage of overweight children between the ages 6 of 11 increased
from 4.2 to 15.8% compared to the 1963–1965 survey. In 2001, nearly 58 million Americans were
overweight; among them, 40 million were obese. Each year, approximately 300,000 die due to
obesity-related disorders [2].
The data collected by the Centers for Disease Control and Prevention/National Center for Health
Statistics between 1999 and 2002 showed that the percentage of overweight adolescents (ages 12
to 19) had increased from 4.6% to 16.1%. A great economic and financial stress has been placed
on society, as obesity-related disorders such as type 2 diabetes, osteoporosis, hypertension, heart
and liver disease, postmenopausal breast cancer, colon cancer, and endometrial cancer have
increased dramatically. Annual medical costs to treat these diseases are expected to exceed $100
billion in the United States, thus making obesity a major public health concern [4]. One of the
national public health goals for the year 2010 is to reduce the incidence of obesity among adults
to less than 15%. The focus of this review is on describing the putative role of DNA methylation
in regulating and altering the function of obesity-related genes and disorders.
115
MOLECULAR GENETICS OF OBESITY

The update of the human obesity gene map in 2005 revealed that about 425 genes or biomarkers
were directly or indirectly linked with the onset of human obesity [4,5]. Some genes, such as those
that regulate the expression of uncoupling proteins, leptin, leptin receptors, adrenergic receptors,
peroxisome proliferator-activated receptors, and fatty-acid-binding protein, modulate the control of
energy metabolism and may be affected by dietary composition and physical activity. Specific genes
such as proopiomelanocortin are involved in controlling food intake, while others such as peroxi-
some proliferator-activated receptors regulate adipogenesis, thus affecting body weight and fat
deposition in individuals who are carriers of defective gene mutations or polymorphisms. Variations
in adrenergic receptors and leptin receptors have been shown to be positively correlated with
increased weight gain [4,5].
The genetic basis of obesity was significantly advanced by the discovery of the leptin gene in
the obese mouse model in 1994 [6]. Since then, autosomal recessive mutations in the genes for
leptin [7,8], leptin and melanocortin-4 receptors [9,10], prohormone convertase 1 [11], and proo-
piomelanocortin [12] have been linked to the onset of obesity in humans. Deletion of a single
guanine nucleotide in the leptin gene in children was associated with increased weight gain, which
was reversed by administration of recombinant leptin, causing a significant loss of weight and
adipose tissue mass [7]. A truncated leptin receptor lacking both the transmembrane and intracellular
domain was present in the children of a family with a mutation in the human leptin receptor gene
and was associated with obesity and pituitary dysfunction. Thus, a genetic defect in leptin or leptin
receptors may be one of the factors contributing to the impaired regulation of body weight in obese
children [13]. As yet, no definitive correlation has been established.
Many candidate genes are found to be altered in Mendelian or rare obesity syndromes, such
as leptin, proopiomelanocortin, melanocortin-4 receptor, and Bardet–Biedel syndrome loci [14].
An established association between monogenic forms of obesity and mutations in the melano-
cortin-4 receptor, accounting for about 4% of early-onset obesity, has been reported [15]; however,
mutations in the melanocortin-4 receptor do not seem to play a prominent role in the late-onset,
more common type of obesity. Mutations in the leptin gene lead to severe early-onset obesity.
Although treatment with leptin successfully reverses the progression of early-onset obesity, it
has not proven to be effective in treating this syndrome [16]. Ultimately, identification of the
rare mutations in candidate genes may facilitate identifying the pathways that can lead to severe
obesity.
Genetic defects in the prohormone convertase 1, which is involved in the posttranslational
processing and sorting of prohormones and neuropeptides, have been implicated in the neuroen-
docrine control of energy balance in obese children [11]. Genetic mutations associated with
additional manifestations of the obesity syndrome, such as adrenal insufficiency, red hair (proop-
iomelanocortin), impaired fertility (prohormone convertase 1, leptin, and leptin receptor), and
impaired immunity (leptin), have been suggested as causative factors [12]. A defect in proopiomel-
anocortin protein due to impaired synthesis of melanocortin peptides; adrenocorticotropin; mel-
anocyte-stimulating hormone (MSH); or the α-, β-, and γ-opioid receptor ligand β-endorphin results
in early-onset obesity due to increased food intake or reduced energy utilization.
The melanocortin-4 gene, which can be detected in 2 to 4% of all extremely obese children
[17,18], has been linked to the onset of obesity. Another important monogenic form of obesity is
due to mutations in the peroxisome proliferator-activated receptor γ2 (PPARγ2) gene [19]. More
than 30 rare mutations have been identified worldwide that occur very infrequently in association
with obesity. Children with melanocortin-4 gene mutations have been found to eat more meals than
controls without mutations [9,16,20]. Experimental studies using melanocortin-4 gene knockout
mice have demonstrated a significant increase in food uptake when compared with controls, leading
to the development of obesity [21]. These findings support earlier observations made by Farooqi
et al. [16] with regard to additional meals being taken by obese children.
Molecular Genetics of Obesity Syndrome: Role of DNA Methylation 117
Recently, it has been suggested that polymorphisms in the sterol regulatory element-binding
transfactor gene predispose diabetic patients to obesity [22]. Analysis of the human melanin-
concentrating hormone receptor-1 gene has identified 11 infrequent variations and 2 single nucle-
otide polymorphisms (SNPs) in its coding sequence and 18 SNPs (8 novel) in the flanking sequence
of this gene in subjects with juvenile-onset obesity syndrome [23]. The mitogen-activated protein
kinases (MAPKs), such as extracellular signal-regulated kinase (ERK), p38, and c-Jun N-terminal
kinase (JNK), have also been proposed to play an important role in the differentiation of preadi-
pocyte cell lines to adipocytes with a consequent effect on obesity [24]. Recent studies with obese
and type 2 diabetic (db/db) mice suggest that osteopontin may also be a factor in the etiology of
obesity syndrome [25,26]. These findings indicate that upregulation of osteopontin signaling in
obese mice potentiates the development of hepatic fibrosis and nonalcoholic steatohepatitis [24,25].
Although heredity and environmental factors play a critical role in the development of obesity and
related disorders, at this stage their respective roles and significance remain unresolved.
CLINICAL SYNDROMES OF OBESITY

The clinical syndromes associated with obesity include Prader–Willi syndrome (PWS) with endo-
crine disorders, acanthosis nigricans characterized by thickening and pigmentation of skin folds,
Blount’s disease associated with orthopedic anomalies, sleep disorders, neurological (pseudotumor
cerebri) and cardiovascular problems, and polycystic ovary syndrome.
PRADER–WILLI SYNDROME: A CLINICAL DESCRIPTION

The Prader–Willi syndrome is a common syndrome associated with human obesity. It was first
described in 1956, although specific diagnostic criteria were not established until 1993 [27]. The
main clinical characteristics of this syndrome are hypotonia during the neonatal period and failure
to thrive due to feeble sucking reflex and low energy intake. In males, bilateral cryptorchidism
associated with profound hypotonia may draw attention to the diagnosis. Hypoplasia of the external
genitalia (labia minora and clitoris) also occurs in females but may be difficult to recognize. Limited
hip and knee extension may be detected during routine newborn examination for congenital dislo-
cation of the hip. Hands are frequently delicate, with a puffy appearance. Orthopedic problems
such as scoliosis are common, as a consequence of both the syndrome itself and the presence of
gross obesity [27]. Gastrointestinal symptoms such as hyperphagia (a continuous hunger apparently
without a normal sensation of satiety), vomiting, and rectal bleeding may occur. The insatiable
hunger has been attributed to anomalies in development of hypothalamic paraventricular nucleus
[27]. Hyperphagia is commonly associated with aggressive and self-abusive behavior, the theft of
food, poor social relationships, and mental retardation. Obesity has been identified as one of the
major factors contributing to the morbidity and mortality associated with the Prader–Willi syn-
drome. Development of non-insulin-dependent diabetes mellitus and impaired cardiac and pulmo-
nary function leading to severe disability and early death have also been described.
ROLE OF DNA METHYLATION

Robinson et al. [29] reported that the Prader–Willi syndrome may be associated with deletion of
the q11–q13 fragment of paternal chromosome 15 or the presence of uniparental disomy (i.e., two
complete chromosomes 15 of maternal origin). A third type of genetic or epigenetic alteration
involving impairment of the imprinting center due to changes in methylation patterns has also been
proposed. DNA methylation is the covalent modification of DNA that is associated with the
regulation of gene expression during development, genomic imprinting, X-chromosome inactiva-
tion, and silencing of functional genes [30,31]. The Prader–Willi syndrome is a neurodevelopmental
disorder that arises from the lack of expression of paternally inherited genes known to be imprinted
and located in the chromosome 15q11–q13 region. It is considered the most common syndrome
causing life-threatening obesity, with an estimated incidence of 1 in 10,000 to 20,000 individuals.
Approximately 99% of patients have an abnormality in the parent-specific methylation imprint
within the Prader–Willi imprinting center at chromosome 15q11.2–q12. Among these subjects, a
de novo paternally derived chromosome 15q11–q13 deletion is the cause of the Prader–Willi
syndrome in about 70% of patients, and maternal disomy-15 accounts for about 25% of cases. The
remaining 5% of cases result from genomic imprinting defects (microdeletions or epimutations)
of the imprinting center in the 15q11–q13 region or from chromosome 15 translocations [32]. A
deficiency of methyl (CpG) binding protein 2 (MeCP2) in the Prader–Willi syndrome causes an
epimutation at the maternal small nuclear ribonucleoprotein polypeptide N promoter allele. This
results in an open chromatin structure that is associated with increased histone H3 acetylation and
H3(K4) methylation and decreased H3(K9) methylation [33]. Methylation-specific polymerase
chain reaction (PCR) and real-time PCR analyses demonstrated that approximately 50% of the
blood cells had an imprinting defect and 50% of the cells were normal in a young woman with
the Prader–Willi syndrome due to a mosaic imprinting defect [34].
Imprinting of the 2-Mb Prader–Willi and Angelman syndrome domain in human chromosome
15q11–q13 and its mouse ortholog in mouse chromosome 7C is believed to be regulated by a
regional imprinting control center; however, the mechanism by which this occurs remains unclear.
The entire 2-Mb domain contains numerous paternally expressed genes and at least two maternally
expressed genes.
A breakthrough in our understanding of the regulation of the imprinting control mechanism
was achieved by studying the Prader–Willi and Angelman syndromes in families with imprinting
mutations caused by microdeletions of two sequences: a 4.3-kb sequence (PWS–SRO) that includes
the small nuclear ribonucleoprotein polypeptide N promoter/exon 1 and an 880-bp sequence
(AS–SRO) located 35 kb upstream from the transcription start site. Deletion of the AS–SRO
sequence was implicated in the Angelman syndrome and deletion of the PWS–SRO sequence in
the Prader–Willi syndrome. These sequences, although separated by a 35-kb intervening sequence,
are able to communicate and constitute an imprinting center that regulates imprinting of the entire
2-Mb domain. In view of the altered methylation patterns in the Prader–Willi syndrome imprinting
center, it is currently being diagnosed by identification of abnormal DNA methylation patterns in
the small nuclear ribonucleoprotein polypeptide N gene [35].
CONCLUSIONS
New molecular and genetic tools are becoming available that should expedite the identification of
candidate obesity genes. Because the complete sequence of the human genome as well as the full
genome sequence of other species are now available, they may be used to study the imprinting
center and its critical sites for methylation-mediated mutations in candidate obesity genes. Infor-
mation about methylation-based functional and transcriptional activation and inactivation of can-
didate genes involved in early-onset obesity may be useful in the development of anti-obesity drugs.
The genetic variants and patterns of common variation elucidated by use of whole-genome linkage
disequilibrium studies to map common genes in disease states will also facilitate the selection of
specific genes for future studies in obesity and related disorders [36].
ACKNOWLEDGMENTS
This investigation was partially supported by grants from the Anderson Foundation, North Suburban
Medical Research Junior Board, Medical Research Institute Council, Wile Foundation. We thank
Dr. Adarsh Rani Bairsetty for her excellent support in manuscript preparation and Ms. Roberta
Gerard for editorial assistance.
Molecular Genetics of Obesity Syndrome: Role of DNA Methylation 119
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Part III
Obesity and Degenerative Diseases
11 Oxidative Stress Status

in Humans with
Metabolic Syndrome
Chung-Yen Chen and Jeffrey B. Blumberg
CONTENTS
Introduction ....................................................................................................................................123
Increases in Oxidation Products in Patients with Components of Metabolic Syndrome ............125
Biomarkers of Lipid Peroxidation..........................................................................................125
Obesity and Lipid Peroxidation ......................................................................................125
Hyperglycemia and Lipid Peroxidation ..........................................................................125
Hypertension and Lipid Peroxidation .............................................................................125
Susceptibility of Low-Density Lipoprotein to Oxidation ......................................................126
Production of Protein Oxidation.............................................................................................126
Changes of Antioxidant Defense Mechanisms in
Patients with Components of Metabolic Syndrome ...................................................................127
Small Molecule Antioxidants .................................................................................................127
Obesity and Dietary Antioxidants ...................................................................................127
Insulin Resistance and Dietary Antioxidants ..................................................................127
Metabolic Syndrome and Dietary Antioxidants..............................................................127
Antioxidant Enzymes..............................................................................................................128
Paraoxonase.............................................................................................................................128
Changes in Biomarkers of Oxidative Stress in
Patients with Components of Metabolic Syndrome ...................................................................128
Physical Activity, Metabolic Syndrome, and Oxidative Stress Status...................................129
Hypocaloric Diets, Metabolic Syndrome, and Oxidative Stress Status ................................129
Pharmacotherapy of Metabolic Syndrome and Oxidative Stress ..........................................130
Antihyperglycemia Therapy ............................................................................................130
Antihypertension Therapy ...............................................................................................130
Dyslipidemia Therapy .....................................................................................................130
Antioxidant Supplementation ..........................................................................................131
Conclusion......................................................................................................................................132
References ......................................................................................................................................133
INTRODUCTION
The concept of metabolic syndrome (MS) was first introduced by Reaven as “syndrome X” [1].
Subsequently, the World Health Organization (WHO) [2] and the National Cholesterol Education
Program Adult Treatment Panel (ATP III) [3,4] defined criteria of MS with a specific focus on
dyslipidemia, hyperglycemia, hypertension, and obesity as key signs — that is, a constellation of
123
Regulation of antioxidant Increase of oxidation Loss of small-molecule

enzyme activity products antioxidants
superoxide dismutase ascorbate

tocopherols
glutathione peroxidase carotenoids
uric acid
catalase
lipoic acid
ubiquinol
glutathione
total antioxidant capacity
Lipid Protein DNA
malondialdehyde protein carbonyls oxidatively modified bases

F2-isoprostanes oxidized amino acids strand breaks
dityrosine, Cl-tyrosine,
lipid peroxides NO2-tyrosine, O-tyrosine
conjugated dienes
expired hydrocarbons
FIGURE 11.1 Oxidative stress sorted by functionality of antioxidants and products of oxidation.
risk factors leading to cardiovascular disease (CVD) [4]. Using ATP III criteria, the National Health
and Nutrition Examination Survey (NHANES) II Mortality Study [5] indicated a nearly linear
correlation between the number of these MS components and mortality from CVD [5] and estimated
a prevalence of MS at 23.7%, or ~47,000,000 adults in the United States [6]. Although the precise
etiology of MS is unresolved and undoubtedly complex, abdominal obesity, insulin resistance, and
physical inactivity are significant contributing risk factors and, thus, suggest a number of practical
solutions for both prevention and treatment of the condition [7].
Reactive oxygen, nitrogen, and halide species (or free radicals), such as hydrogen peroxide,
peroxynitrite, and hypochlorous acid, respectively, have been implicated in the etiology of CVD
and diabetes [8]. Consistent with free radicals initiating or promoting the pathophysiology of these
diseases, dietary antioxidants have been implicated in a reduction of their risk, although it is
important to recognize that these compounds may function via mechanisms unrelated to their
antioxidant properties [9,10]. These relationships have given rise to hypotheses that oxidative stress
may be linked to early events in the development of CVD (as well as diabetes) via both independent
mechanisms and dynamic interactions between the dyslipidemia, hyperglycemia, hypertension, and
obesity of MS. Examining antioxidant defenses and biomarkers of oxidative stress in vivo in human
studies offers a robust approach to testing these hypotheses. These studies generally utilize deter-
minations of: (1) the modulation of antioxidant enzyme activity, (2) the concentration of antioxidants
or measures of total antioxidant capacity, or (3) products of oxidatively modified lipids, protein,
or DNA (Figure 11.1). However, these data must be interpreted with caution as they may not
necessarily reflect a clinically significant or pathogenic event but instead indicate a temporary
response of the antioxidant defense network. Assays for determining oxidation products of lipids,
proteins, and DNA have been previously reviewed [11–16] and are beyond the scope of this chapter.
We consider here evidence from human studies suggesting a role of antioxidant defenses and
oxidative stress in the etiology and progression of MS and subsequent risk for CVD.
Oxidative Stress Status in Humans with Metabolic Syndrome 125
INCREASES IN OXIDATION PRODUCTS IN PATIENTS

WITH COMPONENTS OF METABOLIC SYNDROME
Oxidative stress is the disturbance in the oxidant/antioxidant balance in favor of the former and
can be a consequence of diminished protection by antioxidant defenses or increased generation of
free radicals, with both resulting in production of oxidation products (e.g., lipid peroxides) [16].
BIOMARKERS OF LIPID PEROXIDATION

Obesity and Lipid Peroxidation
Obesity, a key component of MS [17–19], appears to be associated with increased generation of

free radicals and lipid peroxidation reactions [20]. For example, in an observational study of 140
nondiabetic men and women (mean age, 59 years), body mass index (BMI; in kg/m2) and waist
circumference (WC; in cm) were directly associated with plasma thiobarbituric acid reactive
substances (TBARS) and urinary 8-epi-prostaglandin-F2α (8-iso), products of lipid peroxidation
[21]. Analyses of 2828 subjects (mean age, 61) from the Framingham cohort revealed a linear
correlation between obesity and lipid peroxidation, as each 5 kg/m2 of BMI was associated with a
9.9% increase in urinary 8-iso after adjustment for creatinine [22]. Similarly, 8-iso has also been
associated in studies of age-matched men with adiposity, insulin resistance, and endothelial adhesion
molecules [23,24]. Although 8-iso is the best validated measure of lipid peroxidation, it is worth
noting that no difference was found when malondialdehyde (MDA), another indicator of lipid
peroxidation, was determined in a study with 9 obese normotensive men (BMI, 32.6; mean age,
31) and age-matched controls [25]. Further, the type of obesity may dictate the magnitude of lipid
peroxidation, as Davi et al. [26] found that urinary 8-iso was higher in 24 android obese, nonsmoking
women (BMI, 39; waist-to-hip ratio [WHR], 0.96; mean age, 45) than in 25 gynoid obese women
(BMI, 33; WHR, 0.80; mean age, 40) but higher in all obese women when compared to 24 non-
obese women (BMI, 22.5; mean age, 38).
Hyperglycemia and Lipid Peroxidation
Hyperglycemia can increase the generation of free radicals via autoxidation events, polyol pathways,
and Amadori reactions [27,28]; for example, an acute oral administration of 100 g glucose to 8
healthy men (BMI, 22.4; mean age, 23) increased plasma MDA [29]. Consistent with this result,
Facchini et al. [30] found that plasma lipid peroxides were significantly higher in 12 insulin-resistant
healthy people (BMI, 25.9; mean age, 49) than in 12 insulin-sensitive individuals (BMI, 24.6; mean
age, 47). Quantifying the relationship between obesity and lipid peroxidation, Keaney et al. [22]
calculated that each 25-mg/dL increase in fasting glucose was associated with a 4.3% increase in
urinary 8-iso (adjusted for creatinine).
Hypertension and Lipid Peroxidation
Koska et al. [31] found increased MDA and lipofuscin concentrations in plasma of 11 men with
essential hypertension (blood pressure [BP, in mmHg], 151/97; BMI, 28.6; mean age, 44.3) when
compared to 10 normotensive men (BP, 119/79; BMI, 25.3; mean age, 44.4) at 0.85 vs. 1.3 ng/mL
and 11.8 vs. 16.2 units, respectively. Importantly, the magnitude of lipid peroxidation appears
greater in people with two or more risk factors of MS than in those with one or less. Konukoglu
et al. [32] found that obesity and hypertension were associated with a greater oxidative stress status
than with either obesity or hypertension alone, as plasma TBARS ascended in order in 25 non-
obese normotensives (BP, 95.5/75.4; BMI, 21.5; mean age, 54.5), 25 non-obese hypertensives (BP,
165.5/105.3; BMI, 23.5; mean age, 56.5), 35 obese normotensives (BP, 109.5/75.5; BMI, 32.5;
mean age, 60.5), and 45 obese hypertensives (BP, 168.8/115.6; BMI, 33.8; mean age, 58.5) at 5.55,
6.85, 7.20, and 8.45 µmol/L, respectively. When Stojiljkovic et al. [33] examined the relationship
between lipid peroxidation and hypertension, obesity, and insulin resistance, they found increased
urinary 8-iso excretion in 10 obese hypertensives with insulin resistance (BMI, 31; BP, 131/88;
mean age, 40) compared to 12 healthy normotensives without insulin resistance (BMI, 22; BP,
106/72; mean age, 38) at 5.0 vs. 3.3 ng/mg creatine, respectively. Using ATP III guidelines, Hansel
et al. [34] found that plasma 8-iso was 3.7-fold greater in 10 MS patients (BMI, 31.1; WC, 102.3;
BP, 148/85; mean age, 53.5) than in 11 healthy individuals (BMI, 23.4; WC, 81; BP, 127/80; mean
age, 52.3) in a case control study. In contrast, also using ATP III criteria, Sjogren et al. [35] observed
no difference in urinary 8-iso between 22 men with MS (BMI, 30.1; WC, 108; BP, 148/87) and
healthy men (BMI, 24.2; WC, 92; BP, 120/75) or men with one or two MS risk factors (BMI, 26.1;
WC, 97; BP, 141/83) in a cross-sectional cohort of 289 men (ages 62 to 64). The absence of a
correlation here between lipid peroxidation and MS could be attributed to a lack of power with so
few MS patients in this population.
SUSCEPTIBILITY OF LOW-DENSITY LIPOPROTEIN TO OXIDATION

Oxidation of lipoproteins, especially low-density lipoprotein (LDL), has been implicated in the
pathogenesis of atherosclerosis and CVD [36]. Thus, it is of interest to note that Myara et al. [37]
found that the resistance of LDL to oxidation in vitro was negatively correlated with BMI (r =
–0.35) in 75 obese patients (BMI, 30–50). However, as in vitro LDL oxidation assays may indicate
only the oxidizability of LDL with a modest relationship to in vivo pathophysiology, some studies
have evaluated circulating oxidized LDL (ox-LDL) in vivo, although the origin of ox-LDL in the
circulation is unclear. Consistent with Myara et al. [37], Couillard et al. [24] found a positive
correlation (r = 0.52) between ox-LDL and WC in 56 sedentary men with abdominal obesity (WC,
102; BMI, 30.4; mean age, 40). Extending this relationship to glycemic status, Kopprasch et al.
[38] found that ox-LDL was higher in 113 subjects with impaired glucose tolerance (BMI, 28.0;
mean age, 60) than in 376 with normal glucose tolerance (BMI, 26.4; mean age, 57). Similarly,
Mizuno et al. [39] found higher ox-LDL in 12 healthy, nonsmoking, insulin-resistant men (BMI,
24.5; mean age, 29.1) than in 24 insulin-sensitive men (BMI, 22.1; mean age, 28.7) at 146 vs. 101
IU/L, respectively. In contrast, Schwenke et al. [40] found no correlation between glucose intoler-
ance and in vitro LDL susceptibility to oxidation in 352 men and postmenopausal women from
the Insulin Resistance Atherosclerosis Study.
Examining directly 1147 MS patients (BMI, 29; WC, 102; BP, 139/72; mean age, 74) with
their multiple risk factors for CVD according to ATP III criteria, Holvoet et al. [41] found elevated
ox-LDL in comparison to 1886 healthy subjects (BMI, 27; WC, 98; BP, 134/71; mean age, 74),
independent of sex and ethnicity. Employing World Health Organization (WHO) criteria, a similar
correlation between increasing number of MS criteria and ox-LDL was reported in a cross-sectional
study in Sweden among 391 nondiabetic men [42,43]; however, as with their inability to detect a
difference using urinary 8-iso, Sjogren et al. [35] found no difference in ox-LDL concentrations
between MS and healthy men.
PRODUCTION OF PROTEIN OXIDATION

Nitrotyrosine (NT) can serve as a biomarker of peroxynitrite radical attack on proteins, although
no studies have been conducted assessing MS with NT [44–46]. Although Marfella et al. [47] found
that acute hyperglycemia induced by glucose infusion increased plasma NT from 0.2 to 0.5 µmol/L
in 20 healthy subjects (BMI, 24; mean age, 34), Bo et al. [48] found no different in plasma NT
between 96 healthy subjects (BMI, 22.9; WC, 85.9; BP, 126.9/80.5; mean age, 53.8) and 204 people
with central obesity (BMI, 29.4; WC, 101.9; BP, 138.6/86.4; mean age, 55.3) in a cohort study.
Plasma NT was found to be elevated in 40 type 2 diabetic patients (BMI, 26.2; mean age, 56.2)
relative to 35 healthy subjects with a similar BMI (BMI, 25.9; mean age, 55.4) [45].
CHANGES OF ANTIOXIDANT DEFENSE MECHANISMS IN

PATIENTS WITH COMPONENTS OF METABOLIC SYNDROME
SMALL MOLECULE ANTIOXIDANTS
Non-enzymatic, small-molecule dietary antioxidants include vitamins C and E, carotenoids,
polyphenols, and other compounds. In addition to their presence in some foods, endogenous
synthesis of α-lipoic acid, glutathione (GSH), uric acid, ubiquinols, and other compounds contrib-
utes to the body’s antioxidant defense network. If the etiology or progression of MS were associated
with oxidative stress, then an increased utilization and requirement or lower concentrations in a
vicious cycle with oxidative stress would be anticipated for these antioxidants.
Obesity and Dietary Antioxidants
The increases in lipid peroxidation associated with obesity suggest an increased utilization of
antioxidant vitamins. Indeed, Myara et al. [37] found an inverse association between BMI and
plasma vitamin E (r = –0.53) in a study of 75 nondiabetic, normotensive obese patients (mean age,
39.1). In contrast, no such association was found by Visentin et al. [25] with plasma vitamins A,
C, and E; β-carotene; or lycopene in 9 obese, normotensive men (BMI, 32.6; mean age, 31) and
9 non-obese men (BMI, 23.3; mean age, 29). Menke et al. [49] reported that the plasma coenzyme
Q10 and redox ratio (oxidized to total coenzyme Q10) was not different between 67 obese children
and 50 age-matched, normal weight children. However, these studies are of small size and also
absent assessments of diet and oxidative stress, so it is not possible to determine whether the results
are due to changes in antioxidant intake or utilization in vivo, free radical generation, or compen-
satory mechanisms in endogenous antioxidant synthesis.
Insulin Resistance and Dietary Antioxidants
Inverse associations between insulin resistance and plasma vitamin E (r = –0.21) and β-carotene
(r = –0.2) were observed among 103 Korean children by Konukoglu et al. [51]. Facchini et al. [30]
also observed lower plasma α- and β-carotene, lutein, and α-tocopherol in 12 healthy insulin-
resistant individuals (BMI, 25.9; mean age, 49) than in 12 insulin-sensitive individuals (BMI, 24.6;
mean age, 47). Konukoglu et al. [51], however, found that erythrocyte GSH was not different
between 18 middle-aged subjects with normal glucose tolerance and 15 with impaired glucose
tolerance. To date, the evaluation of insulin resistance with assays purporting to measure total
antioxidant capacity have not revealed any relationship between these parameters, even when other
biomarkers of oxidative stress were affected [38] or when hyperglycemia or hyperinsulinemia were
induced [52].
Metabolic Syndrome and Dietary Antioxidants

Ford et al. [53] observed in 8808 adults from the NHANES III cohort that those with MS had lower
plasma retinyl esters, vitamins C and E, and carotenoids after adjustments for age, sex, race, education,
smoking, physical activity, fruit and vegetable intake, and supplement use. Concerned by the growing
prevalence of MS among children [54], Molnar et al. [55] examined 15 children with MS (BMI, 34.2;
mean age, 13.4), 17 with obesity (BMI, 30.4; mean age, 14.4), and 16 healthy children (BMI, 20.7;
mean age, 16.2) and also found significant reductions in plasma α-tocopherol, β-carotene, and total
antioxidant capacity. In contrast, using ATP III criteria, Miles et al. [56] found that total plasma
ubiquinol was higher in 134 MS subjects (BMI, 33.2; mean age, 49.9) than in 178 healthy subjects
(BMI, 26.5; mean age, 43). It may be possible, then, that MS is associated with lower dietary antioxidant
status due to increased utilization but higher endogenous antioxidant status due to induction of com-
pensatory mechanisms and thus no readily apparent change in total antioxidant capacity.
ANTIOXIDANT ENZYMES
Antioxidant enzymes could be subject to compensatory regulation in MS associated with oxidative
stress. Ozata et al. [57] found that the activity of erythrocyte superoxide dismutase (SOD) and GSH
peroxidase (GSHPx) was lower in 76 obese men (BMI, 36.6; mean age, 49.1) than in 24 healthy
men (BMI, 21.2; mean age, 48.5). However, Visentin et al. [25] found no difference in the activity
of erythrocyte SOD, GSHPx, or catalase in 9 normotensive, obese men (BMI, 32.6; mean age, 31)
vs. 9 healthy men (BMI, 23.3; mean age, 29). Although neither of these studies suggests an
upregulation of antioxidant enzymes with obesity, it should be noted that their populations were
small and of different ages, factors that can affect this outcome [58]. Further, questions regarding
compensatory mechanisms might best include a longitudinal rather than a cross-sectional exami-
nation. Investigating the response of antioxidant enzymes to acute hyperglycemia, Koska et al. [29]
induced an increase in erythrocyte GSHPx and SOD activity by administering 100 g glucose to 8
healthy males (BMI, 22.4; mean age, 23); however, the chronic hyperglycemia of 103 Korean
children with insulin resistance was associated with an attenuated activity of erythrocyte catalase
[50]. Interestingly, Pedro-Botet et al. [59] found that hypertension was also associated with lower
activity of SOD and GSHPx when they compared 30 normolipidemic, untreated mild hypertensive
patients with 164 age-matched, healthy subjects at 806 vs. 931 U/g Hb and 5491 vs. 6669 U/L,
respectively; however, the influence of the combined constellation of MS signs on antioxidant
enzymes has yet to be determined.
PARAOXONASE
Paraoxonase-1 (PON-1) is an ester hydrolase bound to high-density lipoprotein (HDL) that catalyzes
the hydrolysis of a number of organic esters and protects LDL from oxidation. PON-1 activity is
considerably lower in patients with diabetes, hypercholesterolemia, and myocardial infarction
[60,61]. With regard to symptoms of MS, Ferretti et al. [62] found that 12 obese women (BMI,
45.3; mean age, 38.2) had fourfold less PON-1 activity than 31 healthy controls (BMI, 20.1; mean
age, 31.5) at 112.2 vs. 470.5 U/mg. Further, an inverse correlation (r = –0.76) was observed between
PON-1 activity and LDL lipid peroxides. Employing WHO criteria, Garin et al. [63] observed that
139 MS patients (BMI, 30; BP, 139/82; mean age, 62.1) had 22% lower serum PON-1 activity than
634 non-MS patients (BMI, 26.6; BP, 130/79; mean age, 59.6), a decrement sufficient to attenuate
the antioxidant protection of LDL by HDL [64]. Using ATP III criteria, Senti et al. [65] found that
the magnitude of attenuation of PON-1 activity was dependent on the number of MS symptoms
and related metabolic disturbances in a cohort of 713 men and 651 women (ages 25 to 74). In
contrast and also using ATP II criteria, Hansel et al. [34] found no difference in serum PON-1
activity between 10 MS patients (mean age, 53.5) and 11 healthy, normolipidemic controls (mean
age, 52.3), although they did observe that HDL from MS patients had less antioxidant activity to
protect LDL against oxidation in vitro. Results such as these are encouraging investigations explor-
ing the therapeutic potential of PON-1 induction in patients with MS.
CHANGES IN BIOMARKERS OF OXIDATIVE STRESS

IN PATIENTS WITH COMPONENTS
OF METABOLIC SYNDROME
The management goal for patients with MS is reducing the risk of atherosclerosis and CVD [66];
thus, the initial treatment emphasis, before introducing pharmacotherapy, is on mitigating the
modifiable lifestyle factors of obesity and physical inactivity [66–68]. Both lifestyle changes and
medications may affect MS and CVD risk via an impact on oxidative stress status.
PHYSICAL ACTIVITY, METABOLIC SYNDROME, AND OXIDATIVE STRESS STATUS

Regular exercise training in older adults is associated with significant reductions in several metabolic
risk factors for CVD [69]. Similar exercise programs may contribute to the prevention of MS, as
Ekelund et al. [70] found that the level of energy expenditure in physical activity was inversely
associated in a dose-dependent fashion with development of MS signs over 5.6 years in a prospective
study of 605 healthy adults (BMI, 26; mean age, 53.2). In a randomized clinical trial, Stewart et
al. [71] provided 6 months of supervised exercise training (per the American College of Sports
Medicine [72]) to 51 older adults (BMI, 29.4; BP, 140/77; mean age, 63), 22 who presented with
MS according to ATP III criteria. In addition to improvements in body composition and fitness,
the subjects lost 2.2 kg body weight and reduced their BP by 5.3/3.7. Importantly, no subjects
developed MS during the intervention period, and 9 who presented with MS were no longer so
classified. Physical activity can also increase insulin sensitivity. For example, by subjecting 28 MS
patients (BMI, 32; mean age, 52) to a 40-minute exercise program for 3 days a week over 8 weeks,
Dumortier et al. [68] found that their insulin response improved twofold, and they also noted
significant decreases in body weight (–2.6 kg), BMI (–0.96), and body fat (–1.55%).
Exercise programs can also impact measures of oxidative stress. For example, Vasankari et al.
[73] found that a 10-month program of 3 to 5 hours of walking per week decreased the ratio of
LDL conjugated dienes to LDL by 16% and enhanced the total antioxidant capacity of LDL by
13.5% in 104 sedentary volunteers (BMI, 29; mean age, 44). Exercise training can also significantly
reduce measures of lipid peroxidation and inflammation in vivo in obese individuals [74]. For
example, Roberts et al. [75] reported that 45 to 60 minutes of supervised aerobic exercise at 70 to
85% maximum heart rate over 3 weeks decreased serum 8-iso from 202.6 to 131.3 pg/mL in 31
obese, older men (BMI, 35.4; mean age, 63.3), including 15 presenting with MS and all others
with at least one MS factor. At the end of the exercise program, the number of men with MS
according to WHO criteria decreased from 15 to 5.
HYPOCALORIC DIETS, METABOLIC SYNDROME, AND OXIDATIVE STRESS STATUS

Calorie reduction or restriction is an established approach to reducing body weight, and some
studies indicate that success is associated with a reduction in measures of oxidative stress, as well.
For example, Dandona et al. [76] found that a 1000-kcal/day diet regimen over 4 weeks induced
a 12.3-kg loss of weight in 9 obese patients (BMI, 40.7; mean age, 45.3) and concomitantly
significant reductions in oxidative damage to lipids (1.68 vs. 1.47 µmol TBARS per L), proteins
(1.39 vs. 1.17 µmol protein carbonyls per mg protein), and amino acids (o-tyrosine/phenylalanine,
0.42 vs. 0.36) with no changes in the status of α-tocopherol, β-carotene, or lycopene. Similarly,
Davi et al. [26] found that a 1200-kcal/day diet consumed by 11 android obese women was
associated with a significant 32% reduction in urinary 8-iso; 9 other women in this study who
failed to comply with the diet and lost no weight showed no change in their urinary 8-iso.
Although drug treatments specific for MS signs are discussed below, gastrointestinal lipase
inhibitors such as orlistat are described here as they are specifically indicated as adjuncts to
hypocaloric, weight-loss diets [77]. Use of orlistat for 6 months in an obese population (BMI, 36.1;
WC, 105; mean age, 49.7) not only reduced BMI and WC but also reduced plasma MDA from 2.0
vs. 0.89 µmol/L, the latter value being equivalent to non-obese controls, in direct association with
BMI (r = 0.36) [78]. However, Samuelsson et al. [79] observed no change in plasma 8-iso with
orlistat and/or hypocaloric diets. As exercise can modulate antioxidant defenses [58], it is worth
noting that the combination of orlistat with exercise and a low-calorie diet decreased serum MDA
from 1.79 to 1.20 µg/mL in a study of 12 obese subjects (BMI, 39.1; mean age, 37.3), while 11
subjects in the drug-plus-diet group (BMI, 37.9; mean age, 40) showed no such relationship [80].
However, results on oxidative stress from studies of orlistat are confounded by their action in
decreasing the absorption of fat-soluble antioxidants such as carotenoids and tocopherols.
PHARMACOTHERAPY OF METABOLIC SYNDROME AND OXIDATIVE STRESS

them with at least a dual mechanism action in their use for patients with dyslipidemia as well as
MS and type 2 diabetes mellitus. For example, 3 months of atorvastain therapy in vitro increased
the resistance of LDL to in vitro oxidation in 12 normocholesterolemic type 2 diabetic patients
[92]. Similarly, 12 weeks of rosuvastatin therapy reduced ox-LDL by 55% compared to placebo
in a trial of 18 patients with familial combined hyperlipidemia (BMI, 28; mean age, 53.9) [93].
Further, Kural et al. [94] reported that a 10-week atorvastatin regimen enhanced total antioxidant
capacity and serum PON activity by 7.6 and 23.6%, respectively, in 40 patients (mean age, 53.5)
with dyslipidemia.
Studies of statins and oxidative stress are confounded by the inhibitory action of these drugs
on 3-hydroxy-3-methylglutaryl coenzyme A, a critical step in the pathway not only for cholesterol
but also for the synthesis of antioxidant ubiquinols such as coenzyme Q10. Significant reductions
in the ubiquinol content of LDL and a greater oxidizability of LDL in vitro were found in a trial
of 28 men with primary hyperlipidemia and coronary heart disease (BMI, 27.1; BP, 147/88; mean
age, 56) who received a 6-week treatment with lovastatin [95]. Similarly, atorvastain has been
found in clinical trials to reduce plasma ubiquinol concentrations [96]. Perhaps as a function of
their lipid-lowering action, statins have also been reported to decrease vitamin E status [95]. Thus,
in addition to supplementing patients taking statins with coenzyme Q10, some investigators have
suggested including vitamin E supplements. For example, Manuel-Keenoy et al. [97] supplemented
11 type 1 diabetics receiving atorvastain with 250 IU vitamin E daily for 6 months and found that
their α-tocopherol status was markedly enhanced, while 11 patients receiving the drug alone showed
a decrease in plasma concentrations of the vitamin. Consistent with these results, the TBARS
content of LDL was reduced in the vitamin-E-supplemented group and elevated in the drug-only
group. Importantly, several studies have revealed that the antioxidant potency of statins in LDL
varies by individual compounds and is independent of their cholesterol-lowering potency (e.g., with
atorvastatin and fluvastatin increasing resistance to oxidation but little such action by simvastatin,
depending on the assay utilized) [98,99].
Statins have also been shown to beneficially affect biomarkers of oxidative stress other than
LDL oxidizability. Among a group of 35 hypercholesterolemic patients (BMI, 29; mean age, 54),
Shishehbor et al. [100] found a reduction in plasma measures of protein oxidation independent of
improvements in lipid profiles (i.e., declines in chlorinated tyrosine, nitrotyrosine, and di-tyrosine
by 30, 25, and 32%, respectively) following a 12-week atorvastatin regimen. However, as noted
above, studies of statins in MS patients are few, and those that address in a comprehensive way
the impact of the therapy on antioxidant defenses and biomarkers of oxidative stress are even more
limited.
Antioxidant Supplementation
A theoretical rationale for antioxidant supplementation in MS can be proffered by examining the

effect of these nutrients on each of the four individual components of the syndrome and their
contribution to the generation of oxidative stress; however, as little direct evidence is available to
test this hypothesis, further research in this area is warranted. For example, as noted above,
hypertension increases oxidative stress as indicated by increases in plasma TBARS and urinary
8-iso [31–33]. Conversely, Hajjar et al. [101] have shown in a randomized clinical trial that
supplementation with 500 to 2000 mg/day vitamin C for 6 months reduced BP by 4.4/2.8 in 31
hypertensives (BP, 140–180/90–100). Also, Ward et al. [102] obtained a mean decrease of systolic
blood pressure (SBP) 1.8 with 500 mg/day vitamin C in a trial of 69 treated hypertensives (SBP,
136.5; BMI, 28.7; mean age, 62) already receiving antihypertensive therapies. The vitamin C
supplement did not affect plasma levels of urinary 8-iso or serum ox-LDL.
Vitamin E has been well established as a chain-breaking antioxidant effective in reducing lipid
peroxidation reactions. Brockes et al. [103] found that LDL in normotensive individuals had a
greater resistance to oxidation in vitro than in hypertensives but after 400-IU/day vitamin E
supplementation for 2 months in both groups significant differences in this parameter were elimi-
nated. Vitamin E has also been noted to increase insulin sensitivity via an inhibition of protein
kinase C and activation of diacylglycerol kinase [104]. For example, in a randomized clinical trial,
Barbagallo et al. [105] supplemented 24 hypertensive patients with normal blood glucose and
insulin (BP, >140/90; BMI, 25.3; mean age, 47) with 600 mg/day vitamin E for 4 weeks and found
significant increases in whole body glucose disposal and the ratio of plasma reduced to oxidized
GSH. Investigating 41 overweight subjects (BMI, 32.3; mean age, 47) with normal glycemic status,
Manning et al. [106] tested 800 IU/day vitamin E in a randomized clinical trial for 3 months and
found significant reductions in fasting plasma insulin and lipid peroxides and an increase in insulin
sensitivity compared to no change in any of these parameters among the 39 subjects (BMI, 33.2;
mean age, 51) receiving placebo. The decrease in plasma insulin was significantly correlated with
the increase in plasma vitamin E (r = –0.235). In contrast, McSorley et al. [107] found no effect
of 800 IU/day vitamin E supplementation for 12 weeks on fasting plasma glucose or insulin
sensitivity in 13 adult children of parents with type 2 diabetes with normal glucose tolerance (BMI,
24.8; mean age, 28) in a randomized, crossover trial. Results from Skrha et al. [108] suggested a
deleterious effect of 600 mg/day vitamin E administered for 3 months when they observed a 7.3%
reduction in insulin sensitivity in 11 obese subjects with type 2 diabetes (BMI, 31.6; mean age, 45).
Hildebrandt et al. [109] tested 600 mg/day N-acetylcysteine, a GSH prodrug, for 8 weeks in
11 obese subjects with impaired glucose tolerance (BMI, 35.7; mean age, 45.4) and observed
increased plasma thiol status but further reduced glucose tolerance. Like the outcome of the study
by Skrha et al. [108], these results suggest that some people may experience untoward results from
an antioxidant intervention and caution in future studies is advisable.
CONCLUSION
Each component of the constellation of MS signs — dyslipidemia, hyperglycemia, hypertension,
and obesity — has been associated, though not unequivocally, with an elevation of oxidative stress.
Moreover, reductions in these conditions appear generally associated with attenuation of biomarkers
of oxidative stress, although these inverse correlations are not always strong. Although hypotheses
can be readily proffered regarding a vicious cycle of free radicals and pathology in the progression
of these conditions and the potential for a beneficial impact of antioxidants in slowing the progress
of MS toward CVD, few direct data are available to support this approach as an adjunct to established
lifestyle modifications and drug therapies for prevention or treatment. Nonetheless, the biological
plausibility of these relationships clearly warrants further research in this area.
New research should consider variables that are particular to current approaches to MS; for
example, without careful planning, hypocaloric diets can readily be poor in antioxidant nutrients
such as carotenoids and vitamin E, particularly when low-fat menus are stressed. Physical activity
is to be encouraged, but it is important to recognize that intense exercise can generate free radicals
and increase the requirement for antioxidant nutrients. While training regimens can upregulate some
antioxidant enzymes, although perhaps not in older adults, this may not obviate the need for greater
intake of antioxidant nutrients from food and supplements. Further, some of the drugs used to treat
MS interact with the antioxidant defense network (e.g., statins, which inhibit ubiquinol synthesis
and reduce vitamin E status), again suggesting a value for supplementation. Of course, the potential
for adverse drug–nutrient interactions, particularly with regard to dietary supplements, should always
be considered. As it is always a challenge to design antioxidant interventions to alleviate oxidative
stress, studies must be undertaken to determine the optimal combinations and doses, together with
specific lifestyle modifications and drug therapies, as well as the best time to intervene in MS.
Importantly, studies must include not only relevant clinical outcomes but also measures of oxidative
stress and related pathways such as inflammation. These measures not only will serve to provide a
biological basis for the mechanisms of action but will also help to identify individual differences
between patients and the nature of responders and nonresponders for each intervention.
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12 Obesity and
Type 2 Diabetes
Subhashini Yaturu and Sushil K. Jain
CONTENTS
Introduction ....................................................................................................................................139
Prevalence.......................................................................................................................................140
Diagnostic Criteria for Diabetes ....................................................................................................141
Trends in Weight, Body Mass Index, and Type 2 Diabetes .........................................................141
Obesity and Comorbidities ............................................................................................................141
Impact of Diabetes and Obesity on Cardiovascular Disease ........................................................142
Impact of Obesity on Type 2 Diabetes..........................................................................................142
Impact of Childhood Obesity on Type 2 Diabetes........................................................................142
Impact of Catch-Up Growth ..........................................................................................................142
Obesity and Dyslipidemia..............................................................................................................143
Pathophysiology of Diabetes: Obesity, Type 2 Diabetes, and Insulin Resistance .......................143
Free Fatty Acids, Obesity, and Diabetes .......................................................................................143
Visceral Adiposity, Obesity, Insulin Resistance, and Type 2 Diabetes.........................................143
Visceral Fat Tissue as a Proinflammatory Tissue and Its Role in Insulin Resistance .................144
Insulin Resistance in Type 2 Diabetes and Obesity......................................................................144
Adipocyte Hormones, Obesity, Insulin Resistance, and Progression to Diabetes .......................144
Fatty Liver ......................................................................................................................................145
Benefits of Weight Loss in Type 2 Diabetes.................................................................................146
Pharmacotherapy for Obesity and Improvement in Metabolic Risk Factors and Diabetes .........146
Prevention of Type 2 Diabetes by Weight Reduction ...................................................................147
Mouse Models for Obesity-Induced Diabetes...............................................................................148
Conclusions ....................................................................................................................................148
References ......................................................................................................................................149
INTRODUCTION
Obesity and diabetes are emerging pandemics in the 21st century. Both are major public health
problems throughout the world and are associated with significant, potentially life-threatening
comorbidities. A strong association exists between obesity and type 2 diabetes. The increase in the
prevalence of diabetes parallels that of obesity. Some experts call this dual epidemic diabesity. Not
all subjects with type 2 diabetes are obese, and many obese subjects do not have diabetes, but most
of the subjects with type 2 diabetes are overweight or obese. A significant number of obese
individuals have diabetes. Both obesity and type 2 diabetes feature insulin resistance and similar
atherogenic lipid profiles such as increased triglycerides and decreased high-density lipoprotein
cholesterol (HDL-C). The genetic basis of human obesity predisposing individuals to insulin
resistance and development of type 2 diabetes is multigenic rather than monogenic.
139
Obesity Trends* Among U.S. Adults

BRFSS, 1991, 1996, 2004
(* BMI ≥30, or about 30 lb overweight for 5ʼ4”person)
1991 1996
2004
No Data <10% 10%–14% 15%–19% 20%–24% 25%
FIGURE 12.1 Obesity and diabetes mellitus in U.S. adults. Over the 10-year period from 1991 to 2001, the
prevalence of obesity and diabetes among U.S. adults increased in every region of the nation. Obesity is
associated with the development of type 2 diabetes mellitus and may be the root cause underlying the increased
prevalence of type 2 diabetes.
PREVALENCE
In the United States, diabetes affects at least 20.8 million adults (7.0% of the population), which
includes 14.6 million diagnosed and 6.2 million undiagnosed people [5]. Type 2 diabetes is the
predominant form of diabetes worldwide, accounting for 90% of cases [6,7]. Figure 12.1 shows
that the prevalence of diabetes, overweight, and obesity are increasing worldwide, with a 49%
increase between 1991 and 2004. The age-adjusted prevalence of obesity ranges from 13.1 to
30.0% and that of type 2 diabetes from 3.3 to 9.2% [8]. In the United States, the Centers for
Disease Control and Prevention (CDC) analyzed the prevalence of overweight and obesity among
U.S. adults ≥20 years old with previously diagnosed diabetes by using data from two surveys:
the Third National Health and Nutrition Examination Survey (NHANES III) 1988–1994 and
NHANES 1999–2002 [9]. Their report summarized the results of that analysis, which indicated
that most adults with diagnosed diabetes were overweight or obese. During the period from 1999
to 2002, the prevalence of overweight or obesity was 85.2%, and the prevalence of obesity was
54.8%. The prevalence of obesity among adults overall in the United States increased from 22.9%
(during the period from 1988 to1994) to 30.5% (during the period from 1999 to 2002). The
prevalence of obesity among adults with diagnosed diabetes remained high, at 45.7% (1988 to
1994) and 54.8% (1999 to 2002). Obesity and overweight are often defined by the World Health
Organization (WHO) in terms of excess weight for a given height [1,10]. Overweight is defined
as a body mass index (BMI) of 25.0 to 29.9 and obesity as a BMI of ≥30.0. The BMI, calculated
by dividing weight (kg) by height (m2) and adjusted for height, is used as a measure of weight
standards.
Obesity and Type 2 Diabetes 141
93.2
100
Women
Men 54.0
70
risk of type 2 diabetes

40.3 42.1
Age-adjusted relative
40 27.6
21.3
15.8
11.6
10
8.1
6.7
5.0
4.3 4.4
5
2.9
2.2
1.0 1.0 1.5
1.0
0
<22 <23 23– 24– 25– 27– 29– 31– 33– 35+
23.9 24.9 26.9 28.9 30.9 32.9 34.9
Body mass index (kg/m2)
FIGURE 12.2 Relationship between body mass index and type 2 diabetes in adult men and women in the
United States. The vertical line separates underweight and lean subjects (left side) from overweight and obese
subjects (right side). The data demonstrate that the risk of diabetes begins to increase at the upper end of the
lean BMI category. (From Larsen, P.R. et al., Williams Textbook of Endocrinology, 10th ed., Saunders,
Philadelphia, 2002. With permission.)
DIAGNOSTIC CRITERIA FOR DIABETES

The criteria for diagnosis of diabetes mellitus as recommended by the American Diabetes Associ-
ation (ADA) include a fasting plasma glucose (FPG) value after an 8-hour fast that is higher than
126 mg/dL, a 2-hr post-load glucose (PG) level that is ≥200 mg/dL, or symptoms of diabetes
mellitus and a random plasma glucose concentration that is ≥200 mg/dL [11].
TRENDS IN WEIGHT, BODY MASS INDEX, AND TYPE 2 DIABETES

The increasing prevalence of obesity is said to play a significant role in the increase in cases of
type 2 diabetes [12]. Data from NHANES III indicate that two thirds of adults, both men and
women, had BMI values greater than 27 kg/m2 [13]. The risk of diabetes increases linearly with
BMI; the prevalence of diabetes increased from 2% in those with a BMI of 25 to 29.9 kg/m2 to
8% in those with a BMI of 30 to 34.9 kg/m2 and, finally, to 13% in those with a BMI greater than
35 kg/m2 [14]. As shown in Figure 12.2, the risk of type 2 diabetes increases with an increase in
BMI to >22 kg/m2 [12,15]. More than generalized obesity, the risk of obesity increases with increase
in waist circumference, waist-to-hip ratio, visceral adiposity, or abdominal obesity [16–18].
OBESITY AND COMORBIDITIES

Obesity is becoming a major public health problem throughout the world and is associated with
significant, potentially life-threatening comorbidities. Either obesity itself or comorbidities of obe-
sity are responsible for increased cardiovascular risk. Obesity is associated with most of the
components of metabolic syndrome, the leading cause of type 2 diabetes. The comorbidities of
obesity and type 2 diabetes associated with insulin-resistance syndrome include obstructive sleep
apnea, hypertension, polycystic ovary syndrome, nonalcoholic fatty liver disease, and certain forms
of cancer.
IMPACT OF DIABETES AND OBESITY

ON CARDIOVASCULAR DISEASE
Cardiovascular disease (CVD) is a major cause of morbidity and mortality among subjects with
type 2 diabetes and is responsible for up to 75% of deaths among them. The risk of coronary artery
disease (CAD) in subjects with type 2 diabetes is considered equivalent to that in nondiabetic
subjects who have CAD [19,20].
IMPACT OF OBESITY ON TYPE 2 DIABETES

Although an increase in weight or BMI is a major risk factor for diabetes [22], an increase in BMI
is a better predictor of diabetes. Prospective studies in nondiabetic overweight adults noted a 49%
increase in the incidence of diabetes over 10 years for every 1-kg/year increase in body weight;
similarly, each 1 kg of weight lost annually over 10 years was associated with a 33% lower risk of
diabetes in the subsequent 10 years [23]. Similar studies in Pima Indians reported that weight gain
was significantly related to diabetes incidence only in those who were not initially overweight
(BMI, <27.3 kg/m2) [24]. Similarly, in the Behavioral Risk Factor Surveillance System (BRFSS)
for 1991 to 1998, Mokdad et al. [25] reported that every 1-kg increase in average self-reported
weight was associated with a 9% increase in the prevalence of diabetes.
IMPACT OF CHILDHOOD OBESITY ON TYPE 2 DIABETES

The prevalence of obesity is on the rise in children and adolescents. As defined by a BMI greater
than the 95th percentile for age and gender from the revised National Center for Health Statistics
growth charts, 10 to 15% of 6- to 17-year-old children and adolescents are overweight in the United
States [13] and worldwide [62]. Similar to the situation observed in adults, diseases that are
commonly associated with obesity, such as type 2 diabetes, hypertension, hyperlipidemia, gall-
bladder disease, nonalcoholic steatohepatitis, sleep apnea, and orthopedic complications, are now
increasingly observed in children [26,27]. Evidence suggests that the prenatal, early-childhood, and
adolescent periods are critical in the development of obesity. Significant negative health outcomes
are associated with childhood obesity, including the presence of cardiovascular risk factors and
greater prevalence of various medical problems such as insulin resistance, type 2 diabetes mellitus,
metabolic syndrome, orthopedic problems, and pseudotumor cerebri. Of further concern is the
increased risk for obesity in adulthood with its attendant comorbidities. BMIs in childhood change
substantially with age and are not applicable when defining childhood obesity [28,29]. In the United
States, the 85th and 95th percentiles of BMI for age and sex based on nationally representative
survey data have been recommended as cut-off points to identify overweight and obesity [26,30].
The increasing prevalence of type 2 diabetes in adolescents is linked to the epidemic of
childhood obesity in the United States and around the world [31,32]. Altered glucose metabolism,
manifested as impaired glucose tolerance (IGT), appears early in obese children and adolescents.
Obese young people with IGT are characterized by marked peripheral insulin resistance and a
relative β-cell failure [33]. Caucasian adolescent subjects with obesity without diabetes were noted
to have approximately 50% lower levels of adiponectin [34]. In addition, the study noted that
hypoadiponectinemia was a strong and independent correlate of insulin resistance, β-cell dysfunc-
tion, and increased abdominal adiposity [34].
IMPACT OF CATCH-UP GROWTH

Maternal insulin resistance promotes the transfer of nutrients to the fetus. Accelerated childhood
growth is another risk factor for adiposity and insulin resistance, especially in children with low
birth weight [35]. The risk of type 2 diabetes is high among adults with low birth weight (small
for gestational age) who were also overweight during childhood [36–39].
OBESITY AND DYSLIPIDEMIA

Obesity and insulin resistance often coexist along with other abnormalities such as hypertension
and dyslipidemia. The original description of metabolic syndrome by Reaven consisted of obesity,
insulin resistance, hypertension, impaired glucose tolerance or diabetes, hyperinsulinemia, and
dyslipidemia characterized by elevated triglyceride and low HDL concentrations [3,40]. The primary
dyslipidemia related to obesity is characterized by increased triglycerides, decreased HDL levels,
and abnormal small, dense low-density lipoprotein composition, which seem to be closely related
to insulin resistance. The dyslipidemia associated with obesity no doubt plays a major role in the
development of atherosclerosis and CVD. All of the components of dyslipidemia, including higher
triglycerides, decreased HDL levels, and increased LDL particles, have been shown to be athero-
genic. Combined weight loss and exercise, even if they do not result in normalization of body
weight, can improve dyslipidemia and thus reduce CVD risk. In obesity and type 2 diabetes, the
altered communication between adipose tissue and the liver results in the altered regulation of
VLDL production. A number of studies indicate that adipocytokines, in particular adiponectin, may
be seminal players in the regulation of fat metabolism in the liver [41].
PATHOPHYSIOLOGY OF DIABETES:
OBESITY, TYPE 2 DIABETES, AND INSULIN RESISTANCE
Normal glucose homeostasis is maintained by a delicate balance between insulin secretion by the
pancreatic β-cells and insulin sensitivity of the peripheral tissues (muscle, liver, and adipose tissue).
Decreased insulin sensitivity and impaired β-cell function are the two key components in type 2
diabetes pathogenesis based on long-term experience in adults [42,43]. Insulin resistance is fre-
quently observed in obese subjects and has been established as an independent risk factor for the
development of both type 2 diabetes and coronary artery disease [2,44–47].
FREE FATTY ACIDS, OBESITY, AND DIABETES

Studies have shown that both obesity and type 2 diabetes impair insulin-induced suppression of
glycogenolysis and gluconeogenesis and that the degree of impairment correlates with plasma free
fatty acid (FFA) concentrations [48,49]. Plasma FFA concentrations correlate with rates of gluco-
neogenesis and glycogenolysis, suggesting that they influence the regulation of both processes. The
hepatic insulin resistance associated with obesity and type 2 diabetes results in impaired insulin-
induced suppression of glycogenolysis and gluconeogenesis. A growing body of evidence indicates
that obesity and diabetes both cause hepatic insulin resistance [48,50–53].
VISCERAL ADIPOSITY, OBESITY,

INSULIN RESISTANCE, AND TYPE 2 DIABETES
Obesity-related metabolic abnormalities are significantly associated with overall accumulation of
fat in the body; substantial evidence indicates that central obesity is a better predictor of morbidity
than excess fat in the lower body [2,44,47]. Accumulation of fat in abdomen regions has major
implications for metabolism and particularly for insulin sensitivity [2,44,47]. This high prevalence
of comorbidities relates more to waist circumference than to BMI. Visceral or abdominal obesity
is associated with an increased risk of cardiovascular disease and type 2 diabetes. A high prevalence
of obesity and abdominal obesity in Mexicans is associated with a markedly increased incidence
of diabetes and hypertension [54]. Visceral adiposity is considered a risk factor for insulin resistance
in children [33,55–57] and metabolic syndrome [58] and type 2 diabetes in adults [59], as well as
in first-degree relatives of patients with type 2 diabetes with normal glucose levels [60]. Adipocy-
tokines, hormones secreted by the visceral adipocytes, generate the insulin-resistant state and the
chronic inflammatory profile that frequently goes along with visceral obesity [61].
VISCERAL FAT TISSUE AS A PROINFLAMMATORY TISSUE

AND ITS ROLE IN INSULIN RESISTANCE
When analyzed using stepwise multivariate analysis, age, sex, fasting plasma glucose, and BMI seem
to be the most important factors contributing to the variation of vascular reactivity [63]. Visceral fat
exhibits accelerated lipolytic activity with increased release of free fatty acids, which can adversely
affect insulin action and glucose disposal in several tissues [64–68]. These increases in circulating
FFA levels may also result in the development of triglyceride reservoirs in both muscle and liver,
depressing insulin action and increasing hepatic very-low-density lipoprotein output [69,70]. Con-
versely, declines in visceral adiposity and reduced FFA levels following weight-loss diets have been
associated with enhanced insulin sensitivity [71,72]. Tumor necrosis factor α (TNF-α) and interleukin
6 (IL-6) are expressed in adipose tissues [73], with visceral fat being responsible for more TNFα
production than subcutaneous fat [74]. These cytokines inhibit insulin signaling [75], and TNFα may
play a crucial role in the systemic insulin resistance of type 2 diabetes [76]. TNFα inhibits tyrosine
kinase phosphorylation of the insulin receptor, resulting in defects in insulin signaling and ultimately
leading to insulin resistance and impaired glucose transport [77]. An imbalance in favor of proinflam-
matory cytokines from adipose tissue (hypoadiponectinemia and increased levels of IL-6) and other
sources may trigger C-reactive protein (CRP) secretion. CRP levels are related strongly to insulin
resistance and adiposity, and elevated levels of CRP correlate with impaired endothelial dysfunction
(ED) and CAD. This in turn can exacerbate mild insulin resistance and accentuate other metabolic
abnormalities that together constitute metabolic syndrome. Thus, insulin resistance itself appears to
be an endothelial dysfunction risk equivalent. The pathways are clearly intertwined with and sparked
by obesity, in large part by excess adipokine production. Abnormalities in vascular reactivity and
biochemical markers of endothelial cell activation are present early in individuals at risk of developing
type 2 diabetes. The association of endothelial dysfunction with insulin resistance in the absence of
overt diabetes or metabolic syndrome provides evidence that the atherosclerosis may actually begin
earlier in the spectrum of insulin resistance, ultimately resulting in a progression of metabolic
syndrome to prediabetes and then to type 2 diabetes [78].
INSULIN RESISTANCE IN TYPE 2 DIABETES AND OBESITY

Insulin is a critical regulator of virtually all aspects of adipocyte biology, and adipocytes are one
of the most highly insulin-responsive cell types [79]. Insulin resistance is a fundamental aspect of
the etiology of type 2 diabetes and is also linked to a wide array of other pathophysiologic sequelae,
including hypertension, hyperlipidemia, atherosclerosis (i.e., metabolic syndrome, or syndrome X),
and polycystic ovary syndrome [80]. The association between obesity and type 2 diabetes has been
well recognized for decades, and the major link is insulin resistance. In the natural history of
diabetes, obesity and insulin resistance precede abnormal glucose (Figure 12.3). Insulin resistance
in both obesity and type 2 diabetes is manifested by decreased insulin-stimulated glucose transport
and metabolism in adipocytes and skeletal muscle and by impaired suppression of hepatic glucose
output [80]. Type 2 diabetes is characterized by four major metabolic abnormalities: obesity,
impaired insulin action, insulin secretory dysfunction, and increased endogenous glucose output
(EGO) [43,81]. Insulin resistance is the earliest observable abnormality in individuals who are
predisposed to, and who later develop, type 2 diabetes.
ADIPOCYTE HORMONES, OBESITY,

INSULIN RESISTANCE, AND PROGRESSION TO DIABETES
Adipose tissue is a highly active metabolic and endocrine organ. The important endocrine function
of adipose tissue is emphasized by the adverse metabolic consequences of both adipose tissue
excess and its deficiency [82]. Adipose tissue produces several proteins (adipocytokines), such as
Obesity IGT* Diabetes Uncontrolled

Hyperglycemia
Plasma Post-meal
Glucose Glucose
Fasting Glucose
120 (mg/dL)
Relative β-Cell
Function Insulin Resistance
100 (%)
Insulin Level
–20 –10 0 10 20 30
Years of Diabetes
*IGT = impaired glucose tolerance
FIGURE 12.3 Diabetes, obesity, and insulin resistance precede abnormal glucose. (Adapted from Interna-
tional Diabetes Center, Minneapolis, MN.)
leptin, adiponectin, resistin, TNFα, and IL-6, which modulate insulin sensitivity and appear to play
important roles in the pathogenesis of insulin resistance, diabetes, dyslipidemia, inflammation, and
atherosclerosis [82–84]. During the progression from normal weight to obesity and then to overt
diabetes, the adipocyte-derived factors contribute to the occurrence and development of β-cell
dysfunction and type 2 diabetes. In addition to inducing insulin resistance in insulin-responsive
tissues, adipocyte-derived factors play an important role in the pathogenesis of β-cell dysfunction.
Leptin, free fatty acids, adiponectin, TNFα, and IL-6 are all produced and secreted by adipocytes
and may directly influence aspects of β-cell function, including insulin synthesis, secretion, insulin
cell survival, and apoptosis [85].
Adiponectin is a protein secreted by adipocytes only and accounts for approximately 0.01% of
total plasma protein. In healthy patient populations, adiponectin can be found in concentrations of
7 to 12 mg/L. Adiponectin correlates with decreased free fatty acid blood concentrations and reduced
BMI or body weight. Adiponectin may be the molecular link between obesity and insulin resistance
and may serve as a biomarker for metabolic syndrome [86]. Association of altered levels of
adiponectin with insulin resistance and free fatty acid metabolism is well established. Interventions
to reduce insulin resistance by increasing adiponectin concentrations may be particularly effective
in obese, insulin-resistant individuals [86]. Although adiponectin replacement in humans may
represent a promising approach to prevent or treat obesity, insulin resistance, and type 2 diabetes,
clinical studies with adiponectin administration must be conducted to confirm this hypothesis [87].
Plum treatment (plum juice) significantly increased plasma adiponectin concentrations and perox-
isome proliferator-activated receptor γ (PPARγ) mRNA expression in adipose tissue from Wistar
fatty rats [88]. Visfatin (also known as pre-B-cell colony-enhancing factor, or PBEF) is a cytokine
highly expressed in visceral fat whose blood levels correlate with obesity. Increasing concentrations
of visfatin were independently and significantly associated with type 2 diabetes [89].
FATTY LIVER
Fatty liver is common in type 2 diabetes, with estimates of prevalence ranging from 21 to 78%
[90–92]. The risk factors for fatty liver include obesity, insulin resistance, and increased concen-
trations of plasma fatty acids; each of these metabolic factors is also characteristic of type 2 diabetes.
Fatty liver is relatively common in overweight and obese subjects with type 2 diabetes and is an
aspect of body composition related to severity of insulin resistance, dyslipidemia, and inflammatory
markers [39]. Nonalcoholic fatty liver disease (NAFLD) is very common in subjects with morbid
TABLE 12.1
Benefits of Weight Loss in Type 2 Diabetes
Improved glucose levels
Improved glycemic control
Reduced fasting insulin
Increased insulin sensitivity
Reduced upper-body adiposity
Improved atherogenic lipid profile:
Decreased triglycerides
Increased high-density lipoprotein (HDL) cholesterol
Larger, less small, more dense low-density lipoprotein (LDL) cholesterol particles
Reduced blood pressure
Improved mortality
obesity [93,94]. The fatty liver may help to explain why some but not all obese individuals are
insulin resistant and why even lean individuals may be insulin resistant and thereby at risk of
developing type 2 diabetes and cardiovascular disease [95].
BENEFITS OF WEIGHT LOSS IN TYPE 2 DIABETES

Weight loss is an important therapeutic objective for individuals with type 2 diabetes [113]. Both
short-term and long-term weight loss in overweight or obese type 2 diabetic subjects on very low
calorie diets was shown to decrease insulin resistance, improve measures of glycemic control,
improve lipid abnormalities, and reduce blood pressure [114–116]. Recommendations from a
National Institutes of Health (NIH) consensus conference indicate that a weight loss of 5 to 10%
can significantly improve risk factors for obesity-related diseases [96]. Weight reduction has been
shown to improve glycemic control and cardiovascular risk factors associated with insulin resistance
in obese individuals with type 2 diabetes. A list of benefits is shown in Table 12.1. The most
effective interventions include comprehensive behavioral management, dietary modification, exer-
cise, pharmacotherapy, and bariatric surgery. Bariatric surgery for severe obesity results in long-
term weight loss, which leads to an improved lifestyle and recovery from diabetes [121,122],
hypertriglyceridemia, low levels of HDL cholesterol, hypertension, and hyperuricemia [122–124].
The most widely investigated drugs, sibutramine and orlistat, result in modest, clinically worthwhile
weight loss, with demonstrable improvements in comorbidities, among which is type 2 diabetes.
Observational and interventional studies have clearly shown that type 2 diabetes can be pre-
vented by lifestyle measures, including reduced energy intake to induce a modest but sustained
weight reduction, together with changes in diet composition [97]. Even in elderly individuals, diet-
induced weight loss results in improved insulin sensitivity and improved β-cell function [98]. In
short-term [99] as well as long-term studies [100], the use of a low-carbohydrate diet in obese
subjects with type 2 diabetes has improved glucose profiles and insulin sensitivity and lowered
plasma triglyceride and cholesterol levels.
PHARMACOTHERAPY FOR OBESITY AND IMPROVEMENT

IN METABOLIC RISK FACTORS AND DIABETES
Orlistat, a gastrointestinal lipase inhibitor drug, has been used effectively and safely in the treatment
of obesity [101]. Orlistat significantly reduces body weight and improves glycemic control and
several cardiovascular risk factors in overweight and obese subjects with type 2 diabetes [102–104].
In type 2 diabetic patients, orlistat also attenuates postprandial increases in triglycerides, remnant-
like particles, cholesterol, and free fatty acids [105]. The antihyperglycemic effect of orlistat has
been attributed to weight loss associated with a decrease in insulin resistance [104] and augmentation
of the postprandial increases in plasma levels of glucagon-like peptide 1 (GLP-1) [106].
Rimonabant is a selective cannabinoid-1 (CB1) receptor blocker with both central and peripheral
actions [107]. In the RIO–Europe study [108], a 2-mg/day dose of rimonabant along with a low-
calorie diet resulted in significant weight reduction and improvement in cardiovascular risk factors
such as waist circumference, HDL cholesterol, triglycerides, insulin resistance, and the incidences
of metabolic syndrome. In another study [109], rimonabant use at a daily dose of 20 mg resulted
in an increase in plasma adiponectin levels that was partly independent of weight loss alone.
Sibutramine is an anti-obesity drug that induces satiety and thermogenesis [110]. Sibutramine
use has been shown to reduce weight, lower the levels of nonesterified fatty acids, decrease hyper-
insulinemia, and reduce insulin resistance. It has been used as an effective adjunct to oral hypogly-
cemic therapy in obese subjects with type 2 diabetes [111]; however, the magnitude of weight loss
was modest, and the long-term health benefits and safety remain unclear [112]. Metformin, an oral
hypoglycemic agent, decreases calorie intake in a dose-dependent manner and leads to a reduction
in body weight in subjects with type 2 diabetes and obesity [117–119]. Exenatide, a member of a
new class of agents known as incretin mimetics, is currently in development for the treatment of
type 2 diabetes. In short-term studies, exenatide improved glycemic control and helped to reduce
body weight over 28 days in patients with type 2 diabetes who had been treated with diet and
exercise or metformin [120].
Studies have shown that adiponectin administration in rodents has insulin-sensitizing, anti-
atherogenic, and antiinflammatory effects and under certain settings also decreases body weight.
Adiponectin replacement in humans may represent a promising approach to prevent or treat obesity,
insulin resistance, and type 2 diabetes; however, clinical studies with adiponectin administration
must be conducted to confirm this hypothesis.
PREVENTION OF TYPE 2 DIABETES BY WEIGHT REDUCTION

Several interventional studies have demonstrated that significant weight reduction could lead to a
decreased incidence of progression to type 2 diabetes:
• Finnish study [125] — This study from Finland included middle-aged obese subjects
with impaired glucose tolerance who were randomized to receive either brief diet and
exercise counseling (control group) or intensive individualized instruction on weight
reduction, food intake, and guidance on increasing physical activity (intervention group).
After an average follow-up of 3.2 years, a 58% relative reduction in the incidence of
diabetes was observed in members of the intervention group compared with the control
subjects.
• Diabetes Prevention Program (DPP) [126] — This was a multicenter study that enrolled
subjects with impaired glucose intolerance who were slightly younger and more obese.
Approximately 45% of the study subjects were recruited from minority groups (e.g.,
African-Americans, Hispanics) and 20% of subjects were ≥60 years old. Subjects were
randomized to one of three intervention groups: the intensive nutrition and exercise
counseling (lifestyle) group or either of two masked medication treatment groups (the
metformin group or the placebo group). Participants in both the placebo group and the
metformin group received standard diet and exercise recommendations. After an average
follow-up of 2.8 years, compared with the control group, a 58% relative reduction in the
progression to diabetes was observed in the lifestyle group and a 31% relative reduction
in the metformin group. On average, 50% of the subjects in the lifestyle group achieved
the goal of ≥7% weight reduction, and about 74% maintained at least 150 min/week of
moderately intense activity.
• Da Qing Study [127] — This study from China included subjects with impaired glucose
tolerance, as determined by oral glucose tolerance tests, who were randomized to a
control group or to one of three active treatment groups: diet only, exercise only, or diet
plus exercise. Subjects were followed biannually. After an average of 6 years’ follow-
up, the diet, exercise, and diet plus exercise interventions were associated with 31, 46,
and 42% reductions, respectively, in the risk of developing type 2 diabetes.
• Xenical in the Prevention of Diabetes in Obese Subjects (XENDOS) Study [128] — This
study addressed the benefit of weight reduction achieved by the addition of orlistat to
lifestyle change with regard to delaying the progression of type 2 diabetes in a group
with BMIs ≥30 kg/m2 with or without impaired glucose tolerance. After 4 years of
treatment, the effect of adding orlistat corresponded to a 45% reduction in risk factors
in the IGT group, with no effect observed in those without IGT [128].
MOUSE MODELS FOR OBESITY-INDUCED DIABETES

Obesity-driven type 2 diabetes (diabesity) involves complex genetic and environmental interactions
that trigger the disease. The New Zealand Obese mouse (NZO/HlLt) represents one such model.
These mice are hyperphagic and develop juvenile-onset obesity, even when fed a low-fat (4 to 6%)
diet. Approximately 50% of NZO/HlLt males transit from impaired glucose tolerance to diabetes
by 24 weeks of age [129]. The new mouse models of obesity-induced diabetes (diabesity models)
have been created by combining independent diabetes risk-conferring quantitative trait loci from
two unrelated parental strains: New Zealand Obese (NZO/HlLt) and Nonobese Nondiabetic
(NON/Lt) [130–132]. Recombinant congenic strains are particularly useful for the analysis of
polygenic syndromes. The NZO strain, selected for polygenic obesity, is known to contribute
obesity/diabetes quantitative trait loci (QTL) on chromosomes (Chr) 1, 2, 4, 5, 6, 7, 11, 12, 13, 15,
17, and 18. Recombinant congenic strain (RCS)-10 recreates the 100% incidence seen in
(NZO×NON) F1 males, but with less weight gain. Similarly, RCS-6, -7, -8, and -9 represent
diabetes-prone strains with different combinations of diabetogenic QTL [129]. M16 mice represent
an outbred animal model used to facilitate gene discovery and elucidate the pathways controlling
early-onset polygenic obesity and type 2 diabetic phenotypes. Phenotypes prevalent in the M16
model, with obesity and diabesity exhibited at a young age, closely mirror current trends in human
populations [133].
CONCLUSIONS
The dramatic increase in obesity in adults and children has reached epidemic proportions. The
resultant comorbidities are associated with significant health and financial burdens, warranting
vigorous and comprehensive preventive efforts. Obesity is strongly associated with insulin resistance
and vascular inflammation, as well as with a cluster of numerous risk factors, including athero-
sclerosis, hypertension, and diabetes. Prevention of overweight is critical, because long-term out-
come data for successful treatment approaches are limited. Knowledge of the genetic basis for
differences among the complex of hormones and neurotransmitters (including growth hormones,
leptin, ghrelin, neuropeptide Y, melanocortin, and others) responsible for regulating satiety, hunger
lipogenesis, lipolysis, and growth will eventually refine our understanding of obesity and lead to
more effective therapies [134]. The American Diabetes Association recommends changes in life-
style, such as weight loss to a desirable BMI, increased physical activity, and healthy eating habits
[135]. Dietary nutrients known to lower inflammatory mediators include omega-3 fatty acids,
vitamin E, chromium, flavonoids, coumarins, and anthocyanins. Dietary nutrients that tend to raise
inflammatory markers include omega-6 fatty acids, iron, trans fats, and cholesterol. Optimal
approaches to prevent the development of diabetes in obese adults and children should combine
dietary and physical interventions.
ACKNOWLEDGMENTS
SKJ was supported by a grant from NIDDK and the Office of Dietary Supplements of the National
Institutes of Health (RO1 DK064797). The authors thank Ms. Georgia Morgan First for the excellent
editing of this manuscript.
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13 Angiogenesis-Targeted
Redox-Based Therapeutics
Shampa Chatterjee, Debasis Bagchi,
Manashi Bagchi, and Chandan K. Sen
CONTENTS
Introduction ....................................................................................................................................155
Adipokines, Adipokinomes, Inflammation, and White Adipose Tissue .......................................156
Hypoxia, Cancer, and Angiogenesis..............................................................................................157
Role of Leptin, Product of the ob Gene, in Angiogenesis............................................................157
Antiangiogenic Therapeutic Strategies to Regulate Obesity.........................................................158
Redox Control of Angiogenesis: Oxidants as Inducers
of Angiogenic Factors and Angiogenesis....................................................................................159
Antiangiogenic Function of Antioxidants .....................................................................................160
Antiangiogenic Antioxidant Nutrients ...........................................................................................160
Obesity, Angiogenesis, and Cancer ...............................................................................................161
Conclusions ....................................................................................................................................161
Acknowledgment............................................................................................................................161
References ......................................................................................................................................161
INTRODUCTION
Obesity is now a worldwide epidemic [1–3]. The prevalence of overweight and obesity in the
United States and other industrialized and developing countries is increasing exponentially (Table
13.1) [1–6]. Approximately half a billion of the world’s population is now considered overweight
(body mass index [BMI], 25–29 kg/m2) or obese (BMI, >30 kg/m2) [1–3,9]. Genetic predisposition,
inadequate energy expenditure, increased caloric intake, environmental and social factors, and
sedentary lifestyle represent major contributors to obesity [1–9].
Recent studies have shown that approximately a third of the variance in adult body weights
is secondary to genetic influences [10]. Leptin, an adipocyte- and placenta-derived circulating
protein, regulates, to some extent, the magnitude of fat stores in the body causing obesity [11].
Gastrointestinal peptides, neurotransmitters, and adipose tissue may also have an etiologic role
in obesity [12]. Low caloric diets with or without exercise can help with temporary weight loss;
nevertheless, diet and exercise alone have not proven universally successful for long-term
solutions in weight management. In addition, supplementation with drugs that suppress appetite,
reduce food intake, increase energy expenditure, or influence nutrient partitioning or metabolism
have potential efficacy, but unfortunately they are accompanied by adverse side effects, some
life threatening [13,14].
155
TABLE 13.1
Percentage of Population Obese Worldwide
Country Adults (%) Children (%)
United Kingdom 22 22
Spain 13 30
Finland 11 13
Denmark 10 18
Sweden 9 18
France 9 18
Italy 9 36
United States 31 15
The genesis and development of metabolic syndromes such as obesity are directly fed by
angiogenesis. Angiogenesis, the growth or formation of new blood vessels by capillary sprouting
from preexisting vessels, is critical to the expansion of adipose tissue. New blood vessels, by
providing nutrients and oxygen deep into the adipose tissue, spur the development and maturation
of adipocytes [15–18]. This is further enhanced as adipocytes themselves induce angiogenic factors
such as vascular endothelial growth factor (VEGF), monobutyrin, and leptin [15]. In addition,
adipocytes also induce endothelial cell-specific mitogens that cause proliferation of endothelial
cells lining the vasculature of these vessels. Such endothelial cell proliferation and differentiation
within the fat tissue are presumed to be involved in the development and maintenance of adipose
tissue [15–17]. Endothelial cells also interact with adipocytes and promote their maturation and
proliferation. These cells secrete basic fibroblast growth factors, platelet-derived endothelial cell
growth factor, and other soluble matrix-bound preadipocyte mitogens, which stimulate preadipocyte
replication and promote differentiation [15–17]. Thus, newly formed adipose tissue depends on
continued angiogenesis for further growth [15]. The interaction between microvascular endothelial
cells and preadipocytes promotes the expansion of adipose tissue [16,18,19]; therefore, the devel-
opment of adipose tissue, also known as adipogenesis, is intrinsically associated with angiogenesis.
In other words, the expanding adipose tissue in adults represents one of the few sites of active
angiogenesis.
ADIPOKINES, ADIPOKINOMES, INFLAMMATION,

AND WHITE ADIPOSE TISSUE
Conventionally, white adipose tissue or fat was known to provide thermal and mechanical insulation
to the body [17,20]. In addition, it serves as an energy storage depot for mammals [16]. The white
adipose tissue has now emerged as a dynamic, multifunctional endocrine organ involved in a wide
range of physiological and metabolic processes [15–17]. The tissue acts as a central reservoir of
lipids subject to deposition and the release of fatty acids [15–18,20].
White adipocytes secrete several major hormones, most importantly leptin and adiponectin,
and a diverse range of signaling mediators collectively known as adipokines or adipocytokines
[17–20]. The total number of adipokines is now well over 50, and their main functional categories
include appetite and energy balance, immunity, insulin sensitivity, angiogenesis, homeostasis, lipid
metabolism, and blood pressure [16,20]. Furthermore, a growing list of adipokines is involved in
inflammation: tumor necrosis factor α (TNFα), interleukin 1β (IL-1β), IL-6, IL-8, IL-10, trans-
forming growth factor β (TGF-β), plasminogen activator inhibitor 1 (PAI-1), haptoglobin, and
serum amyloid A [15–19]. Under conditions of obesity, the production of these inflammatory
Angiogenesis-Targeted Redox-Based Therapeutics 157
adipokines by adipose tissue is increased. This has led to the hypothesis that obesity is characterized
by a state of chronic low-grade inflammation and that this provides a link to insulin resistance and
metabolic syndrome [15,17]. The term adipokinome refers to proteins involved in lipid metabolism,
insulin sensitivity, the alternative complement system, vascular homeostasis, regulation of blood
pressure and energy balance, and angiogenesis [16,17,20]; however, the extent to which adipose
tissue contributes quantitatively to the elevated circulating levels of these inflammatory adipokines
in obesity is unclear. Moreover, it is also unknown whether this is a generalized or local state of
inflammation [17,20]. Overall, increased production of inflammatory cytokines and acute-phase
proteins by the adipose tissue in obesity primarily relates to localized events within the expanding
fat depots [16].
HYPOXIA, CANCER, AND ANGIOGENESIS

Hypoxia or low levels of oxygen availability to the adipose tissue, as might happen to the
peripheral white fat mass ahead of angiogenesis, could be a key trigger for the inflammation-
related events in white adipose tissue in obesity [17–20]. Adipose-derived inflammatory cytokines
may directly stimulate angiogenic factors, such as VEGF and leptin, or induce them through
activation of the transcription factor hypoxia-inducible factor 1 (HIF-1) [18,20]. HIF-1 controls
the cellular response to hypoxia by activating numerous genes, as a recent study of global gene
expression using DNA microarrays has shown [21]. Immunohistochemical analysis of human
tumor biopsies has revealed stabilization of HIF-1α in neoplastic tissues [22]. High HIF-1α
levels in tumors reflect the frequent presence of intratumoral hypoxia and the fact that many
common genetic alterations in cancer cells affect HIF-1α expression [23]. Because HIF-1α binds
to and activates transcription of the gene encoding VEGF [23], there seems to be a link between
HIF, oncogene gain-of-function, and tumor vascularization. In addition, the remarkable frequency
with which common genetic alterations in cancer cells are associated with increased HIF-1 α
expression suggests that HIF-1α stabilization could contribute to the accumulation of mutations
during tumor progression. This hypothesis is supported both by mechanistic studies in animal
models of cancer and by clinical studies demonstrating that HIF-1 α stabilization is associated
with increased risk of mortality in a variety of human cancers [24]. HIF-1 also plays critical
roles in angiogenesis by directly activating transcription of the VEGF gene [25]. HIF-1-controlled
VEGF production leads to autocrine signal transduction that is critical for angiogenesis, and
many of the biological processes in angiogenesis, extracellular matrix invasion, and tube forma-
tion by endothelial cells are stimulated through HIF-1 [21,26].
ROLE OF LEPTIN, PRODUCT OF THE ob GENE,

IN ANGIOGENESIS
Leptin, an adipocyte-derived 16,000 molecular weight cytokine-like hormone, plays a pivotal role
in the regulation of body weight and obesity, as well as in the control of food consumption,
sympathetic nervous system activation, thermogenesis, and proinflammatory immune responses
[27]. Because angiogenesis and adipogenesis are integrally linked during embryonic development
of adipose tissue mass, Bouloumié et al. [27] evaluated the regulatory role of leptin in the growth
of the vasculature using human umbilical vein endothelial cells (HUVECs) and porcine aortic
endothelial cells. Leptin, via activation of the endothelial leptin receptor (Ob-R), generates a growth
signal involving a tyrosine-kinase-dependent intracellular pathway and promotes angiogenic pro-
cesses [16,27]. This leptin-mediated stimulation of angiogenesis is viewed as a prime event in the
development of obesity [15,16,27]. Leptin also contributes to the modulation of growth under
physiological and pathophysiological conditions in other tissues [15–17,27].
ANTIANGIOGENIC THERAPEUTIC STRATEGIES

TO REGULATE OBESITY
Rupnick et al. [28] explored the corelationships between adipose tissue growth, angiogenesis, and
leptin levels in ob/ob mice, which rapidly accumulate adipose tissue and develop spontaneous
obesity because of a lack of functional leptin. The authors also examined endothelial cell prolifer-
ation, apoptotic cell death in adipose tissue, and metabolic consequences in these mice following
treatment with antiangiogenic inhibitor TNP-470, a synthetic analog of fumagillin, which is also
an inhibitor of endothelial cell proliferation in vitro [28]. TNP-470-treated ob/ob mice dose-
dependently lost body weight and adipose tissue weights as compared to the control animals.
Obesity-associated hyperglycemia, serum glucose levels, and appetite levels were also reduced.
TNP-470-treated mice also had the lowest average lean mass [28]. Several angiogenesis inhibitors,
including endostatin, Bay12-9566 (a matrix metalloproteinase inhibitor), thalidomide, angiostatin,
and TNP-470, were tested on ob/ob mice, and all treatment groups gained less or lost weight
compared to the control animals [28]. Mice from other obesity models also yielded similar results.
The authors also treated 3T3-L1 preadipocytes with different concentrations of TNP-470 to evaluate
whether suppression of preadipocyte proliferation contributes to this effect, and the results dem-
onstrate that both endothelial-mediated mechanisms and preadipocyte suppression are involved in
this pathophysiology [28]. When cell proliferation and apoptosis were assessed in epididymal fat
sections from TNP-470-treated and control ob/ob mice, TNP-470 decreased endothelial cell pro-
liferation and increased apoptosis. Furthermore, basal metabolic rate (as measured by oxygen
consumption, VO2max) was also increased in TNP-470-treated ob/ob mice [28].
Brakenhielm et al. [29] evaluated the effect of TNP-470 on C57Bl/6 wt and ob/ob mice fed a
high-fat diet. Systemic administration of TNP-470 prevented obesity in high-caloric-diet-fed
C57Bl/6 wt mice as well as in genetically leptin-deficient ob/ob mice. This containment of obesity
in mice was accompanied by a reduction of vascularity in the adipose tissue [29]. TNP-470
selectively affected the growth of adipose tissue as measured by the ratio between total fat and
lean body mass, as well as decreased serum levels of low-density lipoprotein (LDL) cholesterol
[29]. Furthermore, TNP-470 increased insulin sensitivity as demonstrated by reduced insulin levels,
suggesting the therapeutic role of a potent angiogenesis inhibitor in the prevention of type 2 diabetes
[15,29]. The investigators demonstrated that adipose tissue growth is dependent on angiogenesis
and that potent antiangiogenic compounds may serve as novel therapeutic agents for the prevention
of obesity and symptoms of metabolic syndrome [29].
Voros et al. [30] studied the intricate aspects of the development of vasculature and mRNA
expression of 17 pro- and antiangiogenic factors during adipose tissue development in nutritionally
induced or genetically predisposed murine obesity models. Male C57Bl/6 mice were maintained
either on a standard food diet (SFD) or on high-fat diet (HFD), and male ob/ob mice were maintained
on a SFD over a period of 15 weeks. The ob/ob mice and male C57BL/6 mice on the HFD had
significantly larger subcutaneous and gonadal fat pads, accompanied by significantly higher blood
content, increased total blood vessel volume, and higher number of proliferating cells [30]. Fat pad
growth was accompanied by increased vascularization. Both mRNA and the protein levels of
angipoietin-1 were downregulated, whereas those of thrombospondin-1 were upregulated in the
developing adipose tissue in both obesity models. Angiopoietin-1 mRNA levels correlated nega-
tively with adipose tissue weight in the early phase of nutritionally induced obesity as well as in
genetically predisposed obesity [30]. Placental growth factor and angiopoietin-2 expression were
increased in subcutaneous adipose tissue of ob/ob mice, and thrombospondin-2 expression was
increased in both subcutaneous and gonadal fat pads. No changes were observed in the mRNA
levels of VEGF-A isoforms VEGF-B; VEGF-C; VEGF receptor-1, -2, and -3; and neuropilin-1 [30].
Neels et al. [18] examined the angiogenic process using the 3T3-F442A model of adipose tissue
development. These investigators subcutaneously implanted 3T3-F442A preadipocytes into athymic
Balb/c nude mice to study the neovascularization of developing adipose tissue [18]. These cells
FAT MASS FAT MASS

•VEGF ANTIANGIOGENIC
•Leptin THERAPY
•Monobutyrin
•Nonproliferation
of endothelial cells
Proliferation of •Diminished growth
•endothelial cells of vasculature
•smooth muscles
•preadipocytes
•adipocytes
CONTROL OF
FAT EXPANSION
Growth of vasculature,
new vessels
EXPANDING FAT MASS
FIGURE 13.1 Pathophysiology of angiogenesis in expanding fat mass and significance of antiangiogenic
therapy.
developed into highly vascularized fat pads over the next 14 to 21 days, and these fat pads were
morphologically similar to normal subcutaneous adipose tissue. Histological studies demonstrated
that a new microvasculature comes up as early as 5 days after cell implantation, and real-time
polymerase chain reaction (RT-PCR) quantitative analyses indicated that the expression of endo-
thelial cell markers and adipogenesis markers increased simultaneously in parallel during fat pad
development [13]. Thus, neovasculature originates by sprouting from larger host-derived blood
vessels that run parallel to peripheral nerves, and the endothelial progenitor cells play a minor role
in this process [18]. Figure 13.1 demonstrates the key factors involved in adipose tissue development
and the influence of antiangiogenic therapy.
REDOX CONTROL OF ANGIOGENESIS: OXIDANTS AS

INDUCERS OF ANGIOGENIC FACTORS AND ANGIOGENESIS
Endothelial cells (ECs) lining the blood vessels generate reactive oxygen species (ROS) such as
O2•– and H2O2, which play a role in physiological and pathophysiological responses. High concen-
trations of ROS cause apoptosis and cell death [31]. In addition, ROS-induced oxidative stress is
associated with cardiovascular diseases such as atherosclerosis and diabetes. However, low levels
of ROS, as perhaps produced in response to growth factor, hypoxia, or ischemia, function as
signaling molecules to mediate EC proliferation and migration which may contribute to angiogen-
esis in vivo [32,33].
Cellular ROS can be generated from a number of sources, including the mitochondrial electron
transport system, xanthine oxidase, cytochrome P450, NADPH oxidase, and nitric oxide synthase
(NOS). NADPH oxidase is one of the major sources of ROS in vasculature [31]. Neutrophil NADPH
oxidase releases large amounts of O2– in bursts, whereas vascular NADPH oxidases continuously
produce low levels of O2•– intracellularly in the basal state, yet production can be further stimulated
acutely by various agonists and growth factors [31]. NADPH oxidase is activated by numerous
stimuli such as VEGF, angiopoietin-1, cytokines, shear stress, hypoxia, and G-protein-coupled
receptor agonists, including angiotensin II in ECs [31,34,35]. ROS produced via activation of
NADPH oxidase stimulate diverse redox signaling pathways leading to angiogenic responses in
ECs as well as postnatal neovascularization in vivo [33].
In addition to ECs, ROS stimulates the induction of VEGF in various other cell types including
vascular smooth muscle cells to promote cell proliferation and migration [32,36], cytoskeletal
reorganization, and tubular morphogenesis in ECs [37]. Hypoxia and the adhesion of activated
polymorphonuclear leukocytes to ECs cause ROS production, which results in capillary tube
formation [38,39]. Angiogenesis growth factors such as VEGF and angiopoietin-1 increase ROS
and thus induce EC migration and proliferation [31,34,35].
Compounds that cause ROS formation often stimulate angiogenesis. Ethanol stimulates actin
cytoskeletal reorganization, cell motility, and tube formation in a ROS-dependent manner in ECs
[40]. Leptin, a circulating adipocytokine, upregulates VEGF mRNA and stimulates cell proliferation
through an increase in ROS in ECs [41].
A strong correlation exists among ROS production, neovascularization, and VEGF expression
in the eyes of diabetics [42,43] and in balloon-injured arteries [44]. The generation of ROS during
ischemia/reperfusion can also lead to angiogenesis. Reperfusion of the ischemic retina has been
reported to upregulate VEGF mRNA [45]. Short periods of ischemia/reperfusion induce an increase
in ROS, thereby stimulating myocardial angiogenesis in the ischemic noninfarcted heart [46]
ANTIANGIOGENIC FUNCTION OF ANTIOXIDANTS

Because ROS is involved in angiogenesis, antioxidants that scavenge ROS should inhibit formation
of new vessels. It has been reported that antioxidants such as pyrrolidine dithiocarbamate [47],
epigallocatechin-3-gallate [48], resveratrol (a novel phytoalexin found in grapes, red wine, and
diverse functional foods), and other natural polyphenols inhibit neovascularization in the mouse
model [49,50]. Green tea catechins, vitamin E, etc. also inhibit angiogenic responses in ECs [51].
Antiangiogenic therapy also reduces plaque growth and intimal neovascularization [52], and anti-
oxidants such as vitamins C and E are reported to reduce vascular VEGF and VEGFR-2 expression
in apolipoprotein-E-deficient (apoE–/–) mice [53]. ROS are also involved in neovascularization
during tumor growth. The thiol antioxidant N-acetylcysteine (NAC) attenuates EC invasion and
angiogenesis in a tumor model in vivo [54].
ANTIANGIOGENIC ANTIOXIDANT NUTRIENTS

Tumor vascularization is a key step in the development of solid tumors, and the vast majority of
pharmaceutical activity surrounding angiogenesis relates to the development of therapeutic strate-
gies to destroy existing tumor vasculature and to prevent neovascularization [16–19]. Thus, anti-
angiogenic approaches to treat cancer represent a prime area in vascular tumor biology. Antioxidant
nutrients demonstrate potent antiangiogenic functions. Catechin derivatives exhibited novel anti-
angiogenic properties in three different in vitro bioassays with concentrations ranging from 1.56
to 100 µM [55,56]. Epigallocatechin-3-gallate (EGCG) exhibited the most potent antiangiogenic
activity in all three assays among all catechins tested. EGCG inhibited the binding of VEGF to
HUVECs in a concentration-dependent manner [55,56], and resveratrol and quercetin exhibited
antiangiogenic properties in a concentration-dependent manner (6 to 100 µM) [50]. Pure flavonoids,
including rutin, kaempferol, ferrulic acid, genistein, fisetin, and luteolin, also exhibited novel
antiangiogenic properties [57,58]. These studies demonstrate that functional foods are effective in
limiting angiogenesis in vivo [55–58].
OptiBerry, a blend of six edible berry extracts (blueberry, bilberry, cranberry, elderberry,
raspberry seeds, and strawberry), was recently developed in our laboratories [58,59]. OptiBerry
was shown to possess a high antioxidant capacity, low cytotoxicity, and potent antiangiogenic
properties. In terms of antiangiogenic properties, OptiBerry was superior to individual berry antho-
cyanins, thus highlighting the synergistic power of the blend. OptiBerry significantly inhibited both
H2O2 as well as TNFα-induced VEGF expression by human keratinocytes [58,59]. Angiogenesis

as monitored by Matrigel assay using human microvascular endothelial cells was also impaired in
the presence of OptiBerry [58,59]. In addition to these in vitro cell models, OptiBerry significantly
inhibited inducible transcription factor NF-κB in an in vivo model [35]. In 129 P3 mice, endothe-
lioma cells pretreated with OptiBerry showed a diminished growth of neoplastic vasculature by
more than 50% [59]. These studies highlight the novel antiangiogenic and anticarcinogenic potential
of select natural food constituents, including catechin derivatives, curcumin (comprising about 40%
of the spice turmeric), selected flavonoids (e.g., quercetin, rutin, kaempferol, ferrulic acid, genistein,
fisetin, luteolin, resveratrol), and berry anthocyanins [55–59].
OBESITY, ANGIOGENESIS, AND CANCER

The link between obesity and angiogenesis illuminates the complex association between obesity
and cancer. As mentioned earlier, adipocytes can accelerate tumor vascularization by triggering an
angiogenic signaling cascade; however, the exact mechanisms behind its multifaceted functions
remain unknown. Obesity itself develops via complex mechanisms involving an interplay among
heredity, nutrition, and physical lifestyle. In addition to the role of adipocytes in increasing vascu-
larization and inflammation, fat deposits can also cause hormonal imbalances. High levels of
estrogens contribute to the proclivity toward cancer. The increased risk of breast cancer after
menopause in obese women is believed to be caused by increased levels of estrogens as fat tissues
replace ovaries to become the primary source of estrogen [60]. Obesity is often associated with
the development of insulin resistance with high circulating levels of insulin and insulin-like hor-
mones [61]. Insulin is known to stimulate cell proliferation, suggesting that an overproduction or
high concentrations may be responsible, at least to some extent, for cancer development. High
insulin and insulin-like hormone levels are closely associated with an increased risk for breast
cancer and poorer survival after breast cancer diagnosis [62].
CONCLUSIONS
Overweight and obesity pose epidemic threats to human health, especially in the Western world.
Healthy diet, proper nutrition, and exercise represent the fundamental prerequisites to fighting such
threats. Growth of adipose tissue depends on the blood vessels that feed the fat mass. Emergent
studies reveal that the growth of adipose tissue may be regulated by inhibiting the development of
vasculature. Antiangiogenic therapeutics show significant promise to manage the undesired expan-
sion of fat mass. Given that oxidants stimulate angiogenesis, it is understandable why antioxidants
also possess antiangiogenic properties. Antiangiogenic nutrients provide a safe and potentially
effective strategy to directly fight obesity and thus have an effect on controlling cancer. Several
polyphenolic antioxidants, especially berry anthocyanins, possess potent antiangiogenic properties
and should be considered as countermeasures for managing obesity in humans.
ACKNOWLEDGMENT
This work was supported in part by NIH-GM069589.
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14 Obesity as an Occult Risk

Factor for Drug and
Chemical Toxicities
George B. Corcoran
CONTENTS
Introduction ....................................................................................................................................165
Animal Models of Human Obesity ...............................................................................................166
Roles of Genetics and Environment ..............................................................................................167
Overfed Rat Model vs. Zucker Rat Model....................................................................................167
Toxicity of Drugs and Chemicals ..................................................................................................168
Perspective......................................................................................................................................170
References ......................................................................................................................................171
INTRODUCTION
It is widely accepted in the medical community that obesity is a leading disease that has far-reaching
negative health consequences. Despite this general agreement, the full implications of obesity,
particularly its adverse impacts, are underappreciated more often than not. Large percentages of
populations in Western countries qualify as substantially overweight, obese, or morbidly obese.
Obesity is the most common disease in the United States. Bray [1] noted that the current worldwide
epidemic of obesity will be followed by an epidemic of diabetes, a disease closely linked to
metabolic syndrome seen in most obese individuals [2–4]. In investigating the recent surge in
childhood obesity, Bray and colleagues observed a direct correlation with increased consumption
of beverages rich in high-fructose corn syrup [5].
It is deeply troubling that the Worldwatch Institute reported in 2004 that, for the first time, the
number of overfed and obese people, about 1.1 billion and growing, would soon outnumber the
number of underfed people in the world, about 1.1 billion and stable or declining. Overweight and
obesity are estimated to account for 4 to 9% of total healthcare costs annually [6] and 30% of the
increase in healthcare costs seen since 1987 [7].
Life expectancy has increased from 73.7 years in 1980 to 77.0 years in 2000 [8]; however, we
may live to see the first generation in this country to experience a decline in life expectancy [9].
Obesity and morbid obesity (body mass index [BMI] ≥30 and ≥40, respectively) result in substan-
tially increased morbidity and mortality, arising from many different sources. The death rate rises
when body weight exceeds the desired value for height by a little as 20% [10]. As noted in the
Framingham Heart Study [11], the risk of death in 26 years is increased by 1% for each extra
pound of body weight at ages 30 to 41 and increased by 2% for each extra pound of body weight
at ages 50 to 62. It was only 20 years ago that obesity was officially declared a disease, distinct
165
from the large number of well-known comorbidities, including heart and liver disease, hypertension,
diabetes, and numerous cancers [12,13]. Total cancer mortality is increased by obesity in men by
a relative risk of 1.52. Specific cancer increases include liver (4.52), pancreas (2.61), stomach
(1.94), colon and rectum (1.84), and gallbladder (1.76). Total cancer mortality shows a greater
increase in obese women (1.88) [14].
Liver disease is a hallmark of obesity, particularly morbid obesity. Why many forms of liver
disease are increased is not well understood, but it may involve increased injury by drugs and
chemicals. Wanless and Lentz [15] reported large differences between the livers of obese vs. lean
humans: steatosis (70% vs. 35%), nonalcoholic steatohepatitis (18.5% vs. 3%), and cirrhosis (2–3%
vs. 0%). A factor that may contribute to increased liver and other organ disease may be exaggerated
drug toxicity. It is well known, for example, that obese patients and rats undergoing surgical
anesthesia with halothane, methoxyflurane, and enflurane suffer higher rates of liver and kidney
damage due to increased toxic metabolite formation [16–18]. Additional clinical studies show that
obesity increases the clearance of many drugs that are eliminated primarily by metabolism in the
liver [19,20], including acetaminophen [21] and lorazepam [22]. This increased metabolic activity
is also capable of activating drugs and chemical to toxic metabolites at increased rates in obese
individuals.
This chapter considers findings, primarily from historical data, that support the hypothesis that
obese individuals are at substantially increased risk of drug toxicity. This increased risk arises from
varied sources. These sources include higher rates of toxic metabolite formation, greater accumu-
lation of the toxic form of a drug, and increased susceptibility due to decreased defenses, including
those related to glutathione. The chapter does not consider or present the quite substantial body of
evidence showing that many drugs also induce higher incidences of toxicity due to inappropriately
high doses of drugs administered to obese individuals. In these cases, dosing is based on total body
mass or other values that systematically overestimate actual distribution and clearance values in
obese individuals. This also results in acute or chronic exposure to higher and more prolonged drug
concentrations and an increased frequency of drug-related toxicities.
ANIMAL MODELS OF HUMAN OBESITY

It can be quite difficult and in many cases impossible to perform studies that would be a direct test
of one’s working hypothesis in human volunteers or patients due to ethical and other considerations.
For this and other reasons, it is often necessary to perform some or most studies with models that
duplicate the human condition. In the case of obesity, a wide variety of models exists today. Each
has a different array of strengths, weaknesses, and distinguishing attributes. Models divide into those
primarily of genetic origin and those primarily of environmental origin [2]. By selecting a model,
the implications of the study results become thus specified, as do the possible relevance of results
for drug-related mortality or morbidity in obese humans. When the hypothesis that drugs are more
toxic in obesity first came under examination, some key animal models that exist today were poorly
characterized or were not available because they had not been developed. Although models based
on leptin defects, including the leptin null (ob/ob) mouse and the leptin receptor null (db/db) mouse,
were in use, the genetic bases of these models were not understood. Some current models that exploit
melatonin defects — AGR Agouti, ART Agouti-related protein, melanocortin-4 receptor (MC4R),
proopiomelanocortin (POMC), carboxypeptidase, and tubby mice — were available, but others were
not [23]. Other environmental models in which mice or rats acquire obesity include dietary models
(cafeteria diet, force feeding, overfeeding), surgical models (hypothalamic lesion), and chemically
induced models (gold thioglucose). Rat models offer many advantages for studying drug disposition
and toxicity, including the ability to obtain multiple blood samples from the same animal to estimate
pharmacokinetic parameters. Leading rat models of obesity include the Zucker rat (a genetic model)
and the overfed rat (a model in which obesity is acquired).
Obesity as an Occult Risk Factor for Drug and Chemical Toxicities 167
TABLE 14.1
Content of Pellet Control and Energy-Rich Dietsa
Diet Component Pellet Control Diet Energy-Dense Diet
Fat 6.5 60.0
Protein 14.5 24.5
Carbohydrate 57.5 7.5
Moisture 10.0 1.0
Fiber 4.0 2.0
Ash 7.5 5.0
Energy content (kcal/g)b 3.47 6.68
a Shown as percentage (w/w) and based on representative lot analysis of
Prolab R-M-H 1000 by the manufacturer (Agway, Inc.; Syracuse, NY) and
a description of an energy-dense diet adapted from Schemmel et al. [29].
b Calculated from 9, 4, and 4 kcal/g for fat, protein, and carbohydrate,
respectively.
ROLES OF GENETICS AND ENVIRONMENT

It is widely understood that both genetic and environmental factors contribute to the majority of
human obesity. Obesity is a complex disorder in which genetic predisposition interacts with
environmental factors, which together produce an array of different human phenotypes of the disease
[24]. The pioneering studies of Stunkard and others [25–27] who observed monozygotic and
dizygotic twin pairs, as well as adopted twins raised apart, showed that at least 50%, and possibly
as high as 90%, of obesity is heritable. The heritability of obesity is polygenetic. Only 173 human
obesity cases have been shown to be due to single-gene mutations occurring in 10 genes [28].
Although some studies present data showing low rates of cultural transmission of obesity, these
stand in direct opposition to a well-established body of findings showing strong socioeconomic
determinants of obesity. It can be said with some certainty that both genetic predisposition and
environmental factors are important keys to successful modeling of human obesity.
OVERFED RAT MODEL VS. ZUCKER RAT MODEL

The goal of using animal models to examine a given mechanism involved in human obesity should
not be sidetracked by the desire to work with a near-perfect model but to employ one that will be
informative and relevant for the question at hand. It is likely that some models are better mimics
of drug disposition than others. This guided our thinking in selecting and then characterizing the
overfed rat model of human obesity for pharmacokinetics and metabolism studies. This model
seemed to start with recapitulating a key environmental factor contributing to human obesity, the
increasing percentage of daily caloric intake that has been represented by dietary fat over the past
5 decades. Sprague–Dawley rats become obese when maintained for more than 12 weeks on an
energy-dense diet developed by Schemmel et al. [29] (see Table 14.1 and Figure 14.1).
Overfed rats that became obese on an energy-rich diet were compared to Zucker rats, genetically
obese rodents that inherit obesity through an autosomal recessive trait caused by a mutation of the
leptin receptor gene [30]. The latter mechanism accounts for no more than a fraction of a percent
of human obesity. Comparisons showed that overfed rats resembled obese humans in 11 of 12
characteristics selected for their importance to drug disposition and toxicity, including those that
control drug clearance and volume of distribution. Zucker rats resembled obese humans in only 5
of 12 characteristics, and the discrepancies were highly meaningful. There were no increases in
FIGURE 14.1 Pellet control rat vs. obese overfed rat. Pictured animals are representative of groups of rats
that were fed a standard pellet diet (#4) or an obesity-inducing energy-rich diet (#5) for 57 weeks. Total body
mass differed significantly between the group fed the pellet diet (705 ± 110 g, n = 7) vs. the energy-dense
diet (1086 ± 186 g, n = 9) at p < 0.05. Other pharmacokinetic characteristics differed substantially between
pellet control and obese rats [28].
fat-free mass or creatinine clearance, while thyroid function was abnormally depressed [31].
Differences of the greatest significance involved hepatic cytochrome P450, which increased in
proportion to total body mass in obese overfed rats but remained unchanged in obese Zucker rats
and refractory to induction by phenobarbital. Although P450 status is not fully characterized in
obese humans, many reports show increased drug oxidation in obese individuals, consistent with
increased P450 levels.
TOXICITY OF DRUGS AND CHEMICALS

Being ill more often, obese individuals receive drug treatment more frequently and beginning earlier
in life than those of normal weight. Ironically, information to guide the appropriate treatment of
this substantial population has only recently begun to accrue, and tools to adjust drug dosing for
obese patients remain limited in number and application. Uncertainty in selecting the correct dose
of a drug for an obese patient is a problem that has become more acute rather than better understood.
Because of higher rates of morbidity, obese individuals are over-represented among those receiving
medical attention and drug treatment.
Studies with the obese overfed rat demonstrate that representative drugs and chemicals are
more toxic to obese animals, even when dosing biases are eliminated by dosing according to fat-
free body mass. Experiments with acetaminophen (Table 14.2) show that this analgesic produces
greater liver and kidney necrosis in obese overfed rats when compared to pellet control rats,
independent of whether animals are dosed according to total body mass or to fat-free mass [32].
The latter indicates that obese rats are intrinsically more susceptible to acetaminophen-induced
necrosis in both of these organs. Rats maintained on the energy-dense diet showed increased
glucuronidation and decreased sulfation of acetaminophen (Figure 14.2) [32]. Prior studies dem-
onstrated that these dosing regimens produced initial acetaminophen plasma concentrations that
were not statistically different, but elimination curves differed between control and obese animals,
reproducing the same increase in metabolic clearance in obese rats as seen in obese humans [33].
Acetaminophen activation to its toxic metabolite is increased 28% per mg hepatic microsomal
protein from obese overfed rats, and immunodetectable CYP2E1, the primary catalyst of acetami-
nophen bioactivation, is overtly elevated in obese rats [34].
TABLE 14.2
Increased Acetaminophen-Induced Liver and Kidney Necrosis in Obese Overfed Rats
Relative Incidence and Extent of Necrosis (%)
Liver Kidney
48-Hour
Group Survival 0 1+ 2+ 3+ 0 1+ 2+ 3+ 4+
a
Pellet control 9/9 100 — — — 89 11 — — —
Energy-dense lean 7/9 86 — 14 — 43 29 14 14 —
Energy-dense obesea dosed to 4/9 25 25 25 25 — — — 50 50
total body minerals (TBM)
Energy-dense obeseb dosed to 4/9 25 25 50 — — 33 — 33 33
fat-free mass (FFM)
Note: Three groups of rats received 710 mg/kg acetaminophen i.p. and resided in metabolism cages for 24 hours. The
last group (dosed to FFM) received the same dose as energy-dense lean animals on a fat-free mass basis (i.e., 955 mg/kg
of FFM). Animals were sacrificed at 48 hr and portions of liver and kidney were prepared for light microscopic analysis.
Hepatic and renal necrosis in surviving animals was graded from 0 (absent) to 4+ (>50%) according to the abundance
of dead parenchymal or renal epithelial cells in sections stained with hematoxylin and eosin. Values represent the
percentage of surviving animals within a group exhibiting each grade of injury. Differences in distribution of enumerated
necrosis scores were detected by nonparametric analysis of variance and Tukey-like multiple comparison test.
a Values bearing the same superscript were different at p < 0.05. Both liver and kidney scores differed between pellet
control and obese animals dosed to TBM.
b One kidney histology sample was lost during processing.
Source: Corcoran, G.B. and Wong, B.K., J. Pharmacol. Exp. Ther., 241, 921, 1987. With permission.
Oxidation of ethanol by the microsomal ethanol-oxidizing system (MEOS) system is elevated

by 28% in hepatic microsomes from obese overfed rats compared to rates in microsomes from
pellet control animals [35]. It is possible that this elevation in ethanol oxidation by the MEOS
system could be a contributing factor to the high incidence of liver pathology in obese individuals.
This potential relationship bears further investigation.
80
Pellet
Percent of Administered Dose
Lean
60 Obese-TBM
Obese-FFM
*
40
*
20
* * *
0
A-Gluc A-Sulf APAP Total
FIGURE 14.2 Effects of obesity and dosing normalization on metabolic fate of acetaminophen. Values are
the sum of acetaminophen and metabolites that were excreted into urine plus those remaining in the carcass
at the time of sacrifice. The latter values were estimated by multiplying the terminal plasma concentration by
the volume of distribution. Differences were detected by analysis of variance and Tukey’s multiple comparison
test (* = p < 0.05). Results are expressed as mean ± S.E.M. (From Corcoran, G.B. and Wong, B.K., J.
Pharmacol. Exp. Ther., 241, 921, 1987. With permission.)
TABLE 14.3
Increased Furosemide-Induced Liver and Kidney Necrosis in Obese Overfed Rats
Dosed According to Fat-Free Mass
Relative Incidence and Extent of Necrosis (%)
Livera Kidney
24-Hour
Group Survival 0 1+ 2+ 3+ 0 1+ 2+ 3+
Pellet controla 6/6 83 17 — — 67 17 17 —
Energy-dense obesea dosed 9/9 — 44 44 11 33 22 22 22
to fat-free mass (FFM)
Note: Control and obese rats were dosed with furosemide at 450 mg/kg fat-free mass (519 ± 82 g vs. 589 ±
36 g, respectively). Animals were sacrificed at 24 hours, and portions of liver and kidney were prepared for
light microscopic analysis. Hepatic and renal necrosis in surviving animals was graded from 0 (absent) to 4+
(>50%) according to the abundance of dead parenchymal or renal epithelial cells in sections stained with
hematoxylin and eosin. Values represent the percentage of surviving animals within a group exhibiting each
grade of injury. Differences in the distribution of enumerated necrosis scores were detected by nonparametric
analysis of variance and Tukey-like multiple comparison test.
a Liver but not kidney scores differed between pellet control dosed according to FFM and energy-dense obese
dosed according to FFM at p < 0.05.
Source: Corcoran, G.B. et al., Toxicol. Appl. Pharmacol., 98, 12, 1989. With permission.
The loop diuretic furosemide (LASIX®) also undergoes hepatic metabolism to a toxic metabolite
that accounts for both liver and kidney necrosis and organ failure. In the obese overfed rat,
furosemide is more toxic when dosed on a total body mass basis as well as on a fat-free body mass
basis, again indicating the greater intrinsic susceptibility of the obese liver to damage by drugs
undergoing P450 bioactivation [36] (see Table 14.3).
Gentamicin, a powerful aminoglycoside antibiotic that is reserved for the treatment of severe
or life-threatening Gram-negative infection, has a narrow therapeutic index due to nephrotoxicity
and ototoxicity. For this reason, its use is typically reserved for critically ill patients. An analysis
of critically ill patients treated with aminoglycoside antibiotics shows that the incidence of renal
injury is higher in patients who are substantially overweight [37]. This raised the possibility that
drugs that do not require bioactivation by P450 also are more toxic in obese individuals. Because
obese overfed rats exhibit urinary acidification that perhaps could affect gentamicin renal accumu-
lation and therefore toxicity, a group of obese rats was returned to the pellet diet for 7 days to
restore normal urinary pH. pH-normalized animals were dosed with gentamicin according to ideal
body mass plus 40% of excess body mass, the dosing adjustment used clinically for obese patients.
N-Acetyl-hexosaminidase (NAH) is a sensitive biomarker of renal epithelial necrosis. When this
index of injury was normalized to creatinine excretion, obese rats demonstrated increased renal
injury over pellet controls and obese rats dosed to fat-free mass (Figure 14.3) [38]. Increased
toxicity was accompanied by increased renal accumulation of gentamicin over pellet controls.
Again, obesity was found to potentiate drug-induced organ injury.
PERSPECTIVE
Obesity is a mounting public health problem in the United States and other industrialized countries.
This chapter offers complementary findings that obesity predisposes rats to liver and kidney damage
by chemicals and drugs acting through different toxic mechanisms. These findings also offer several
lines of evidence that support the hypothesis that obesity predisposes humans to drug and chemical
toxicities that may explain, in part, high incidences of liver, kidney, and other organ damage. The
0.60
Control *
Creatinine-Adjusted Urinary NAH

Obese/pH Restored
Obese/pH Restored
IBM + 40% XSBM
(U/mg)
0.30
0.00
–1 0 1 2 3 4 5
Time (days)
FIGURE 14.3 The effects of obesity on creatinine-adjusted urinary excretion of N-acetyl-hexosaminidase

(NAH) after chronic gentamicin dosing based on ideal body mass plus 40% excess body mass. Creatinine-
adjusted urinary excretion of NAH was determined over time for three groups of animals. Control rats were
treated with 30 mg/kg gentamicin i.p. twice daily for 5 days based on ideal body mass ( ). The urine pH of
obese rats was restored to control values (7.25 ± 0.24) by placing animals on a pellet diet for 7 days. These
obese, pH-restored rats were treated with gentamicin based on ideal body mass ( ) or ideal body mass plus
40% of excess body mass ( ). Results are expressed as mean ± standard deviation of six to eight animals
per group (*p < 0.05 vs. control by analysis of variance and Tukey’s test). (From Corcoran, G.B. and Salazar,
D.E., J. Pharmacol. Exp. Ther., 248, 17, 1989. With permission.)
higher rates of injury in obese overfed rats do not appear to arise because obese organs were
exposed to higher drug concentrations than organs of lean controls. This latter observation points
to the importance of underlying susceptibility factors, such as increased cytochrome P450 activities,
diminished defenses by glutathione and other protective mediators, and other mechanisms. It is
possible that increased liver damage and perhaps even the shortened life span of obese humans
may arise, in part, from greater susceptibility to chemical and drug toxicity. It would be valuable
if concepts established with the obese overfed rat were pursued in the clinical setting, where the
uncertainty of animal model extrapolation would be obviated. The negative impact of obesity on
human health and healthcare expenditures will continue to grow over the next decades. Because
obesity is the second most common preventable human disease, the time is now to accelerate the
pace of research into the bases for this disease and discover new means of reversing its progression
and morbidities and preventing premature mortality.
ACKNOWLEDGMENTS
The author wishes to acknowledge the valuable contribution made by his many colleagues and
students, as well as generous support from the National Institutes of Health (NIH GM20852, NIH
GM41564, NIH 2S07RR05454) and the Research Foundation of SUNY.
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Part IV
Novel Concept in Obesity
Drug Development
15 Adipose Drug Targets

for Obesity Treatment
Olivier Boss, Lorenz Lehr, and Jean-Paul Giacobino
CONTENTS
Introduction ....................................................................................................................................177
Pivotal Role of Adipose Tissue ..............................................................................................177
General Criteria for Anti-Obesity Drug Development...........................................................178
Adipose Targets..............................................................................................................................178
Leptin ......................................................................................................................................179
Adiponectin .............................................................................................................................179
Peroxisome Proliferator-Activated Receptors ........................................................................180
Peroxisome Proliferator-Activated Receptor γ ................................................................180
Peroxisome Proliferator-Activated Receptor δ ...............................................................181
Dual PPAR Agonists........................................................................................................182
Potential Unwanted Side Effects of PPAR Ligand Treatments......................................182
Stearoyl-CoA Desaturase 1 ....................................................................................................182
Acyl CoA:Diacylglycerol Acyltransferase 1 ..........................................................................183
Protein Tyrosine Phosphatase 1B ...........................................................................................184
β3-Adrenergic Receptor ..........................................................................................................185
Other Target Candidates .........................................................................................................185
Adipose Tissue Remodeling Conversion of White to Brown-Like Adipocytes ...........................185
Conclusions ....................................................................................................................................188
Molecular Targets with Small-Molecule Leads
or Drugs Successfully Developed (PPARs) .........................................................................188
Key Targets from the Lipid Synthesis Pathway (SCD1, DGAT1) ........................................189
New, High-Potential Molecular Target (PTP1B) ...................................................................189
Acknowledgment............................................................................................................................189
References ......................................................................................................................................189
INTRODUCTION
PIVOTAL ROLE OF ADIPOSE TISSUE

It is well known that diet and exercise can be, in most individuals, effective means to treat obesity;
however, the steadily increasing prevalence of obesity in most countries undoubtedly shows that
knowing this is not sufficient to avoid or cure this disease. Indeed, obesity is still in need of effective
treatments that have a long-term impact on the course of the disease and its associated cardiovascular
risk factors.
177
In the last few years adipose tissue has been recognized as a very important endocrine organ
that communicates with the brain and peripheral tissues to balance energy intake and expenditure
with the level of energy stored in adipocytes. Recent studies have shown that during the development
of obesity macrophages infiltrate the adipose tissue and generate an inflammation-like state [1].
Macrophages residing in adipose tissue, and possibly also enlarged adipocytes, then produce cyto-
kines that are believed to play a role in the development of pathologies associated with obesity (i.e.,
insulin resistance, type 2 diabetes, dyslipidemia, and cardiovascular disease). Adipose tissue plays
a key role in the regulation of energy metabolism, as a source of both fuel (fatty acids) and hormones
(e.g., leptin), and in the metabolic adaptations to body weight or fat loss observed upon food
restriction in both animals and humans [2–5]. At least two energy balance sensor systems would
seem to exist: one that responds to acute changes in adipose mass and another that monitors long-
term levels of fat stores. The former seems to involve leptin and the sympathetic nervous system as
regulator of appetite and metabolic rate. The chronic “adipostat” system, on the other hand, likely
plays a key role in the regain of fat stores after weight loss, and its mechanism remains obscure.
Adipose tissue must be the source of factors informing other tissues of the status of fat stores [6].
GENERAL CRITERIA FOR ANTI-OBESITY DRUG DEVELOPMENT

The treatment of obesity requires induction, for a certain period of time, of a state of negative
energy balance. This can be achieved through a decrease in the entry of energy (food intake), an
increase in the output of energy (metabolic rate), or a combination of both. In most instances, a
modification of the activity of a single target with a drug will have to trigger additional effects in
another part of the system controlling energy balance to result in a state of negative energy balance.
For example, drug inhibition of an enzyme involved in triglyceride (fat) synthesis will have to
cause a decrease in food intake and/or an increase in energy expenditure to have a therapeutic effect
on obesity. This requirement might seem difficult to meet unless several drugs are used simulta-
neously. The endocrinological nature of the control of energy balance implies that metabolic
adaptations develop when one part of the system is altered. Some adaptations prevent long-term
weight loss (such as the drop in metabolic rate appearing upon body weight loss with food
restriction), whereas other adaptations aid weight loss. In fact, in the last few years, a number of
genetic animal models have shown that inhibition of lipid synthesis by targeted disruption of a key
enzyme in the lipogenic pathway (e.g., SCD1 or DGAT1) can lead to an increase in metabolic rate.
These models thus provide biological validation of novel potential drug targets that are expressed
in adipose tissue; however, we must keep in mind that disruption of the gene encoding a target will
not necessarily predict the effects of inhibition of that target by a drug in adult animals, let alone
in humans. Novel drugs to treat obesity should possess some key features [7]. They must be devoid
of significant side effects over the long term, as treatments will be of long duration. To improve
appreciably on currently available medications, future treatments should aim to induce, and sustain,
a weight loss of at least 10% of body weight. Finally, as life-long therapy will probably be necessary,
the cost associated with therapy must be affordable. In this chapter, we discuss the potential of
various adipose targets for the development of drugs to treat obesity and insulin resistance.
ADIPOSE TARGETS
Two categories of adipose drug targets can be distinguished: targets that reside in adipocytes (e.g.,
cell-surface receptors, enzymes, nuclear receptors) and targets that are secreted by adipocytes (i.e.,
adipokines) that act on other tissues (e.g., brain, skeletal muscle, liver). Adipokines stand for any
factors released by adipose tissue, including adipocytes and stromavascular cells [8,9]. In the past
10 years numerous adipokines have been discovered [8,10–15] that influence the regulation of body
weight, insulin sensitivity, and glucose metabolism, as well as the cardiovascular system, but it is
likely that additional adipokines that have an impact on energy metabolism remain to be uncovered
Adipose Drug Targets for Obesity Treatment 179
[12,16,17]. Additional adipokines of importance in the development of insulin resistance, type 2

diabetes, dyslipidemia, and cardiovascular disease (e.g., RBP4, TNFα, resistin, visfatin, IL-1β,
IL-6) will not be discussed here as they do not seem to represent direct drug target candidates for
obesity treatment [18].
LEPTIN
Most people add about a pound of fat per year in adulthood, which represents a less than 1%
inequality in energy balance. This is an indication of the amazingly tight coupling between food
intake and energy expenditure. An afferent signal secreted from the adipose tissue to the central
nervous system (CNS) was discovered in leptin a decade ago [19]. The amount of leptin secreted
into the circulation is usually proportional to the fat mass [20,21], and it is now well established
that leptin plays a major role in coordinating the regulation of food intake and metabolic rate [22].
The effects seen in rodents led to great hopes for leptin as a means to treat obesity; unfortunately,
the effects of leptin on food intake and body weight have not been found to be as strong in humans
as in mice. A very strong response to leptin was seen in a few people with a mutation causing a
lack of leptin [23]; however, in the majority of cases, it seems that obese patients exhibit resistance
to the action of leptin, rather than a deficiency of leptin.
Several clinical studies, however, have shown a significant effect of leptin in obese patients [24,25].
The short half-life of leptin in humans (25 minutes) [26] and the route of administration (injection)
present pharmacodynamic hurdles for the use of leptin as a therapeutic agent. To address this issue,
some studies used a long-acting, polyethylene glycol-modified recombinant human leptin [25]. Results
from human studies highlight a very similar role for leptin in humans and rodents; however, the prevalent
leptin resistance seen in obese patients blunts the response to leptin, as observed in certain obese rodent
models. The mostly disappointing clinical results together with the high cost of production of the
recombinant protein and the inconvenient route of administration have broadly reduced the interest in
leptin as a therapeutic agent [27]. Nevertheless, a few ongoing clinical trials are investigating the use
of recombinant leptin as treatment for severe insulin resistance and lipodystrophy [28]. The clinical
validation of the action of leptin does make the leptin system a very interesting target, and a long-
acting, orally available, small-molecule leptin receptor agonist would be of tremendous value. Devel-
oping a small molecule that mimics the activating effects of leptin (a protein) will be a daunting task,
however. Part of the challenge is due to the fact that the leptin receptor is a cytokine receptor, a class
of drug targets that has traditionally been very difficult to activate with small molecules.
On the other hand, reversing the resistance to the action of leptin on food intake and energy
metabolism, which seems to develop with age [29], looks like a very promising strategy for treating
obesity. Unfortunately, like insulin resistance, leptin resistance is not yet well understood. Interest-
ingly, protein tyrosine phosphatase 1B (PTP1B) has been shown to be implicated in leptin resistance
[30–32], even further increasing the biological validation of PTP1B, a pharmacologically very
challenging target. Very recent results suggest that C-reactive protein (CRP), a blood plasma marker
of inflammation present in higher levels in obese and insulin-resistant patients, could play a role
in the leptin resistance seen in obese patients [33]. If this mechanism operates in most patients,
then inhibitors of CRP binding to leptin might represent novel agents with clear potential to treat
obesity and insulin resistance.
ADIPONECTIN
Adiponectin (also known as adipocyte complement-related protein of 30 kDa [Acrp30], adipoQ,
or adipose most abundant gene transcript [apM1]) was discovered a few years ago as a 30-kDa
protein abundantly produced by adipocytes [34–36]. It is present in the circulation in two major
oligomeric forms with molecular weights of about 180 kDa (hexamer) and 400 kDa (higher order
structure); the respective levels of these two forms have been suggested to be key to the action of
PPAR ligand
RXR PPARα PPARγ PPARδ
PGC-1α
PPAR response element Gene promoter
FIGURE 15.1 PPAR nuclear hormone receptor family. PPARs and PGC-1α play a key role in energy dissipation.
this adipokine [37]. Several studies found that circulating adiponectin levels in humans were
positively correlated with the degree of insulin sensitivity [38]. In addition, increases in the
expression of adiponectin in white adipose tissue, as well as in the plasma levels of adiponectin,
have been shown after treatment with peroxisome proliferator-activated receptor γ (PPARγ) agonists,
which could contribute to the insulin-sensitizing effects of PPARγ agonists [11,12,38–42].
Adiponectin knockout mice were shown by one group [43], but not another [44], to display
severe diet-induced insulin resistance. This apparent discrepancy suggests that genetic background
influences compensatory mechanisms with regard to the effect of adiponectin on insulin action
[38]. Administration of adiponectin to mice was reported to increase fatty acid oxidation in muscle,
decrease hepatic glucose production, and induce weight loss [45–48], suggesting that this hormone
could represent a therapeutic agent to treat insulin resistance, type 2 diabetes, and obesity. In fact,
a recombinant adiponectin fragment (Famoxin from Genset, now part of Serono) has been tested
in early clinical trials in recent years, but the results of these investigations have not been published.
Due to the apparent complexity of adiponectin biology (with multiple complexes having
potentially different effects) and the cost and inconvenience associated with recombinant protein
treatments, the development of small-molecule adiponectin mimetics seems preferable. For this
purpose, knowledge of the receptors mediating the effects of adiponectin is essential. Recently,
adiponectin cell-surface receptors (AdipoR1, AdipoR2, and T-cadherin) expressed in skeletal mus-
cle and liver have been described [42,49,50], and signaling pathways downstream of adiponectin
receptors have the potential to uncover novel molecular targets amenable to small-molecule drug
development. Given the phenotype of the mouse genetic model and the effects of adiponectin
treatment in mice, it seems that adiponectin and its signaling pathway represent potential therapeutic
agent and drug targets for the treatment of insulin resistance/type 2 diabetes, dyslipidemia, and
cardiovascular disease, rather than obesity per se [11].
PEROXISOME PROLIFERATOR-ACTIVATED RECEPTORS

Peroxisome proliferator-activated receptors are a family of three (α, β or δ, γ) nuclear receptors
that affect the transcription and expression level of target genes. PPARs act in conjunction with
the retinoid X receptor, their activity is controlled by the recruitment of coactivators and corepres-
sors, and they can be modulated by ligands [12,51] (see Figure 15.1).
Peroxisome Proliferator-Activated Receptor γ

Peroxisome proliferator-activated receptor γ (PPARγ) is primarily expressed in adipose tissue (white
and brown), and it plays an essential role in adipogenesis (i.e., adipocyte differentiation) [52].
Ligands that activate PPARγ improve insulin resistance in obese, insulin-resistant animals and
Increase in mitochondriogenesis and fatty acid oxidation
PPARα agonists
PPARα agonists
PPARδ agonists
Decrease in adipogenesis
PPARγ antagonists or modulators
Dual, Janus-like action of

PPARγ agonists;
PPARγ agonists they improve insulin
sensitivity and
increase adipogenesis
FIGURE 15.2 PPAR ligands might improve insulin sensitivity and treat obesity.
humans. Thiazolidinediones (TZDs) are a class of PPARγ agonists currently on the market for the
treatment of type 2 diabetes that include rosiglitazone (Avandia® from GlaxoSmithKline) and
pioglitazone (Actos® from Takeda and Eli Lilly). Unfortunately, because full activation of PPARγ
enhances adipocyte differentiation (and mildly increases metabolic efficiency), animals and humans
treated with TZD tend to gain weight. It is now clear, however, that the beneficial effects of PPARγ
ligands on insulin sensitivity are not dependent on their effects on adipogenesis [53,54]; thus, it
should be possible to develop agents that modulate the activity of PPARγ in such a way that the
compounds improve insulin sensitivity but have no effects on adipogenesis (and metabolic effi-
ciency). Several companies are currently trying to achieve this with new compounds that do not
fully activate PPARγ but modulate its activity (selective PPAR modulators, or SPPARMs) [53].
Such agents should induce PPARγ to recruit a different set of coactivators and corepressors in the
adipocytes than those induced by full PPARγ agonists, ultimately leading to improvement of insulin
resistance without increasing adipogenesis and body weight [12,55,56]. In addition, mouse models
where the PPARγ gene was disrupted (gene knockout mice) and studies with PPARγ antagonists
show that inhibition of PPARγ can also improve insulin resistance and, contrary to what is observed
with full activation of PPARγ, cause a decrease in fat mass [12,53,54,57–62] (see Figure 15.2).
Peroxisome Proliferator-Activated Receptor δ
Peroxisome proliferator-activated receptor δ (PPARδ; also called PPARβ) is the lesser known
member of the PPAR family. This protein is abundantly expressed in most tissues, and it was
recently shown to play a key role in mitochondriogenesis and fatty acid oxidation in adipose tissue
and skeletal muscle in mice [14,52,55,63,64]. Overexpression of PPARδ in skeletal muscle was
found to increase muscle mitochondrial content and oxidative capacity and to decrease diet-induced
obesity and insulin resistance [65,66]. Also, overexpression of a constitutively active PPARδ in
adipose tissue of mice was reported to enhance uncoupling protein 1 (UCP1) gene expression and
fatty acid oxidation, and as a result it prevents the development of obesity induced by a high-fat
diet [67]. PPARδ-deficient mice, on the other hand, were found to be more prone to obesity [52,67].
In addition, treatment of obese mice with the PPARδ agonist GW501516 induced a reduction in
body fat, apparently by promoting fatty acid oxidation in skeletal muscle and adipose tissue and
by increasing adaptive thermogenesis [12,63,66,68]. These results suggest that activation of PPARδ
might represent a promising strategy for the treatment of obesity and insulin resistance [69–71]
(see Figure 15.2).
Dual PPAR Agonists
An alternative to activating a single PPAR is to develop dual PPAR agonists or pan PPAR agonists,
which activate both PPARα and PPARγ or all three PPARs, respectively, hoping that the PPARα
or PPARδ part (which might both activate fatty acid oxidation) will balance out the adipogenic
effects of PPARγ activation [14,55]. This strategy has the potential to produce agents that treat the
metabolic syndrome as a whole (obesity, type 2 diabetes, dyslipidemia, atherosclerosis, and hyper-
tension) and not only obesity.
Potential Unwanted Side Effects of PPAR Ligand Treatments
It is currently hoped that PPARδ agonists, SPPARMs, dual PPARα/PPARγ agonists, or pan PPAR
agonists will develop into successful drugs to treat obesity and type 2 diabetes; however, prolonged
treatment with reasonable doses (10 mg/kg) of the PPARδ agonist GW501516 was found to cause
hepatomegaly in diet-induced obese C57BL/6J mice [68]. In fact, it is well known that pure PPARα
agonists (e.g., fibrates) induce peroxisome proliferation and hepatomegaly in rodents but appear
well tolerated in humans, where peroxisome proliferation is not observed [52,72]. That some PPAR
agonists can have hepatotoxic effects was demonstrated by the withdrawal of troglitazone, the first
PPARγ agonist of the TZD family that went to market, following cases of acute liver failure;
however, more recent TZDs currently on the market for the treatment of type 2 diabetes (rosigli-
tazone and pioglitazone) have shown extremely rare (and reversible) signs of hepatotoxicity [73].
PPARγ agonists have been reported to promote the growth of colon cancer tumors in mice, although
the effects on human colon cancer cell lines showed conflicting results [52]. Similarly, the PPARδ
agonist GW501516 was shown to accelerate the growth of small intestine polyp in cancer-prone
mice [52]. Recent phase III clinical studies with the dual PPARα/PPARγ agonist muraglitazar
showed encouraging therapeutic efficacy but also revealed a dose-related higher incidence of weight
gain, edema, and congestive heart failure.
In summary, the potential toxicity on liver, heart, and skeletal muscle and the carcinogenicity
of PPAR agonists will have to be carefully investigated in the evaluation of drug candidates for
chronic treatments. The U.S. Food and Drug Administration (FDA) now requires the completion
of 2-year carcinogenicity studies before clinical studies of more than 6-months’ duration with PPAR
agonists can be initiated [56,72].
STEAROYL-COA DESATURASE 1
Stearoyl-CoA desaturase 1 (SCD1) is an essential enzyme for the desaturation of long-chain fatty
acids to generate monounsaturated fatty acids, mainly oleic acid (C18:1). This fatty acid desaturation
seems to be key for triglyceride synthesis and body fat accumulation [74,75]. Indeed, lines of mice
with either a targeted disruption of the Scd1 gene (Scd1 knockout) or a natural inactivating mutation
in the Scd1 gene (asebia) show a decrease in high-fat-diet-induced obesity and insulin resistance,
apparently as a consequence of an elevated metabolic rate as compared to wild-type mice. In
addition, treatment of mice with antisense oligonucleotides (ASOs) repressing the expression of
Scd1 in liver and adipose tissue resulted in prevention of high-fat-diet-induced obesity, hepatic
steatosis, and insulin resistance without affecting food intake [76]. In this latter study, SCD1 ASO
also reduced de novo fatty acid synthesis, decreased the expression of lipogenic enzymes, and
increased the expression of genes potentially promoting energy dissipation in liver and adipose
Inhibitor of DGAT1
Glucose
Glycerol phosphate
Dietary
Fatty acids
fats DGAT1
C18:1
Oleic acid
Inhibitor of SCD1 SCD1Re-esterification Triglycerides
C18
Stearic acid Lipolysis
Fatty acid
Fuel for tissues
FIGURE 15.3 Inhibitors of triglyceride synthesis that might help treat obesity. DGAT1, acyl CoA:diacylglyc-
erol acyltransferase 1; SCD1, stearoyl-CoA desaturase 1.
tissue. Interestingly, SCD1 has been shown to be a major effector of leptin action on fatty acid
metabolism in liver [77–79], and it could play a similar role in adipose tissue and skeletal muscle.
These results strongly support, from a biological point of view, SCD1 being a high-potential target
for treating obesity. In addition, the fact that SCD1 is an enzyme that would have to be inhibited
by therapeutic drugs represents a very attractive avenue from a drug development point of view.
Mice that completely lack Scd1 (homozygous knockout) have abnormal skin, eyelid, and hair
due to deficiencies in triglycerides and cholesterol ester synthesis; however, mice lacking only one
allele of the Scd1 gene (heterozygous knockout) [75] or treated with an SCD1 ASO [76] showed
no such abnormalities despite a 50 to 75% reduction in Scd1 expression and SCD activity. These
results suggest that partial inhibition of SCD1 might have beneficial metabolic effects without
significant repercussions on skin, eyelid, and hair development [79]. This last point is very encour-
aging for the development of SCD1 inhibitors for the treatment of obesity and insulin resistance.
Importantly, inhibition of other enzymes also involved in triglyceride synthesis (i.e., ACC2 and
DGAT1) is also associated with enhanced energy expenditure and resistance to the development
of obesity in mice, suggesting that triglyceride synthesis is a promising target pathway for the
development of anti-obesity drugs [79] (see Figure 15.3).
ACYL COA:DIACYLGLYCEROL ACYLTRANSFERASE 1

Acyl CoA:diacylglycerol acyltransferase 1 (DGAT1) is a microsomal enzyme that catalyzes the
final and committed step in the glycerol phosphate pathway. Targeted disruption of the DGAT1
gene produced mice that are resistant to high-fat-diet-induced obesity and hepatic steatosis [80],
apparently as a consequence of an increase in energy expenditure and physical activity [81].
DGAT1-deficient mice also highlighted enhanced insulin and leptin sensitivity [82]. Intriguingly,
the protection against obesity and insulin resistance was not seen in ob/ob (leptin-deficient) mice
(crossed with DGAT1 knockout mice), possibly due to an increase in DGAT2 expression in the
white adipose tissue of this animal model [83]. These data support the value of DGAT1 as a
molecular target for the development of anti-obesity drugs. A total lack of DGAT1 was reported
to cause alopecia and to impair the development of the mammary gland, abnormalities that were
not seen in animals with only partial DGAT1 deficiency [80]. Importantly, obesity resistance and
enhanced insulin sensitivity were also observed in wild-type mice transplanted with white fat pads
from DGAT1 knockout mice, suggesting that adipose tissue lacking DGAT1 secretes a factor that
can decrease fat stores and enhance glucose disposal [16,83]. Thus, partial inhibition of the enzyme
seems sufficient to produce desired effects on adiposity, suggesting that pharmacological inhibition
of the enzyme should be a productive therapeutic strategy for human obesity and type 2 diabetes
(Figure 15.3). Furthermore, identification of the putative factor secreted by adipose tissue lacking
DGAT1 that improves blood glucose homeostatis could provide additional target candidates for
drug development.
PROTEIN TYROSINE PHOSPHATASE 1B

Protein tyrosine phosphatase 1B (PTP1B) is a protein tyrosine phosphatase expressed in most
tissues that can interrupt insulin signaling by dephosphorylating Tyr residues on the insulin receptor
and possibly also on the insulin receptor substrate 1 (IRS1) [84]. PTP1B has also been shown to
dephosphorylate Janus kinase 2 (JAK2) and interrupt leptin signaling in hypothalamus [30–32].
Thus, inhibition of PTP1B has the potential to reverse the resistance to the action of both insulin
(type 2 diabetes) and leptin (obesity) [85].
With the exception of the β3-AR, no other adipose target has been as strongly validated (in
animals) as PTP1B in the field of obesity and insulin resistance. Mice that lack the PTP1B gene
were found to be resistant to high-fat-diet-induced obesity and insulin resistance through an increase
in skeletal muscle and possibly liver, insulin sensitivity, and an increase in resting and total daily
metabolic rate (expressed per gram of body weight) [86,87]. The phenotype of these mice suggested
that PTP1B plays a critical role in the action of insulin on glucose metabolism in muscle and liver.
Recent studies using RNA inhibition technology to repress the normal expression of PTP1B in
mice suggest that PTP1B also plays a significant role in adipose tissue [88,89]. In fact, the PTP1B
antisense oligonucleotides that, in mice, reached the adipose tissue and liver, where they strongly
decreased the expression of PTP1B but did not reach the skeletal muscle or the brain [89–91],
induced improvements in glucose metabolism and insulin sensitivity, as well as a decrease in body
weight in obese, insulin-resistant ob/ob and db/db mice [88–91]. These studies suggested that
inhibition of PTP1B expression in adipose tissue and liver can lead to improvements in glucose
metabolism and insulin sensitivity and a decrease in body weight in obese, insulin-resistant ob/ob
and db/db mice [88–91].
At this point, it is not yet clear what the main target tissues for PTP1B inhibition are. Results
from the gene knockout mice suggest that skeletal muscle and liver, but not adipose tissue, are
responsible for the enhanced action of insulin (anti-insulin resistance), whereas the mechanism
underlying lower body fat and weight (anti-obesity) is uncertain [87]. The results from the PTP1B
antisense oligonucleotides studies, on the other hand, suggest that adipose tissue and liver play a
key role in increased insulin sensitivity, as inhibition of PTP1B expression in only these two tissues
was sufficient to improve insulin resistance [89–91]. The lack of PTP1B in parts of the brain
involved in the control of body weight and glucose metabolism might play an important role in
the phenotype of PTP1B knockout mice [30,32]. Investigation of the impact of brain-specific
disruption of the PTP1B gene might clarify the role of central PTP1B on energy metabolism.
The development of PTP1B inhibitors that are active in vivo (animals) turned out to be a major
challenge, in part because the protein tyrosine phosphatase family represents a new, largely unex-
plored class of drug targets and because it seems that compounds that bind to the enzymatic active
site are highly charged and do not readily permeate the cell membrane or show poor oral bioavail-
ability [85]. Nonetheless, some reports have recently described remarkable effects of small-molecule
PTP1B inhibitors (e.g., IDD-3, PTP-3848, KR61639) in obese, insulin-resistant ob/ob, db/db,
KKAy, and C57BL mice [92–98]. In fact, these effects were quite similar to those observed with
antisense oligonucleotides repressing the expression of PTP1B. Interestingly, the inhibitor IDD-3
was shown to improve insulin sensitivity and glucose homeostasis after only 3 days of treatment
in ob/ob mice and after a single dose in high-fat-fed, insulin-resistant Wistar rats [99]. This
pharmacodynamic profile suggests that, if the mechanism of action is similar in humans, proof-of-
concept early clinical studies could be performed quite rapidly and give valuable indications
regarding the validity of PTP1B as a drug target in human obesity and type 2 diabetes.
In summary, inhibition of PTP1B is one of the most promising approaches for treating obesity
and insulin resistance, and we will soon know whether the challenges met by many companies in
their efforts to develop small-molecule inhibitors for this enzyme can be overcome.
β3-ADRENERGIC RECEPTOR
The pharmacological effects of β3-adrenergic receptor (β3-AR) agonists developed so far represent
a classical example of the risks of extrapolating the effects observed in rodent models to clinical
effects in humans. Rodent adipose tissues (brown and white) express high levels of β3-AR, and β3-
AR agonists are well known to be effective in these animals in terms of reducing body weight and
fat stores and improving insulin resistance and blood glucose homeostasis. Human adipose tissue,
however, has been shown to express very low levels of β3-AR [100–102], possibly because humans
live at thermoneutrality and, unlike rodents kept at room temperature, do not need to rely on non-
shivering thermogenesis to maintain their body temperature. Because of this low expression level,
it is hardly surprising that β3-AR agonists have very weak effects on energy metabolism in humans
[103,104]. The possibility remains that the expression of β3-AR in human adipose tissue could be
upregulated by future treatment strategies; however, there is currently no clear target candidate to
achieve this effect [104,105]. A different but related approach would be to induce the conversion
of white to brown-like adipocytes with significant levels of expression of β3-AR in human adipose
tissue.
OTHER TARGET CANDIDATES

Thyroid hormones have been used to treat obesity in the past, but their use showed unacceptable
adverse effects on the heart function and skeletal muscle mass; however, recent data suggest that
selective activation of thyroid hormone receptor β (TRβ) can induce an increase in metabolic rate
and a decrease in body weight in rodents and nonhuman primates without adverse effects on the
heart function [106,107]. Thus, new TRβ-selective agonists, or possibly TRβ modulators, represent
a new class of therapeutic candidates against obesity [108]. The realization that the activity of
nuclear receptors (e.g., PPARs) can be modified in different ways (and not only by full activation
or inhibition) opens up new avenues in drug discovery for thyroid hormone receptors.
ADIPOSE TISSUE REMODELING: CONVERSION

OF WHITE TO BROWN-LIKE ADIPOCYTES
The main effector of cold- and diet-induced thermogenesis in rodents is brown adipose tissue (BAT).
Thermogenesis in this tissue is mainly regulated by the sympathetic nervous system. Sympathetic
activation leads to the local release of catecholamines by the sympathetic nerve terminals. Cate-
cholamines then mediate their effects through α- and β-adrenergic receptors (ARs). The β-AR
family consists of β1/β2/β3-AR subtypes, and the three β-subtypes coexist in the BAT. In contrast
to rodents maintained at room temperature (i.e., below their thermoneutrality temperature), adult
humans do not possess significant amounts of BAT. Induction of brown adipocyte differentiation
with drugs might be possible, although no druggable molecular target has yet been identified to
achieve this in humans [7,104,109].
Various studies have shown that the white and brown preadipocytes differentiate in vitro in
characteristic white and brown adipocytes, respectively [110–112]. Multilocular fat cells, expressing
UCP1 and rich in mitochondria, have been observed for the first time in a white adipose tissue
A B
FIGURE 15.4 (A) Cold-exposure recruitment in the mouse white adipose tissue (WAT) of brown adipocyte-
like multilocular cells expressing UCP1. (B) Thermogenic cells act as a Trojan horse to transform the lipid-
storing WAT into an energy dissipating tissue. (From Jimenez, M. et al., Eur. J. Biochem., 270, 699–705,
2003. With permission.)
(WAT) depot by Young et al. [113]. The emergence of these so-called ectopic brown adipocytes in
the WAT was found to be induced by cold acclimation in rats [114,115] and mice [116–118] (see
Figure 15.4). This phenomenon is generally called recruitment. The new cells were found to be
sympathetically innervated [119] and to remain present as long as a sympathetic stimulation
persisted [117].
Several reports showed that in mice the administration of selective β3-AR agonists such as CL
316243 induced the emergence of brown adipocytes in WAT depots [118,120–122] and that this
phenomenon was strongly dependent on the mouse genetic background [118,121,123]. It was,
however, recently shown that transgenic overexpression of the human β1-AR in the WAT of mice
also induced the appearance of abundant brown adipocytes in this tissue [124]. These results
suggested that the β3-AR might not be the only β-subtype controlling the emergence of brown
adipocytes in the WAT; however, administration of β1-AR agonists would not be appropriate for
the treatment of obesity due to the well-known effects of these agents on the heart.
Cells expressing UCP1 should, by dissipating energy, provide heat and therefore contribute
with the BAT to maintain body temperature and energy balance. Administration of the β3-AR
agonist CL 316243 was found to induce the recruitment of brown adipocytes in WAT depots and
at the same time to reduce adiposity in the Zucker fa/fa rat [122]. Important information on the
physiological importance of brown adipocyte recruitment in the WAT was obtained by comparing
obesity-prone and obesity-resistant strains of mice. Chronic treatment with CL 316243 prevented
obesity induced by a high-fat diet in the obesity-resistant A/J but not in the obesity-prone C57BL/6J
mice. As CL 316243 also induced a marked UCP1 expression in the WAT depots of the A/J but
not of the C57BL/6J mice, it could be postulated that the ability of the β3-AR agonist to prevent
diet-induced obesity depended on the recruitment phenomenon [121]. A strong correlation was
found, in response to cold exposure or CL 316243 treatment in various mouse strains, between
body weight loss and UCP1 levels in the retroperitoneal WAT [118].
Transgenic mice ectopically expressing UCP1 in their WAT displayed an increase in the oxygen
consumption of this tissue and were protected from genetic and dietary obesity [125]. Surprisingly,
their BAT was atrophied and the animals were cold sensitive [126]. On the other hand, mice with
a genetic ablation of their BAT were cold sensitive and obese [127]. This raises the possibility of
distinct functions for brown adipocytes depending on their presence in BAT or in WAT depots.
BAT brown adipocytes would impart both cold and obesity resistance, whereas WAT brown adi-
pocytes would be associated only with obesity resistance. However, the phenotype of the UCP1
knockout mice, which are cold sensitive but not obese [128,129], does not support a role for UCP1
in obesity resistance.
The origin and the real nature of the multilocular cells rich in mitochondria and expressing
UCP1 that appear in WAT upon cold acclimation or β3-AR stimulation have yet to be determined.
The presence of brown adipocyte progenitors in the WAT has been suggested by studies showing
that 10 to 15% of the precursor cells isolated from mouse WAT differentiate into brown adipocytes
in culture [130] and that brown adipocyte progenitors are present in human WAT depots [131].
Another hypothesis suggests that a few unilocular white adipocytes are indeed “masked“ brown
adipocytes that can recover a brown phenotype in response to sympathetic nervous system stimu-
lation such as that induced by cold exposure. Himms-Hagen et al. [132], studying the effect of CL
316243 in rats, suggested that the multilocular cells expressing UCP1 that appeared in the WAT
were different from the classical brown adipocytes and postulated that they might derive, at least
in part, from preexisting unilocular adipocytes. Orci et al. [133] showed that hyperleptinemia in
rats induces the transformation of white adipocytes into so-called post adipocytes (or fat-oxidizing
machines) which have the phenotype of brown adipocytes.
Gene expression studies have shown different responses to various stimuli of WAT vs. BAT
brown adipocytes. In the BAT of β3-AR knockout mice, it was observed that UCP1 expression
levels were normal at 24°C as well as after 10 days of cold exposure, whereas in the WAT of β3-AR
knockout mice UCP1 expression levels and the density of multilocular cells were strongly depressed
at 24°C and after a 10-day cold exposure as compared to wild-type mice [134]. These results
confirm that β3-ARs play a major role in the appearance of brown adipocytes in WAT and suggest
that the multilocular cells recruited in the WAT differ from genuine brown adipocytes. Recently,
Coulter et al. [135] evaluated whether the quantitative trait loci controlling UCP1 expression also
modulate PPARγ coactivator-1α (PGC-1α) expression levels, by analysis of backcross progeny
from the A/J and C57BL/6J mouse strains. They found, comparing mice on a low- or high-fat diet,
allelic variations modulating the expression of UCP1 and PGC-1α in brown adipocytes in the WAT
but not in the BAT. These results suggested fundamentally different regulatory mechanisms for the
control of UCP1 expression in WAT vs. BAT.
Several studies using transgenic animals have demonstrated the strong implication of various
genes in the occurrence of ectopic brown adipocytes in the WAT. Among them, we have selected
a few possible early target candidates for anti-obesity drugs. 4E-BP1 was found to play an important
inhibitory role on the recruitment of brown adipocytes in the WAT. Indeed, in 4E-BP1 knockout
mice, a robust recruitment of ectopic brown adipocytes was observed in the inguinal and retroperi-
toneal WAT, PGC-1α and UCP1 expression levels were increased in WAT, and body fat mass was
decreased [136]. Thus, a specific inhibitor of 4E-BP1 in the WAT could stimulate the resurgence
of brown adipocytes in this tissue.
Forkhead box protein C2 (FOXC2), a member of the FOX family of transcription factors, has
been shown to have an effect on the switch between WAT and BAT in rodents. Its expression in
mice is restricted to adipose tissues, and mice with adipose-tissue-targeted overexpression of FOXC2
displayed an atrophy of the WAT and a hypertrophy of the BAT [137]. Those mice also exhibited
an increase in insulin sensitivity and a more efficient signaling though β-adrenergic receptors.
Further analysis showed that the overexpression of FOXC2 prevented diet-induced insulin resistance
and intracellular lipid accumulation in the skeletal muscle [138]. It was therefore postulated that
FOXC2 could be a novel therapeutic target for the treatment of obesity and insulin resistance.
Yet another approach would be to induce the conversion of white adipocytes to brown-like
adipocytes, which are cells rich in mitochondria with multilocular lipid droplets, not necessarily
expressing UCP1 [109,132,139]. Induction of mitochondriogenesis in white adipose tissue, assuming
that it would trigger an elevation of adipocyte metabolic rate through partial uncoupling of oxidative
phosphorylation and an increase in thermogenesis, should favor fatty acid oxidation (possibly also
glucose utilization), as well as decrease fat deposition and promote weight loss [140]. The nuclear
hormone receptor coactivators PGC-1α and PGC-1β have been shown to increase mitochondriogenesis
when overexpressed in cells or in mice [141–147]. The resulting increase in cellular or tissue
oxidative capacity was accompanied, in most cases, by an increase in metabolic rate. Direct activation
of PGC-1α (a coactivator) is hardly a possibility with a small-molecule drug, and it might not be a
fruitful strategy to treat obesity and insulin resistance as this would probably enhance PGC-1α-
mediated hepatic glucose production [148]. A possible avenue to activate PGC-1α in adipose tissue
would be to interfere with a tissue-specific factor that inhibits PGC-1α. An inhibitor of PGC-1α
activity, p160MBP, was recently described [149,150], and this factor could represent an interesting
drug target to activate PGC-1α as long as it does not affect the activity of PGC-1α on hepatic
gluconeogenesis. In addition, the nuclear receptor estrogen-related receptor α (ERRα) and possibly
ERRγ have been shown to play a key role in the effects of PGC-1α on mitochondriogenesis
[151–154]. Thus, ERRα and ERRγ could represent novel drug targets for the treatment of obesity
and insulin resistance. These nuclear receptors, as yet orphan, would be a priori more amenable to
drug development [155,156] than a coactivator such as PGC-1α, even though the active conformation
of ERRα (but not ERRγ) was shown to possess a very small ligand-binding pocket [155].
Activation of lipolysis, if it enhances metabolic rate (e.g., by increasing fatty acid cycling),
could represent a strategy to induce weight loss [157]. Alternatively, activation of lipolysis could,
through a locally increased efflux of fatty acids possibly providing ligands to nuclear receptors
involved in mitochondriogenesis, trigger a remodeling of white adipocytes into brown-like adipo-
cytes. This effect has recently been reported after a few days of treatment with the selective β3-AR
agonist CL 316243 in mice [102] and shown to be mediated by PPARα [102,158]. This suggests
that PPARα agonists (e.g., fibrates) could have direct anti-obesity properties in addition to their
well-known effects on dyslipidemia. Alternatively, PPARα modulators (rather than full agonists)
might recapitulate some of the effects seen with β3-AR agonists in rodent white adipose tissue.
Interestingly, a PPARα agonist (K-111, formerly BM 17.0744) was shown to produce, in addition
to improvements of dyslipidemia and insulin resistance, body weight loss in nonhuman primates
[159,160].
CONCLUSIONS
Obesity and insulin resistance or type 2 diabetes are pathologies with rapidly growing prevalence
in most of the world and with dire, unmet medical needs. Novel, effective long-term treatments of
these medical conditions are urgently needed to help decrease patient suffering as well as contain
the rapidly increasing cost of health care. Fortunately, remarkable progress in the understanding
of the mechanisms controlling energy balance has been achieved in the last decade. Much remains
to be learned until we have an complete understanding of these complex systems, but we are very
optimistic that the near future will bring efficacious treatments of obesity for most patients. It is
unlikely, however, that a single drug against obesity will be effective in most patients; rather, an
assortment of drugs will probably be necessary to treat a large proportion of patients who almost
certainly present heterogeneous mechanistic etiologies of obesity. In this regard, a better charac-
terization of obese patient subcategories could help stratify patient populations for clinical trials
and therapeutic strategies.
MOLECULAR TARGETS WITH SMALL-MOLECULE LEADS

OR DRUGS SUCCESSFULLY DEVELOPED (PPARS)
A few molecular targets offer the most hope for anti-obesity therapeutics. These targets have been
quite well validated biologically (in animals) and are known to be reachable with small molecules
as drugs already exist that act on targets from the same family. PPARs and possibly other nuclear
hormone receptors are part of this category. For PPARs, the key for success will be to find the
optimal combination of PPAR subtype activation or inhibition to obtain the desired effect on body
fat stores and glucose metabolism. PPARα is the target for the fibrate family compounds used for
years to treat dyslipidemia linked to cardiovascular disease. Fibrates activate PPARα in the liver
and adipose tissue, but they do not usually have a strong impact on body weight, fat mass, or blood
glucose levels. PPARδ agonists have shown interesting effects on body fat stores in mice, and these
agents could represent a new generation of anti-obesity drugs. Modulation (partial activation or
inhibition) of PPARγ, rather than full activation, has a promising future, as does the dual activation
of PPARγ and PPARα (or PPARδ). Modulation of the activity of nuclear receptors (e.g., PPARs,
thyroid hormone receptors, orphan nuclear receptors) by affecting the recruitment of their coacti-
vators or corepressors represents a new avenue for future drug development to treat obesity and
type 2 diabetes. Potential safety issues of PPAR ligands with regard to organ toxicity and carcino-
genicity will have to be carefully monitored.
KEY TARGETS FROM THE LIPID SYNTHESIS PATHWAY (SCD1, DGAT1)

Promising targets for anti-obesity drugs include SCD1 as well as other enzymes playing a critical
role in triglyceride synthesis. Even though it might appear odd that inhibiting an enzyme necessary
to store excess energy as fat would help in the treatment of obesity without causing metabolic
problems, rodent models show that lacking these key enzymes can induce an adaptive increase in
metabolic rate that dissipates the excess energy instead of storing it as fat.
NEW, HIGH-POTENTIAL MOLECULAR TARGET (PTP1B)

Protein tyrosine phosphatase 1B is a molecular target with very high potential for the development
of drugs that could be very effective in the treatment of obesity and diabetes. PTP1B inhibitors
would represent an important innovation in drug discovery, as no drugs exist today that act on
protein tyrosine phosphatases. Hence, PTP1B inhibitors would establish a precedent for this new
class of drug targets. In summary, PTP1B is a high-risk but very high-potential drug target that
could generate unmatched gratification to the successful creators of an orally active inhibitor.
Adipocytes have provided several novel potential targets for the development of therapeutic drugs
against obesity and diabetes in recent years. Research and development efforts are still needed for
these recent target candidates to be validated and drugs to be developed. In addition, novel adipose
factors having an impact on energy metabolism will almost certainly be identified in the near future
and will provide additional opportunities for the development of anti-obesity drugs.
ACKNOWLEDGMENT
We thank Nils Bergenhem for his contribution to a recent review article containing information
that was used when writing this chapter.
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Part V
Safety of Obesity Drugs
16 Safety of Obesity Drugs

Alok K. Gupta and Frank L. Greenway
CONTENTS
Background ....................................................................................................................................199
Obesity Drugs: A Historical Prescriptive ......................................................................................200
Thyroid Hormone ...................................................................................................................200
Dinitrophenol ..........................................................................................................................200
Amphetamines ........................................................................................................................201
Rainbow Pills ..........................................................................................................................201
Aminorex Fumarate ................................................................................................................202
Fenfluramine and Dexfenfluramine ........................................................................................202
Phenylpropanolamine..............................................................................................................202
Ephedra ...................................................................................................................................203
Obesity Drugs Currently Available................................................................................................203
Amphetamine Derivatives.......................................................................................................203
Benzphetamine.................................................................................................................204
Phendimetrazine...............................................................................................................204
Diethylpropion .................................................................................................................204
Phentermine .....................................................................................................................204
Sibutramine .............................................................................................................................205
Orlistat.....................................................................................................................................205
Rimonabant .............................................................................................................................206
Drugs Approved for Other Reasons Associated with Weight Loss ..............................................206
Bupropion................................................................................................................................206
Exenatide.................................................................................................................................207
Fluoxetine and Sertraline........................................................................................................207
Metformin ...............................................................................................................................208
Pramlintide ..............................................................................................................................208
Somatostatin............................................................................................................................209
Topiramate...............................................................................................................................209
Zonisamide..............................................................................................................................210
Potential for Using Herbs to Develop New Obesity Drugs..........................................................210
Discussion and Conclusions ..........................................................................................................211
References ......................................................................................................................................212
BACKGROUND
During the early development of mankind, acquisition of food for sustenance was a major physical
endeavor. It was also a difficult task due to the paucity of food. Humans have thus evolved by
adapting to famine more than plenty [1]. An increased availability of food without the need for
physical activity to acquire it is thought to have resulted in obesity, due to a mismatch between
199
energy intake (easy availability of energy dense foods) and energy expenditure (increasingly
sedentary lifestyle). This trend for overweight and obese began growing dramatically around 1980
in the United States [2] and is being observed worldwide today [3,4], affecting both adults [5] and
adolescents [5]. Which environmental changes explain the increased prevalence of obesity is not
clear, but genetic mutations are too slow to be responsible. Obesity predisposes to cardiovascular
disease, diabetes, and other medical problems [6], which have both medical and economic conse-
quences. Obesity alone has been estimated to cost the United States $100 billion per year and is
clearly a major public health problem [7,8].
Only since the National Institutes of Health (NIH) consensus conference of 1985 [9] classified
obesity as a chronic disease have drugs been approved for long-term obesity treatment. It was the
discovery of leptin in 1994, however, that spurred scientific inquiry into the mechanisms of obesity.
Despite the new scientific interest in obesity, we are at the same place with obesity drugs today
that we were with hypertension drugs in the 1950s. In the 1950s, we had thiazide diuretics that
caused a loss of sodium in the urine and centrally acting drugs, such as reserpine, with side effects
related to their upstream mechanisms. Only two obesity drugs are approved for long-term use:
orlistat and sibutramine. Orlistat, by causing a loss of fat in the stool, can be likened to thiazides
causing urinary sodium loss for the treatment of hypertension. Sibutramine suppresses central
noradrenergic neuronal reuptake which prevents improvement in hypertension and causes stimula-
tion associated with its upstream target.
Since 1994, obesity mechanisms have been actively investigated, and potential drug targets
now fill the developmental pipeline. Just as hypertension drugs now act upon peripheral blood
vessel targets with minimal side effects [10], it is likely that a similar evolution will be seen in the
development of obesity drugs by targeting peripheral mechanisms associated with improved safety.
Because the scientific tools available for drug development are more advanced today than in the
1950s, it is reasonable to believe that the search for safer and more effective obesity drugs will be
quicker and more efficient.
Not only does obesity represent a public health concern, but it is also a stigmatized condition,
especially for women in Western societies [11]. Because the stigma may induce some to take
unwarranted risks to lose weight, the safety of obesity drugs takes on a particular concern. In this
chapter, we review the safety of obesity drugs from a historical perspective, pointing out that their
history is littered with safety disasters [12]. We also review the safety of currently available drugs
for the treatment of obesity and of rimonabant, an obesity drug that has received an approvable
letter from the U.S. Food and Drug Administration (FDA). We then discuss the safety of drugs
available for other indications that also result in weight loss, and we touch on the potential of herbs
as safe and effective obesity drugs.
OBESITY DRUGS: A HISTORICAL PRESCRIPTIVE

THYROID HORMONE
As early as 1893, thyroid hormone was used to induce weight loss [13]. Thyroxine at 150 µg/d
increases weight loss, but 75% of this occurs from loss of the lean tissue rather than from the loss
of fat [13]. A loss of lean tissue increases mortality, but a loss of fat decreases mortality [14].
Thyroid hormone stimulates cardiac muscular inotropy and chronotropy and leads to cardiac
muscular hypertrophy. Because obesity by itself increases the cardiac work load, thyroid hormone
adds to that burden. Thyroid hormone, appropriately, is no longer used as a treatment for obesity.
DINITROPHENOL
In World War I, French munitions workers who handled a mixture of dinitrophenol and trinitirophe-
nol were noted to have toxic symptoms and even death from hyperthermia [15]. Animal studies
demonstrated a stimulation of respiration and rise in body temperature due to dinitrophenol [16,17].
Safety of Obesity Drugs 201
Dinitrophenol is a weak acid that binds to protons. It can cross membranes protonated and return
as an anion to repeat the cycle. It thus increases the basal proton conductance of the mitochondria,
uncouples oxidative phosphorylation from adenosine triphosphate (ATP) generation, and increases
the loss of calories as heat. In the 1930s, a series of controlled studies of dinitrophenol were
undertaken at Stanford University. A dinitrophenol dose–response relationship was demonstrated
in which an 11% increase in resting metabolic rate was observed with every dose increase of 100
mg. Patients taking dinitrophenol experienced warmth and sweating but tolerated dosages of 500
mg to 1 g a day when attention was given to the individualization of dosing based on the increase
in metabolic rate. Dosages of dinitrophenol between 300 and 500 mg/d induced a 40% increase in
resting metabolic rate, and this increase was sustained over 10 weeks. Unlike thyroid hormone,
which was being used for weight loss at that time, dinitrophenol did not increase nitrogen excretion
[18], suggesting that weight loss resulted from the loss of fat and not from lean tissue. Dinitrophenol
caused edema in some people, offsetting some of the weight loss. This edema resolved and the
weight loss became apparent after stopping the drug. Dinitrophenol did not increase blood pressure
but instead lowered blood pressure and improved glucose metabolism with continued treatment. It
was released to an enthusiastic populace (100,000 people took dinitrophenol in 1934) [19] as a
weight-loss drug without the need for diet modification. Dinitrophenol was sold directly to the
public in patent medicines, resulting in accidental and intentional overdoses leading to deaths due
to hyperthermia. Rashes, loss of the ability to taste sweet or salt, and cataracts were reported. In
addition, a small number of cases of agranulocytosis was reported. In 1938, the FDA acquired new
powers to regulate drug manufacturers. The sales of dinitrophenol were halted due to threats of
prosecution by the FDA.
AMPHETAMINES
Amphetamine was first synthesized in 1887; however, the psychopharmacological properties of
amphetamine were not described until 1927. Amphetamine was found to induce euphoria, increase
energy, increase wakefulness, increase alertness, and decrease fatigue. During clinical testing in
1937, weight loss was reported [20,21]. Amphetamines and related compounds cause weight loss
by inhibiting food intake through the release of norepinephrine in nerve terminals centrally. Alpha-
methyl-para-tyrosine (AMPT), an inhibitor of noradrenaline synthesis, increased feeding when
injected into the perifornical area of the hypothalamus [22]. In 1938, weight loss was reported in
response to amphetamine in both obese adults and children [23]. Amphetamine has stimulatory
effects on blood pressure and pulse rate and causes the release of free fatty acids through its
adrenergic mechanism. It also has a potential for addiction and abuse. Amphetamine is a Drug
Enforcement Administration (DEA) Schedule II drug, as are dextroamphetamine and methamphet-
amine. Amphetamines, therefore, are rarely used today for the treatment of obesity.
RAINBOW PILLS
Diet pills containing thyroid hormone, digitalis, diuretics, laxatives, and amphetamine became
popular in the 1960s. Because different colors were to be taken at different times of the day, they
were called rainbow pills. The potential for drug interactions and toxicity should be obvious from
the composition of this approach. Hyperthyroidism, digitalis toxicity, and hypokalemia were all
reported and were even responsible for the deaths of patients taking this polypharmaceutical
combination [24,25]. Although case reports suggested toxicity [25], controlled trials by Asher et
al. [26,27] were less troubling. Subjects in these trials lost 20 to 40 lb, the all-cause mortality rate
in the diet pill group was 77% of that seen in the general population, and the cardiac mortality rate
was equal to the general population. Nevertheless, safety concerns resulted in discontinuation of
the use of rainbow pills. Because digitalis produces anorexia only at toxic dosages and diuretics
and laxatives do not reduce fat, the use of these drugs to treat obesity was deemed to be both unsafe
and inappropriate.
AMINOREX FUMARATE
A chemical relative of amphetamine, aminorex fumarate was sold over the counter for the treatment
of obesity [28] in Austria, Switzerland, and West Germany in 1965. The mechanism of action for
weight loss was through the release of noradrenaline in the central nervous system [29]. The
prevalence of primary pulmonary hypertension rose 20-fold from 0.87% (1955–1966) to 15.4%
(1967–1968), but declined to baseline levels by 1972 [30,31]. Aminorex fumarate was withdrawn
from the market in 1968 due to its association with primary pulmonary hypertension. The symptoms
of primary pulmonary hypertension lagged by 6 to 12 months after starting the drug and consisted
of dyspnea on exertion, syncope, and chest pain [28]. These symptoms regressed in about 50% of
the cases, but the other half of the exposed individuals were dead by 1980. This experience sensitized
the obesity research community to the potential association of obesity drugs with primary pulmonary
hypertension.
FENFLURAMINE AND DEXFENFLURAMINE

In 1973, fenfluramine was approved for the treatment of obesity. It did not become popular, however,
until 1992, when it was combined with phentermine and a study using full dosages of both drugs
was published [33]. The efficacy of the two compounds was additive, while the side effects tended
to cancel each other, fenfluramine being a depressant and phentermine being a stimulant [32,33].
Although fenfluramine was approved for 12 weeks of therapy, long-term use became prevalent
when it was combined with phentermine. In 1996, more then 18 million prescriptions were written
for this combination. In 1997, dexfenfluramine was approved for long-term use and was sometimes
substituted for fenfluramine in the combination. Primary pulmonary hypertension surfaced as the
first safety concern associated with fenfluramine in 1996. The risk, however, was judged to be so
small that the benefits of treatment outweighed the risks by 20:1 [34,35]. Heart-valve abnormalities
in 24 women with previously normal hearts were reported in 1997 by Connolly et al. [36]. These
women had been treated with fenfluramine and phentermine for an average of 1 year and presented
with cardiac symptoms and murmurs. Pulmonary hypertension was also present in eight of these
women, the heart valves of whom, at surgery, exhibited the characteristics of right-sided heart valve
lesions associated with the carcinoid syndrome [37]. The study by Ryan et al. [38] was the only
prospective study of fenfluramine and dexfenfluramine performed in subjects who had baseline
echocardiograms. In that series, 16.5% subjects with previously normal heart valves developed
abnormalities taking fenfluramine or dexfenfluramine, and the lesions occurred at or after 6 months
of treatment. The mechanism for fenfluramine-induced weight loss is through increased levels of
serotonin in the central nervous system. The cardiac valvular abnormalities, however, were found
to be due to binding of a major metabolite of fenfluramine, nordexfenfluramine, which has a higher
affinity than serotonin for the serotonin receptors on the heart valves [39]. The valvular pathology
was reversible over 6 months, depending on the severity of the cardiac valvular lesions, as was
pulmonary hypertension (in one subject). Fenfluramine and dexfenfluramine were voluntarily with-
drawn from the market in 1997 due to these safety concerns.
PHENYLPROPANOLAMINE
Phenylpropanolamine, a nonmethylated form of ephedrine, was synthesized in 1910. It was used
as an intravenous agent for postoperative hypotension in the 1930s. It was noted to be a decongestant
with a low propensity for stimulation of the central nervous system or for the elevation of pulse
and blood pressure. Although its effectiveness as an appetite suppressant was observed in 1939, it
was not approved by the FDA as an over-the-counter nasal decongestant until 1976 or as an over-
the-counter appetite suppressant until 1979 [40]. It was a well-tolerated medication, with efficacy
similar to the prescription drugs available for obesity at the time [41]. Although the dose for obesity
was limited to 75 mg/d (half of the nasal decongestant dosage of 150 mg/d), it was reported to
increase the incidence of hemorrhagic stroke in women taking it for obesity but not in men or
women using cough and cold preparations containing phenylpropanolamine. The phenylpropano-
lamine subjects in this case–control study had a statistically higher prevalence of a family history
of hemorrhagic stroke, a personal history of hypertension, and a greater use of alcohol, tobacco,
and cocaine compared to the control group. Nevertheless, after publication of the case–control
study by Kernan et al. [42], in 2000 phenylpropanolamine was withdrawn from the market both
as an agent for obesity and as a nasal decongestant.
EPHEDRA
Ephedra has been used in China for over 2000 years. A sympathomimetic herb, ephedrine is the
most active of the four isomers of ephedra. Ephedrine was introduced into the United States in 1930
by Chen [43], who described its pharmacology and therapeutic uses. It has been used as an agent
for the treatment of asthma in combination with methylxanthines since the 1930s. In the 1970s, a
Danish physician noted weight loss in patients he treated for asthma with ephedrine and caffeine.
A combination pill containing 200 mg caffeine and 20 mg ephedrine, taken three times a day for
weight loss, was eventually approved for prescription use to treat obesity in Denmark. It was well
tolerated and captured 80% of the market share, even when fenfluramine was available [44]. In 1994,
the Dietary Supplement Health and Education Act was passed in the United States, and it classified
herbs as foods. This was landmark legislation in relation to dietary herbal supplements. Not only
did it add impetus to the entire field, but it also gave rise to the widespread use of ephedra in dietary
herbal supplements for weight loss. Widespread, nonregulated use of ephedra in the treatment of
obesity resulted in reports of cardiovascular and neuropsychiatric adverse events. Of these adverse
events, 10 resulted in death and 13 in permanent disability [46]. An extensive review of the controlled
trials of ephedrine and ephedra with and without caffeine demonstrated a 2.2- to 3.6-fold increase
in cardiovascular and neuropsychiatric adverse events compared to placebo; however, no increase
in serious adverse events was observed in controlled clinical trials. Based on the adverse event
reports, the FDA declared ephedra as an adulterant [45]. Because the FDA is required to prove that
a food is unsafe and adverse event reports cannot prove cause and effect, the decision to remove
ephedra from the market was reversed in court. The legal climate relative to ephedra has made
liability insurance coverage almost impossible to obtain by manufacturers of ephedra products, which
makes the return of their widespread use for the treatment of obesity unlikely.
OBESITY DRUGS CURRENTLY AVAILABLE

AMPHETAMINE DERIVATIVES
The amphetamine derivatives benzphetamine and phendimetrazine in DEA Schedule III and dieth-
ylpropion and phentermine in DEA Schedule IV are currently available in the United States for
the treatment of obesity. They have less abuse and addiction potential than amphetamine itself.
Abuse of these drugs during treatment of obesity has rarely been a problem, but these drugs have
been sold and abused on the street for recreational purposes. Although benzphetamine and phen-
dimetrazine are rarely used today, phentermine is the most commonly prescribed obesity medication
[47]. These drugs were approved when obesity was still considered to be the result of bad habits,
and these drugs were approved for continuous use for periods up to 12 weeks. The mechanism by
which amphetamine-related drugs reduce weight is through the release of noradrenaline in the
central nervous system (CNS) which has the potential for CNS stimulation [48]. The potential for
addiction is related to the potential for these drugs to also release dopamine in the CNS. As might
be expected from their mechanism of action, these drugs can increase pulse rate, increase blood
pressure, and stimulate lipolysis.
Benzphetamine
Benzphetamine was first used in 1960, is available as 25-mg tablets, and has similar but less frequent
side effects than amphetamine. Benzphetamine is contraindicated in the presence of hyperthyroid-
ism, advanced arteriosclerotic vascular disease (ASCVD), moderate to severe hypertension (HTN),
symptomatic cardiovascular disease, agitated states, a history of drug abuse, glaucoma, pregnancy
(due to the association with fetal toxicity), lactation, within 14 days of monoamine oxidase inhibitor
(MAOI) drug use, and known sensitivity to sympathetic amines. Benzphetamine should be used
with caution during the operation of hazardous machinery, as it could impair mental alertness and
coordination. It should also be used with caution in the presence of mild to moderate hypertension
or in people younger than 12 years of age, and its potential for addiction must be kept in mind.
Phendimetrazine
Phendimetrazine is available as 35-mg tablets with side effects similar to benzphetamine. Contrain-
dications to the use of phendimetrazine include hyperthyroidism, advanced ASCVD, moderate to
severe HTN, symptomatic cardiovascular disease, concomitant use of CNS stimulants, agitated
states, a history of drug abuse, glaucoma, pregnancy, lactation, within 14 days of MAOI drug use,
and known sensitivity to sympathetic amines. Phendimetrazine should be used with caution during
the operation of hazardous machinery, as it could impair mental alertness and coordination. It
should also be used with caution in the face of mild hypertension or in people younger than 12
years of age, and its potential for addiction must be kept in mind. Abnormal heart valves and
primary pulmonary hypertension have been reported with phendimetrazine, and it should not be
used with other anorectics.
Diethylpropion
Diethylpropion is available as 25-mg, immediate-release and 75-mg, sustained-release tablets. The

potential for CNS stimulation and rise in blood pressure is minimal due to keto substitution on the
β-carbon of the phenethylamine side chain. Diethylpropion is contraindicated in the presence of
hyperthyroidism, advanced ASCVD, severe HTN, agitated states, a history of drug abuse, glaucoma,
pregnancy, lactation, within 14 days of MAOI drug use, and known sensitivity to sympathetic
amines. Diethylpropion should be used with caution during the operation of hazardous machinery,
as its use could impair mental alertness and coordination. Caution should also be exercised in the
presence of hypertension or cardiovascular disease, including arrhythmias, in people younger than
12 years of age and in people with epilepsy, as it has initiated seizures in epileptic patients.
Phentermine
Phentermine is available as a resin in 15- and 30-mg tablets, and it is also available in 37.5-mg
tablets. Phentermine has an α-methyl substitution on the phenethylamine side chain, resulting in
a lower CNS stimulation potential. It can, however, increase blood pressure and pulse rate, in
addition to causing insomnia and dry mouth. Phentermine is the most prescribed obesity drug in
the United States, and treatment on alternate months has been shown to be as efficacious as
continuous treatment. Alternate-month treatment allows the drug to be used for prolonged periods
of time while staying within the constraints of the package insert, which limits the drug to no more
than 12 weeks of continuous use [49]. Phentermine is contraindicated in the presence of hyperthy-
roidism, advanced ASCVD, moderate to severe HTN, symptomatic cardiovascular disease, agitated
states, a history of drug abuse, glaucoma, pregnancy, lactation, within 14 days of MAOI drug use,
and known sensitivity to sympathetic amines. Phentermine should be used with caution during the
operation of hazardous machinery, as it could impair mental alertness and coordination. Phentermine
should also be used with caution in the presence of hypertension or in people less than 16 years
of age, and its addiction potential should be kept in mind. Phentermine should not be used with
selective serotonin reuptake inhibitors (SSRIs), and administration of the drug should be stopped
for symptoms of primary pulmonary hypertension or valvulopathy. These symptoms include dyspnea,
angina, syncope, ankle edema, and a deterioration in exercise tolerance.
SIBUTRAMINE
Sibutramine is a noradrenaline and serotonin (5-HT) reuptake inhibitor that was approved for the
long-term treatment of obesity in 1997. Because sibutramine causes an increase in the concentration
of noradrenaline and serotonin in the intraneuronal cleft in response to food intake, it increases
satiety. Sibutramine increases thermogenesis to a lesser degree [50]. Like most other obesity drugs,
sibutramine-associated weight loss occurs over 6 months of treatment and plateaus after 6 months,
as observed in registration studies lasting up to 2 years [51,52]. Sibutramine reduces serum triglyc-
erides, increases high-density lipoprotein (HDL) cholesterol [53], and improves glucose control in
patients with diabetes [54,55]. Sibutramine does not produce the decrease in blood pressure and
heart rate expected with weight loss, and it is contraindicated in patients with uncontrolled hyper-
tension, coronary heart disease, cardiac dysrhythmias, congestive heart failure, or stroke [56]. It is
distributed as capsules of 5, 10, or 15 mg and is taken once a day, typically starting at 10 mg/d. The
dose can be adjusted up to 15 mg/d or down to 5 mg/d depending on response while monitoring
the blood pressure and pulse. The rise in blood pressure is modest and is usually offset by the
decrease in weight. Sibutramine is associated with dry mouth, insomnia, constipation, headache,
and dizziness. These symptoms are similar to some of those seen with amphetamine derivatives, as
both medications increase noradrenergic activity. Although no evidence of abuse has been found,
sibutramine is a DEA Schedule IV drug due to its structural similarities with amphetamine [57]
Sibutramine is contraindicated in patients receiving MAOIs or patients who have a hypersen-
sitivity to sibutramine or any of the inactive ingredients and should not be used in the presence of
a major eating disorder (anorexia nervosa or bulimia nervosa) or in patients taking other centrally
acting weight-loss drugs. Sibutramine should be used with caution in patients with a history of
hypertension, coronary artery disease, congestive heart failure, arrhythmias, stroke, narrow-angle
glaucoma, or pulmonary hypertension. The use of sibutramine comes with a warning relative to
blood pressure and pulse, as sibutramine substantially increases blood pressure or pulse rate in
some patients. Blood pressure and pulse should be measured prior to starting therapy and should
be monitored at regular intervals thereafter. For patients who experience a sustained increase in
blood pressure or pulse rate, either dose reduction or discontinuation should be considered. Sibutra-
mine should not be given to patients with uncontrolled or poorly controlled hypertension.
ORLISTAT
Orlistat is a reversible gastrointestinal lipase inhibitor (both gastric and pancreatic) that impairs the
absorption of dietary fat from the intestinal lumen. It is approved for long-term use and acts entirely
within the gastrointestinal tract. Orlistat treatment results in significant and sustained weight
reduction in clinical trials lasting 2 years [58]. Orlistat improves low-density lipoprotein (LDL)
cholesterol more than expected from the weight loss it induces, possibly due to enforcing a low-
fat diet [59,60]. Other lipid parameters improve in the expected manner with weight loss. Orlistat
improves glucose metabolism in obese patients with and without diabetes [61,62] and reduces high
blood pressure in proportion to the weight loss it induces [63,64]. It is supplied as 120-mg capsules
to be taken three times a day with meals. It is recommended that the drug be used with a 30% fat
diet. Orlistat use can result in adverse gastrointestinal events, including flatus with discharge, fatty
stools, oily stools, oily spotting, oily evacuation, fecal urgency, fecal incontinence, increased
defecation, and abdominal pain. These symptoms usually occur early in the course of treatment,
are exaggerated in patients who eat a high-fat diet, and rarely were severe enough to cause
discontinuation in clinical trials. A nightly multivitamin supplementation is recommended to com-

pensate for impaired absorption of fat-soluble vitamins (A, D, E, and K). Despite the demonstrated
benefits of orlistat, its use in clinical practice has been disappointing. This lack of use may be due
to the fear of side effects resulting from FDA-mandated warnings in direct-to-consumer advertising
and the potential for fecal incontinence becoming fodder for late-night television comedians. An
over-the-counter preparation of orlistat with a reduced dosage of 60 mg three times a day may be
available as early as late 2006. Orlistat is contraindicated in patients with chronic malabsorption
syndrome or cholestasis and in patients with known a known hypersensitivity to orlistat.
RIMONABANT
Rimonabant is a selective antagonist of the cannabinoid-1 (CB1) receptor. These receptors are
present in the white adipose tissue, gastrointestinal tract, lateral hypothalamus, and limbic system.
The location of the receptors is consistent with the side effects and the benefits associated with its
use [65–68]. Marijuana contains ∆9-tetrahydrocannabinol (THC), a CB1 receptor agonist, and
smokers experience relaxation, euphoria, and an increased intake of sweet and fat food [69].
Rimonabant was studied in phase III clinical trials with over 6000 patients, including those with
dislipidemia, and has received an approvable letter from the FDA for the treatment of obesity [70].
Published trials have shown a reduction in triglycerides, an increase in HDL cholesterol, a decrease
in small dense LDL particles, and a decrease in the number of patients meeting the criteria for the
metabolic syndrome, which was in excess of that expected for the amount of weight loss induced
by the drug [71]. Rimonabant at 20 mg a day has a weight loss efficacy similar to sibutramine.
Nausea and diarrhea are prominent side effects and consistent with CB1 receptors being present
in the gastrointestinal tract. Anxiety, insomnia, dizziness, and depression are also seen and might
be expected, as they are opposite of the sensations associated with marijuana smoking.
DRUGS APPROVED FOR OTHER REASONS

ASSOCIATED WITH WEIGHT LOSS
BUPROPION
Bupropion is a norepinephrine and dopamine reuptake inhibitor that is approved for the treatment
of depression and smoking cessation. It has been used in weight-loss studies ranging from 8 to 48
weeks in doses of 300 to 400 mg a day. The largest trials included subjects with depressive symptoms
[72] and subjects with uncomplicated obesity [73] enrolled across multiple centers. Among those
who completed the trial, weight loss in subjects with depressed symptoms treated with 300 to 400
mg of bupropion per day over a 6-month period was 6.0% in the bupropion group compared to
2.8% in the placebo group [72]. Weight loss in subjects with uncomplicated obesity was 5%, 7.2%,
and 10.1% of initial body weight in subjects on placebo, 300 mg bupropion, and 400 mg bupropion,
respectively [73]. Dropout rates for the two trials were 45% and 30% at 6 months in subjects with
depressive symptoms and the uncomplicated obese subjects, respectively.
Bupropion can induce epilepsy (0.1% at doses up to 300 mg/d and 0.4% at a dose of 400 mg/d)
and is contraindicated in patients with a seizure disorder. Patients with bulimia or anorexia nervosa
have a higher incidence of seizures, and the use of bupropion in this patient group is contraindicated.
Due to its association with epilepsy, bupropion should be administered with extreme caution in
patients with a lowered seizure threshold (alcohol or drug withdrawal, history of head trauma, or
the use of drugs such as theophylline). Due to its adrenergic mechanism, bupropion can be associated
with hypertension and is contraindicated for use with MAOIs. Allergic reactions, agitation, tinnitus,
pharangitis, insomnia, psychosis, confusion, mania, neuropsychiatric phenomenon, and an increased
risk for suicide in depressed patients have also been associated with bupropion use. Caution is
advised if bupropion is used in subjects with hepatic or renal insufficiency.
EXENATIDE
Glucagon-like peptide 1 (GLP-1), or enteroglucagon, is a protein derived from proglucagon and
secreted by L-cells in the terminal ileum in response to a meal. GLP-1 decreases food intake and
has been postulated to be responsible for the superior weight loss and superior improvement in
diabetes seen with obesity bypass surgery [74,75]. Increased GLP-1 inhibits glucagon secretion,
stimulates insulin secretion, and stimulates glycogenogenesis along with delaying gastric emptying
[76]. GLP-1 is rapidly degraded by dipeptidyl peptidase 4 (DPP-4), an enzyme that is elevated in
the obese. Gastric bypass operations for obesity increase GLP-1 but do not change the levels of
DPP-4 [77].
Exendin-4 is a 39-amino-acid peptide that is produced in the salivary gland of the Gila monster
lizard. It has 53% homology with GLP-1 and has a much longer half-life. Exendin-4 induces satiety
and weight loss in Zucker rats with peripheral administration and crosses the blood–brain barrier
to act in the central nervous system [78,79]. It decreases food intake and body weight gain while
lowering HgbA1c [80]. It also increases β-cell mass to a greater extent than would be expected for
the degree of insulin resistance [81].
In humans, exendin-4 reduces fasting and postprandial glucose levels, slows gastric emptying,
and decreases food intake by 19% [82]. It was tested in a placebo-controlled trial where 377 type
2 diabetic subjects who were failing maximal sulfonylurea therapy were given 10 µg subcutaneously
per day for 30 weeks. Their HgbA1c levels fell 0.74% more than for placebo, fasting glucose
decreased, and a progressive weight loss of 1.6 kg was observed [83]. The side effects include
headache, nausea, and vomiting, which can be lessened by gradual dose escalation [84]. Thus,
exendin-4 shows promise of being an effective treatment for diabetes with a favorable weight-loss
profile. Exenatide, however, is contraindicated in patients with known hypersensitivity to this
product or any of its components. Exenatide should be used with caution in subjects with severe
gastrointestinal disease, as exenatide can cause nausea, vomiting, and diarrhea.
FLUOXETINE AND SERTRALINE

Fluoxetine and sertraline are both selective serotonin reuptake inhibitors approved for the treatment of
depression. Fluoxetine at a dose of 60 mg/d has been used in the treatment of obesity. Goldstein et al.
[85] reviewed several trials: a 36-week trial in type 2 diabetic subjects, a 52-week trial in subjects with
uncomplicated obesity, and two 60-week trials in subjects with dyslipidemia, diabetes, or both. A total
of 1441 subjects were involved in these trials, and approximately 70% completed 6 months of treatment.
(Comment: This dropout rate is not unusual for weight loss trials.) Weight loss in the fluoxetine and
placebo groups at 6 months and 1 year was a modest 4.8, 2.2 and 2.4, 1.8 kg, respectively. The regain
of 50% of the lost weight during the second 6 months of treatment on fluoxetine made it inappropriate
for the treatment of obesity, which requires chronic treatment. Sertraline has resulted in an average
weight loss of 0.45 to 0.91 kg in clinical trials lasting 8 to 16 weeks for depression. Fluoxetine and
sertraline may be preferred over tricyclic antidepressants for the treatment of depression in the obese,
as tricyclic antidepressants are associated with significant weight gain; however, fluoxetine and
sertraline are not, by themselves, good drugs for the treatment of obesity.
Fluoxetine is contraindicated in patients known to be hypersensitive to it. Thioridazine and
MAOIs are contraindicated with its use. The neuroleptic malignant syndrome, a serious and
sometimes fatal reaction, can occur with its use, and the same has been reported with sertraline.
Sertraline is contraindicated with the concomitant use of MAOIs. Sertraline has been associated
with inappropriate antidiuretic hormone secretion and altered platelet function. When these drugs
are used for the treatment of depression, clinical worsening and an increased suicide risk can occur
with both medications. Fluoxetine should be used with caution in subjects with chest pain or chills
or who have attempted suicide. Sertraline use has been associated with impotence, palpitations,
chest pain, and sexual dysfunction.
METFORMIN
Metformin is a biguanide that is approved for the treatment of diabetes mellitus. This drug reduces
hepatic glucose production, decreases intestinal absorption from the gastrointestinal tract, and
enhances insulin sensitivity. In clinical trials where metformin was compared with a sulfonylurea,
it produced weight loss [86]. The best trial of metformin in terms of evaluating weight loss effects
is the Diabetes Prevention Program (DPP) study of individuals with impaired glucose tolerance.
This study included three treatment arms to which participants were randomly assigned; subjects
were over 25 years of age, had a body mass index (BMI) above 24 kg/m2 (except Asian-Americans,
who only needed a BMI ≥ 22 kg/m2), and had impaired glucose tolerance. The three primary arms
included lifestyle (N = 1079 participants), metformin (N = 1073), and placebo (N = 1082). At the
end of 2.8 years, on average, the Data Safety Monitoring Board terminated the trial because the
advantages of lifestyle and metformin were clearly superior to placebo. During this time, subjects
in the metformin-treated group lost 2.5% of their body weight (p < 0.001 compared to placebo),
and the conversion from impaired glucose tolerance to diabetes was reduced by 31% compared to
placebo. In the DPP trial, metformin was more effective in reducing the development of diabetes
in the subgroup who were most overweight and in the younger members of the cohort [87]. Although
metformin does not produce enough weight loss (5%) to qualify as a weight-loss drug using the
FDA criteria, it would appear to be a very useful choice for overweight individuals newly diagnosed
with diabetes. Metformin has also found use in the treatment of women with the polycystic ovarian
syndrome, where the modest weight loss may contribute to increased fertility and a reduction in
insulin resistance [88].
Metformin is known to be substantially excreted by the kidney, and the risk of metformin
accumulation and lactic acidosis increases with the degree of impairment of renal function; thus,
patients with serum creatinine levels above the upper limit of normal for their age should not use
metformin. Renal function should be monitored during metformin treatment, and metformin should
be stopped prior to surgical procedures or procedures using x-ray contrast material. Because alcohol
potentiates the effect of metformin on lactic acid metabolism, excessive alcohol intake should be
avoided. Metformin should be used with caution in patients with congestive heart failure, hepatic
insufficiency, hypoxic conditions, or acidosis. Metformin is also associated with a decline in vitamin
B12 levels.
PRAMLINTIDE
Beta-cells in the pancreas secrete amylin in a fixed ratio to insulin. In type 1 diabetes mellitus,
immunologically damaged β-cells are deficient in amylin. Pramlintide, a synthetic amylin analog,
was recently approved by the FDA for the treatment of insulin-requiring diabetes. Unlike insulin
and many other diabetes medications, pramlintide is associated with weight loss. Maggs et al. [89]
analyzed the data from two 1-year studies in insulin-treated type 2 diabetic subjects randomized
to pramlintide 120 µg twice a day or 150 µg three times a day. Weight decreased by 2.6 kg and
hemoglobin A1C decreased 0.5%. When weight loss was then analyzed by ethnic group, African-
Americans lost 4 kg, Caucasians lost 2.4 kg, and Hispanics lost 2.3 kg. The improvement in diabetes
correlated with the weight loss obtained, suggesting that pramlintide is effective in the ethnic group
with the greatest obesity burden. The most common adverse event was nausea, which was usually
mild and confined to the first 4 weeks of therapy. Pramlintide treatment in insulin-treated type 2
diabetes mellitus may offer an added benefit of weight loss in subjects with preexisting obesity.
Pramlintide is contraindicated in patients with a known hypersensitivity to pramlintide or any of
its components, including metacresol. Because pramlintide delays gastric emptying, it should not
be used in subjects with a confirmed diagnosis of gastroparesis or hypoglycemia unawareness.
Pramlintide and insulin should always be administered as separate injections. Pramlintide should
be used with caution in subjects with moderate or severe renal impairment, local allergy, hepatic
impairment, coughing, or pharangitis.
SOMATOSTATIN
Insulin hypersecretion accompanies hypothalamic obesity [90]. Treatment with octreotide, an ana-
log of somatostatin, resulted in weight loss in children with hypothalamic damage, and their weight
loss correlated with reduced insulin secretion on glucose tolerance tests [91]. This open-label trial
was followed by a randomized controlled trial of octreotide treatment in children with hypothalamic
obesity. The subjects received 5 to 15 µg/kg/d octreotide or placebo for 6 months. The children on
octreotide gained 1.6 kg compared to a 9.1-kg gain for those in the placebo group [92]. A trial of
44 subjects, a subset of obese subjects with insulin hypersecretion by an oral glucose tolerance
test, was undertaken. A dose of 40 mg/month octreotide LAR was given for 6 months. These
subjects lost weight, reduced food intake, and reduced their carbohydrate intake. Weight loss was
greatest in those with insulin hypersecretion, and the amount of weight loss was correlated with
the reduction in insulin hypersecretion [93]. Because a larger prospective study of 172 insulin-
hypersensitive subjects randomized to 40 or 60 mg of long-acting octreotide vs. placebo lost a
maximum of 3.8% of initial body weight in the high-dose group, it does not appear that octreotide
will meet with the criteria for approval as a weight-loss drug by the FDA [94]. Octreotide has been
shown to decrease gastric emptying [95]. Octreotide treatment of patients with the Prader–Willi
syndrome who have elevated ghrelin levels does not cause weight loss but ghrelin levels are
normalized. The reason for the lack of weight loss has been postulated to be the reduction of PYY,
a satiating gastrointestinal hormone that also decreased [96]. Octreotide is contraindicated in the
face of sensitivity to it or any of its components. It causes gallbladder stasis and is associated with
gallstones, gallbladder sludge, and biliary duct dilatation. Octreotide alters the glucose counter-
regulatory hormones and can be associated with hypoglycemia, hyperglycemia, and hypothyroid-
ism. Cardiac conduction abnormalities have developed in patients on octreotide, and cases of
pancreatitis have been reported. Octreotide can alter absorption of dietary fat and depress vitamin
B12 levels.
TOPIRAMATE
Topiramate is an antiepileptic drug that was observed to give weight loss in the clinical trials for
epilepsy. Weight losses of 3.9% of initial weight were seen at 3 months, and losses of 7.3% of
initial weight were seen at 1 year [97]. Bray et al. [98] reported a 6-month, placebo-controlled,
dose-ranging study. In this study, 385 obese subjects were randomized to placebo or topiramate at
64, 96, 192, or 384 mg/d. These doses were gradually reached by a tapering increase and were
reduced in a similar manner at the end of the trial. Weight loss from baseline to 24 weeks was 2.6,
5, 4.8, 6.3, and 6.3% in the placebo, 64 mg, 96 mg, 192 mg, and 384 mg groups, respectively. The
most frequent adverse events were paresthesia, somnolence, and difficulty with concentration,
memory, and attention.
This trial was followed by two large multicenter trials extending for 1 year [99,100]. Despite
impressive weight losses of 7 to 16.5% of initial body weight, a significant improvement in blood
pressure, and improvement in glucose tolerance, the sponsor terminated further study to pursue a
time-released formulation of the drug. Although topiramate is still available as an antiepileptic
drug, the development program to pursue an indication for obesity was terminated by the sponsor
in December 2004 due to associated adverse events.
Topiramate has been evaluated in the treatment of binge eating disorder [101]. Sixty-one
subjects were randomized to 25 to 600 mg/d of topiramate or placebo in a 1:1 ratio. The topiramate
group had improvement in binge eating symptoms and lost 5.9 kg at an average topiramate dose
of 212 mg/d [102,103]. It has also been used to treat patients with the Prader–Willi syndrome
[104–106] and patients with the nocturnal eating syndrome (a sleep-related eating disorder) [107].
Topiramate is a carbonic anhydrase inhibitor associated with kidney stones (1.5%) and meta-
bolic acidosis. Topiramate has been associated with the syndrome of acute myopia and secondary
angle closure glaucoma. Topiramate can decrease sweating and increase the risk of hyperthermia.
Central nervous system adverse events associated with topiramate include psychomotor slowing,
difficulty in concentration, speech difficulties, language problems, word-finding difficulties, som-
nolence, fatigue, irritability, and depression. Peripheral nervous system adverse events consist of
paresthesias. Dosage adjustment of topiramate is necessary in renal and hepatic failure.
ZONISAMIDE
Zonisamide is an antiseizure drug that has been evaluated for the treatment of obesity. It has
serotonergic and dopaminergic activity in addition to blocking neuronal sodium and calcium
channels. In a 16-week trial of 60 subjects (92% women) who were administered a hypocaloric
diet, 400 to 600 mg/d zonisamide was shown to result in greater weight loss compared with placebo,
with few adverse effects [108]. Because zonisamide is a sulfonamide anticonvulsant, it can cause
hypersensitivity reactions in those allergic to sulfa. Zonisamide can reduce sweating and increase
the risk of hyperthermia, and rare but serious cases of aplastic anemia have been reported. The
possible CNS effects of zonisamide include depression, psychosis, psychomotor slowing, difficulty
with concentration, word-finding difficulties, somnolence, and fatigue. Zonisamide is also associ-
ated with asthenia, vomiting, tremor, abnormal gait, hyperesthesia, and incoordination. Because
zonisamide inhibits carbonic anhydrase, it is associated with the formation of renal calculi. A
decrease in glomerular filtration rate that is also associated with zonisamide can cause an increase
in the blood urea nitrogen. Rare reports of creatine phosphokinase elevation and pancreatitis have
been reported with zonisamide. Zonisamide can also cause birth defects and should not be used in
women with the potential for pregnancy unless the benefits are felt to outweigh this risk.
POTENTIAL FOR USING HERBS

TO DEVELOP NEW OBESITY DRUGS
The traditional method of discovering new drugs for obesity, or for other purposes, is to screen
novel compounds for activity in assays measuring a mechanism of the disease in question. Activity
in a screening assay leads to further in vitro testing and eventually to testing in humans. Most
candidate compounds with activity in screening assays fall out of the development process due to
safety considerations. As we have already noted, safety is of particular concern in the treatment of
obesity; thus, we have adopted a slightly different strategy for obesity drug development by selecting
an assay that relates to a mechanism of obesity and screening herbs with a history of safe use in
folk medicine with the belief that they may be active in treating obesity. We will outline an example
of one project that, although unsuccessful, demonstrates the potential for herbs to form the basis
of future obesity medications.
Wei Kai-Yuan developed an herbal decoction, which he called “NT,” to treat obesity; it was
derived empirically using herbs with a history of safety and long-term usage and by applying the
principles of traditional Chinese medicine. He tested this combination using Western scientific
methods, patented his work in China and the United States, and licensed this intellectual property.
The herbal mixture consisted of a combination of 40% rhubarb root and stem (radix et rhizoma
rhei), 13.3% astragulus root (radix astragali), 13.3% red sage root (radix salviae miltiorrhizae),
26 to 27% turmeric (rhizoma curcumae longae), and 6 to 7% dried ginger (rhizoma zingiberis
officinalis). This mixture was extracted in water, and 0.5 g of solids was produced from 10 mL of
liquid. This herbal extract was tested in groups of young, growing, male Wistar rats (mean 220 g),
which were placed on an obesity-inducing diet. The groups of rats was given one of three doses
of NT, fenfluramine, or saline by gavage daily for 90 days. These animals gained 420, 400, 360,
400, and 450, respectively, and the herbal extract was well tolerated [109].
A pilot study using a subtherapeutic dose of the herbal extract was performed in 24 overweight
or obese human females. As expected from the low dose, there was no significant weight loss, but
the herbal extract increased the frequency of bowel movements from 1 per day to 3 per day. Further
testing of the herbal extract revealed the presence of sennosides, which are known to be herbal
laxatives. Because it was obvious that therapeutic levels of the herbal extract would result in
intolerable gastrointestinal symptoms, an attempt was made to use one of its active ingredients [109].
Inhibition of angiogenesis has been shown to reverse animal models of obesity [110]. Brown
et al. [111] described a human placental vein angiogenesis model that uses disks of human placental
vein implanted in a fibrin matrix to evaluate angiogenesis. Gulec and Woltering [112] adapted this
assay to the study of human tumor and other tissue fragments. By maintaining the tissue architecture
in which the blood vessels grow faster than the tissue stroma, one can differentially evaluate the
vascular and tissue compartments. We have adapted this assay to human fat tissue, which has
angiogenic properties different from those of placental tissue [113]. By using the placental assay
and serially fractionating an herbal extract, gallic acid was isolated as an angiogenic inhibitor. The
potential of gallic acid to completely inhibit angiogenesis at 10–3 M and partially inhibit angiogenesis
at 10–4 M was confirmed using the fat tissue assay [114].
Gallic acid has been shown to inhibit food intake in rats when given orally [115] or parenterally
[116]. Because gallic acid is derived from gall nuts and is on the list of Generally Recognized as
Safe (GRAS) ingredients by the FDA, gallic acid (80%) and the herbal extract (20%) were mixed
and tested for the treatment of obesity [117]. Despite the weight loss efficacy in rodents, the herbal
extract and gallic acid mixture did not result in weight loss in humans. When oral pharmacokinetic
studies were performed, 40% of a 50-mg dose of gallic acid was absorbed, but only 6% of an
800-mg dose was absorbed. Thus, the blood levels with the dose used in the trial never exceeded
10–6 M, suggesting a saturated transport system that prevents a therapeutic level of gallic acid from
ever being reached [117]. Although gallic acid does not fulfill the criteria of effective oral dosing
necessary to become a dietary herbal supplement or an obesity drug that will be well accepted, it
was well tolerated in both humans and rodents.
We have also been exploring the mechanisms of lipolysis and 11 β-hydroxysteroid dehydro-
genase inhibition, in addition to angiogenesis inhibition, to identify potential dietary herbal sup-
plements for the treatment of obesity. By screening herbs for which folklore suggests efficacy in
treating obesity, we feel that the potential for a safe therapeutic agent will be greater, as the long-
term use in food and folk medicine already suggests safety. Our assays allow us to isolate the active
chemical compounds, which can be developed as ethical pharmaceutical agents for the treatment
of obesity while a standardized dietary herbal supplement fills the therapeutic gap created by the
lengthy drug development process. We believe this strategy has the potential for much greater safety
than might be possible developing drugs from novel chemical entities.
DISCUSSION AND CONCLUSIONS

Obesity drugs have a very poor track record of safety. Obese individuals, especially women,
experience discrimination in our society [11]. This discrimination encourages some women to take
unreasonable risks to lose weight. This makes drug safety all the more important for the treatment
of obesity. The drugs available today for the treatment of obesity have limited efficacy and work
on upstream targets. The situation with obesity drugs today can be compared to the situation with
hypertension drugs in the 1950s. At that time, we had thiazide diuretics that caused the loss of salt
in the urine and drugs working at the level of the brain, such as reserpine that had side effects on
mood. Orlistat, which leads to the loss of calories in the stool, has parallels with diuretics for the
treatment of obesity. Sibutramine and the older obesity medications derived from the basic amphet-
amine chemical structure provide CNS stimulation and have parallels with the antihypertensive
drugs of the 1950s, such as reserpine, that produced such CNS side effects as depression.
The pipeline of new obesity drug candidates is rich, and the technology available to the
pharmaceutical industry is much more advanced compared to what existed in the 1950s; thus, the
future is bright for a much more rapid development of safe obesity drugs that act on downstream
targets. Drugs acting on downstream targets have less potential for side effects than drugs acting
upstream in the CNS. We now have drugs such as angiotensin receptor blockers that act in the
periphery and treat hypertension with few side effects. As we develop new drugs for obesity that
act on downstream targets, we should see a similar advance in the safety of pharmacological obesity
treatment. Using herbs as a platform for the development of obesity drugs offers an additional
strategy that may increase the safety of future obesity drugs and serves to emphasize why a chapter
on obesity drug safety is germane to a book on phytopharamceuticals and the therapy of obesity.
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Part VI
Natural, Nutritional, and Physical
Approaches to Weight Management
17 The Fundamental Role

of Physical Activity
and Exercise in
Weight Management
Dawn Blatt and Cheri L. Gostic
CONTENTS
The Growing Obesity Epidemic ....................................................................................................219

Initiatives to Combat Obesity ........................................................................................................220
The Fundamental Role of Exercise in Weight Management ........................................................221
Exercise Prescription......................................................................................................................221
Exercise Options ............................................................................................................................222
The Role of Daily Physical Activity in Weight Management ......................................................223
Considerations for Special Populations.........................................................................................224
Pediatrics .................................................................................................................................224
Daily Activity Level and Exercise ..................................................................................224
School-Based Intervention...............................................................................................225
Geriatrics .................................................................................................................................226
Bariatric Surgery.....................................................................................................................226
Considerations for Specific Medical Conditions (Diabetes, Hypertension, Osteoarthritis) .........227
Information Available Online ........................................................................................................228
Summary ........................................................................................................................................228
Thoughts on Prevention .................................................................................................................228
References ......................................................................................................................................229
THE GROWING OBESITY EPIDEMIC

Obesity has grown into one of the most troubling public health epidemics in the United States over
the past two decades. The prevalence of obesity has doubled in adults, while the incidence of
overweight children and adolescents has tripled since 1980 [1]. Data from the National Health and
Nutrition Examination Survey (NHANES) obtained from 2003 to 2004 reveal that 66.3% of adults
are overweight and 32.2% of those meet the criteria for obesity [2]. In the United States, obesity
is ranked second only to the use of tobacco as the leading preventable cause of death [3].
Body mass index (BMI), defined as body weight (kg) divided by height squared (m2), has
become the most commonly used indicator of obesity in recent years. Whereas a BMI equal to or
greater than 30 kg/m2 signifies obesity, the National Center for Health Statistics reports that health
risks actually begin to increase at a BMI greater than 27 kg/m2. Children are at risk of being
overweight if their BMI falls between the 85th and 95th percentile for their sex and age, and they
are deemed obese at or above the 95th percentile.
219
Children and adolescents who are overweight are at risk of developing type 2 diabetes, sleep
apnea, and poor self-esteem and have to deal with the social consequences of being overweight
[4]. They are six times more likely to have at least one cardiovascular risk factor as compared to
children of healthy weight and are at increased risk for various chronic diseases as adults [5]. In
adults, the health risks associated with obesity are well established. Obesity increases the risks of
cardiovascular disease, stroke, diabetes, arthritis, gallbladder disease, certain cancers, and lung
pathologies [6]. Abdominal or central obesity and insulin resistance are also considered the primary
risk factors associated with metabolic syndrome, a cluster of conditions that appear to directly
promote the development of atherosclerotic cardiovascular disease [7]. Research by Shen et al. [8]
suggests that measurement of waist circumference has a stronger correlation to health risks asso-
ciated with metabolic syndrome than BMI or percent body fat measured by dual-energy x-ray
absorptiometry (DEXA) and is an important adjunct in the clinical assessment of obesity. Based
on recent research, Bray [9] has proposed that men with a waist circumference between 100 and
120 cm are at high risk and above 120 cm at very high risk for cardiovascular disease. His new
proposed risk classification categorizes women with a waist circumference between 90 and 109
cm at high risk and those above 110 cm at very high risk.
The problem of overweight and obesity results from an imbalance involving elevated caloric
intake relative to energy expenditure and is influenced by genetic, behavioral, metabolic, and
socioeconomic factors. The World Health Organization Consultation on Obesity (2002) determined
that physical inactivity and overindulgence in food are primarily responsible for the obesity epi-
demic in the United States. Americans’ devotion to television and computers, labor-saving devices,
and contracted household services has contributed greatly to a more sedentary culture. Research
has revealed a strong relationship between the amount of television an individual watches and the
prevalence of obesity and diabetes [10]. The U.S. Department of Health and Human Services reports
that 40% of adults in the United States engage in no leisure-time physical activity, and 80% of
overweight adults are completely sedentary.
A review of the literature by Blair and Brodney [11] demonstrated that regular physical activity
attenuates many of the health risks associated with obesity. They found that overweight or obese
individuals who are physically fit and active have remarkably lower morbidity and mortality than
individuals of normal weight who are sedentary. Research by Hu et al. [12] concluded that a
sedentary lifestyle as well as increased adiposity were strong and independent predictors of death
which together accounted for 31% of all premature deaths among the nonsmoking women involved
in their study. It is clear that regular exercise and physical activity result in improved fitness and
health and should be foundational elements in combating obesity in this country.
Despite national initiatives to reverse the growing problem of obesity in the United States,
research shows that only 42% of adults who are obese are advised to lose weight by their healthcare
providers [13,14]. It is obvious that physicians and other healthcare professionals need to more
consistently educate patients regarding the benefits of physical activity and weight loss if we are
to deal effectively with this growing crisis.
INITIATIVES TO COMBAT OBESITY

Based on a systematic review of the literature from 1980 to 1997, the National Heart, Lung, and
Blood Institute (NHLBI) released clinical guidelines in 1998 on the identification, evaluation, and
treatment of overweight and obese adults. Recommendations included a call for all health profes-
sionals to address risk factor reduction and weight management strategies with patients who are
obese. The NHLBI also advocated the establishment of a modest target weight loss of 10% of body
weight, at a rate of 1 to 2 pounds per week. Studies have demonstrated that even modest weight
loss results in improvement or prevention of hypertension, diabetes, and hyperlipidemia [15]. Goals
related to weight management should focus on achieving and maintaining clinically meaningful
weight loss and on reducing the risk of obesity-related pathologies. The promotion of long-term
The Fundamental Role of Physical Activity and Exercise in Weight Management 221
lifestyle changes in diet and physical activity in conjunction with the establishment of modest
weight-loss goals offers a realistic chance of success in combating the obesity epidemic. An
approach to weight loss that combines an increase in physical activity, restriction of calories, and
behavior modification has been shown to be the most effective regimen for weight loss, weight
maintenance, and improved quality of life [15]. Realistic goal setting, stimulus control, problem-
solving strategies, and contingency planning are all components of an effective behavioral therapy
program. Self-monitoring of exercise and diet using a journal and enlisting the support of family
and friends can be useful in reinforcing positive behavioral change.
THE FUNDAMENTAL ROLE OF

EXERCISE IN WEIGHT MANAGEMENT
Exercise is a critical adjunct to diet and behavioral modification in a comprehensive weight-loss
program. Exercise not only increases energy expenditure, but it has also been shown to diminish
the loss of lean body mass and associated decline in resting metabolic rate characteristic of dieting
alone [16]. Exercise improves the body’s ability to burn fat, thus enhancing the loss of adipose
tissue [17]. In addition, it has been shown to improve dietary adherence while reducing anxiety,
stress, and depression, which can trigger overeating [18]. Research confirms that the combination
of diet and exercise results in greater weight loss than diet or exercise alone [19]. Extreme caloric
restriction alone can produce a significant decrease in metabolic rate that can persist after the dieting
period ends, often leading to rapid weight regain. Research has repeatedly demonstrated that daily
physical activity and exercise adherence are the greatest determinants of weight maintenance
following weight loss [20–22].
EXERCISE PRESCRIPTION
Prior to the initiation of an exercise program, the patient’s risk factors, medical history, and
medications should be assessed and, when indicated, medical clearance obtained from a physician.
The Physical Activity Readiness Questionnaire (PAR-Q) has been recommended by the American
College of Sports Medicine (ACSM) as a minimal standard for participation in a moderate-intensity
exercise program [23]. The ACSM has developed risk stratification guidelines based on age, health
status, coronary artery disease risk factors, and symptoms that can be utilized to determine the
need for a medical exam and exercise testing prior to the initiation of an exercise program [24].
Heart-rate parameters derived from an exercise stress test should be included in the exercise
prescription. Individuals at low risk can be counseled and provided with patient-education literature
to guide them in developing an exercise program that can be incorporated into their lives. It is
recommended that healthcare professionals follow these individuals’ progress on a regular basis to
improve compliance.
Information regarding an individual’s previous level of activity, exercise preferences, physical
impairments, and time constraints should be ascertained. Exercise should be pain free, convenient,
and enjoyable to the participant to facilitate long-term compliance [24,25]. Whereas exercise classes
or group settings may provide valuable support and social benefits for some, home-based exercise
programs may improve compliance for others.
An exercise prescription should include a warm-up, training, and cool-down program, as well
as guidelines for progression of the intensity, duration, and frequency of exercise. The warm-up
and cool-down portions should be designed to address impairments that may contribute to functional
limitations while also serving to prevent injuries and sudden changes in heart rate and blood
pressure. Warm-up and cool-down exercises can include flexibility, resistive, or balance exercises
tailored to address any impairments an individual may have. Flexibility exercises can improve
posture, enhance function, and provide greater freedom of movement. Resistance exercises can be
TABLE 17.1
Indicators of Moderate-Intensity Exercise
55–69% maximum heart ratea
12–14 Borg Ratings of Perceived Exertion Scale (“somewhat hard”)b
3–6 METsc
a Data from Pollock, M.L. et al., Med. Sci. Sports Exer., 30, 975, 1998.
b Data from Borg, G.A., Med. Sci. Sports Exer., 14, 377, 1982.
c Data from Pate, R.R. et al., JAMA, 273, 402, 1995.
useful in improving function. An increase in strength that results in an improved level of mobility
can facilitate an increase in daily physical activity. Resistance exercises should target weak muscle
groups involved in functional tasks. Balance exercises can be a valuable component of a warm-up
or cool-down program, as they reduce the risk of falls, enhance function during gait, and promote
a more active lifestyle. Physical therapists can play an integral role in prescribing an appropriate
exercise program for patients who are overweight or obese.
Individuals should be encouraged to gradually increase the intensity of their exercise from low
to moderate over time. Parameters that can be utilized to define moderate-intensity exercise are
listed in Table 17.1. A gradual increase in duration and frequency of exercise should be implemented
as well, based on the individual’s tolerance and prior activity level. The cumulative effect of exercise
over time is substantial, and research has demonstrated a clear dose–response relationship between
the amount of weekly exercise performed and the amount of weight lost in individuals who are
overweight [26]. The most successful exercise programs for individuals who are obese are of
moderate intensity, of long duration, and performed frequently [27–29]. Individuals should be
counseled to strive for a long-term goal of 60 minutes of moderate-intensity physical activity over
the course of a day. An example of an exercise prescription is provided in Table 17.2.
EXERCISE OPTIONS
Aerobic exercise is the preferred type of exercise for individuals initiating a weight-loss program
due to its well-established cardiovascular benefits and volume of calories burned. Aerobic exercise
options include walking or the use of treadmills, upper-body exercise cycles, stationary or recumbent
cycles, swimming, exercise videos, and exercise classes. The selection of an appropriate mode of
aerobic exercise should be made by individuals based on preferences, access to equipment, time
constraints, and physical impairments. In a randomized controlled trial involving women who were
overweight, having access to exercise equipment at home was associated with better exercise
adherence and weight loss at 18 months when compared with women without home exercise
equipment [30]. Walking can be accomplished indoors at a local mall or on a treadmill or outdoors
around a neighborhood or at a local track. Pedometers can be useful to monitor activity levels and
to improve compliance. Based on available evidence in the literature, it has been proposed that
healthy individuals need to accrue 10,000 or more steps a day to be classified as “active” [31]. The
America on the Move (AOM) Foundation is a nonprofit organization that has established a free
pedometer-based program on the Internet as a national initiative to improve health and the quality
of life. Members establish a baseline step count and aim to increase their daily steps by 2000 per
day toward a long-term goal of 10,000 or more. The website allows members to map their progress
weekly and offers information, support, and dietary tips to enhance success.
Home cycle units are a relatively inexpensive and convenient aerobic option and impart minimal
stress to the joints. Recumbent cycles are more expensive but provide a comfortable alternative to
upright cycles. Swimming or aquatic therapy is an excellent alternative for individuals with arthritis.
TABLE 17.2
Example of an Aerobic Exercise Prescription for Weight Loss
Duration Frequency Intensity Time
Phase Weeks (Minutes) (Times/Week) (% of Maximum Heart Rate) (Optional)
Initial 1–4 15–30 3–4 40–55 5- to 10-minute bouts
Improvement 5–24 30–40 4–5 50–69 15- to 20-minute bouts
Maintenance 25+ 30–60 5–7 60–69 Continuous
Indoor pools can be found by contacting local YMCAs, school districts, health clubs, or hotels for
information about pool membership and class availability. Exercise classes (e.g., yoga, aquatic,
aerobic, t’ai chi) provide a social and structured environment that may improve compliance for
some. Videotapes (e.g., yoga, low-impact aerobics, dance, t’ai chi) are a convenient and inexpensive
choice for those who prefer to exercise at home. Health clubs are an option, but individuals who
are obese must be aware that exercise equipment such as treadmills, cycles, and elliptical trainers
manufactured for the general public tend to have weight limits of 300 to 350 lb. Individuals who
are severely obese may require specialized equipment to facilitate an increase in physical activity.
Bariatric gait training systems, lift-and-transfer devices, tilt tables, walkers, and wheelchairs are
available to meet the needs of these individuals.
THE ROLE OF DAILY PHYSICAL ACTIVITY

IN WEIGHT MANAGEMENT
Daily physical activity plays a fundamental role in energy balance, weight control, and overall
health. New guidelines were issued by the National Academies Institute of Medicine in 2002 on
exercise and nutrition that recommended that children and adults get a minimum of 1 hour of
physical activity daily, twice the previous public health recommendation [32]. The new guidelines
reflect the need for 1 hour of moderate-intensity physical activity to maintain a healthy weight and
acknowledge that this activity can be accumulated in short bouts. This recommendation is derived
from normative data of total daily energy expenditure in healthy adults with normal BMIs. Research
indicates that, although significant health benefits can be obtained through participation in at least
2.5 hours of moderate-intensity physical activity or exercise per week, a gradual progression to 3.3
to 5 hours per week facilitates long-term maintenance of weight loss [27]. Individuals should
establish realistic goals that allow adequate time to steadily progress to this recommended level of
daily physical activity.
The incorporation of “lifestyle” activity in a weight-loss regime can be an effective adjunct or
alternative to more structured, continuous forms of exercise. Research demonstrates that intermit-
tent, moderate-intensity physical activity is an appropriate means to achieve the recommended
quantity of daily physical activity. A weight-loss program of diet with moderate-intensity lifestyle
activity seems to offer similar health and weight-loss benefits as a program of diet in conjunction
with a structured aerobic exercise program [11,20,28]. Participation in a program of intermittent
exercise or activity may appeal to individuals with time constraints or to those that dislike continuous
exercise. A comparison of the effects of performing multiple 10-minute bouts of exercise throughout
the day with a single, longer session in overweight subjects revealed greater adherence among
those exercising in short bouts and no negative impact on long-term weight loss or fitness [30,33].
Participation in moderate-intensity physical activities, such as those listed in Table 17.3, for at
least 1 hour per day satisfies the National Academies Institute of Medicine guidelines. Individuals
should be instructed to park in distant parking spaces, climb stairs whenever possible, get off the
bus or subway a stop early and walk the remaining distance, walk during lunch breaks, perform
TABLE 17.3
Examples of Moderate-Intensity
Physical Activity
Activity METs
Swimming (leisurely) 6.0
General health-club exercise 5.5
Golf (pulling cart or carrying clubs) 5.0
Mowing lawn (power mower) 4.5
Home repair (painting) 4.5
Mopping floors or washing windows 4.5
Gardening (weeding and cultivating) 4.5
Raking the lawn 4.0
Brisk walking (3 to 4 mph) 4.0
Cycling (<10 mph) 4.0
Fishing (standing, casting) 4.0
Yoga, t’ai chi, stretching 4.0
Water aerobics 4.0
Canoeing (leisurely) 3.5
Childcare (bathing, feeding, dressing) 3.5
Housecleaning 3.5
Source: Data from Ainsworth, B.E. et al., Med.

Sci. Sports Exerc., 25, 71, 1993.
more of their own household chores, and participate in more active leisure-time activities on a daily
basis. Yardwork or housework, playing with children, or dancing can meet the Institute of Medicine’s
recommendations if performed at an adequate intensity. The accumulation of physical activity in
intermittent, short bouts has been shown to be an effective means to achieving an adequate activity
level. The literature suggests that the accumulated amount of activity is far more important than
the manner in which the activity is performed [28].
CONSIDERATIONS FOR SPECIAL POPULATIONS

PEDIATRICS
Obesity in children is growing at an alarming rate. Because overweight children are two times as
likely to become obese adults, it is of the utmost importance to treat and prevent obesity in childhood
[34]. The goal of intervention in this population is to promote good nutritional habits and increase
daily physical activity and exercise to improve physical fitness and increase energy expenditure.
For children, the school system affords an additional means to provide education and institute
programs to address the problem of obesity.
Daily Activity Level and Exercise
The U.S. Department of Health and Human Services recommends that children accumulate at least
60 minutes of moderate physical activity on most days of the week [35]. This is a goal that sedentary
children can build up to gradually by incorporating small bouts of activity throughout the course of
the day. Children who are overweight or obese need to strive toward a long-term goal of more than
60 minutes of physical activity most days of the week to facilitate or maintain weight loss. Children
should progress to a level of intensity where they are working up a sweat. If questions arise regarding
the structure of a program for a particular child, referral to an intervention program or physical
therapist may be warranted. Children can participate in structured activities such as team sports,
dance, martial arts, or swimming. If preferred, health-club memberships are options for older children
(many clubs offer membership for children 12 and older), and some health clubs are developing
programs targeted at children under 12 as a need and interest have been identified. Children should
wait until adolescence to pursue resistance training as a mode of exercise. Resistance training should
be limited to a maximum of two times per week and should target 8 to 10 major muscle groups.
Children should limit sets of each exercise to 10 to 15 repetitions and strive for a perceived exertion
rating of 12 to 14 (“somewhat hard”) [36]. The key is to choose an activity that the child enjoys
and one that will allow them to feel good about themselves while participating. They should be
cultivating interests that will allow them to maintain an improved level of fitness into adulthood.
It has been suggested that obese children are less active over the course of a day in moderate
and vigorous activities when compared with nonobese children [37]. Television has been identified
as a common sedentary activity that consumes hours of time each day for the average child.
According to data collected during the NHANES 2003–2004 survey, the average time spent
watching television for adolescents ages 12 to 17 is 4 hours a day; for children ages 6 to 11, it is
2 hours, 13 minutes a day [38]. A report by the Kaiser Foundation in 2004 indicated that other
factors may be related to children’s media use that contribute to weight gain. Not only are children
seated in front of the screen, but they also tend to snack while watching television. It was found
that advertising related to food choices (e.g., candy, fast food, soda) has an additional influence
beyond the sedentary act of watching television [39]. The American Academy of Pediatrics rec-
ommends limiting total screen time (which includes television, videotapes, video games, and
computer games) to 1 to 2 hours a day [40].
Parents play a critical role in setting limits for children, as well as encouraging children to
participate in activities that are not sedentary. Parents should provide active choices to their children
such as going to a park or riding a bike, instead of choices that include sedentary activities. Parents
can influence an overweight or obese child to increase overall energy expenditure by decreasing
sedentary activities and enhancing accessibility to physically active alternatives. Parents must
consider alternatives for their children as they look to change a child’s preferences. During a 2-year
study of a family-based behavioral weight program, it was found that promoting a reduction in
sedentary behaviors was as effective as targeting physical activity [41].
Physical activity can be made appealing to children in an endless number of ways. It is common
for some children to participate in organized sports, but this must be an enjoyable option for them.
If not, they can choose activities such as jumping rope, dancing, or general outdoor play. For the
child who enjoys video games, physical activity can be incorporated into this pastime as well.
Interactive dance mats are a great option; they plug into common game systems and allow children
to set the level of difficulty, time, and mode of play. In addition, stationary cycles are available that
plug into video game systems; these cycles allow interactive play, and physical activity is required
to participate in the game. A child can play alone or compete against another player with either of
these options.
The American Physical Therapy Association has a list of tips for avoiding the obesity trap
available online [42]. They suggest that parents set an example for their children by participating
in physical activities with the child and becoming the child’s “exercise buddy.” Parents should plan
active family activities, instead of simply trying to fit exercise in when time allows.
School-Based Intervention
The school setting provides an additional opportunity to influence children’s daily activity. The
percentage of public schools that provide daily physical education (PE) programs ranges from 17
to 22% at the elementary level; 22% of public schools offer PE only one day per week, and 43%
of first-grade classes and 34% of fifth- and sixth-grade PE classes were found to be 30 minutes
or less in duration [43]. The 2006 Youth Risk Behavior Surveillance Report by the Centers for
Disease Control and Prevention (CDC) found that, as children reach high school, only 54.2%
are enrolled in PE, and, of those participating in PE, only 20% are active for 20 minutes or
longer [44]. The school system has the ability to engage students in more vigorous activities and
provide additional exposure to activities that may be of interest. Healthy People 2010, an initiative
by the CDC and President’s Council on Physical Fitness, includes a goal to increase the proportion
of public and private schools requiring daily PE for all students to 50% [45]. The CDC publishes
a pamphlet titled “Making a Difference at Your School” that offers 10 strategies for schools to
utilize to aid in the battle against obesity in children and adolescents [46]. Recess is another
prime opportunity for schools to offer activities that get children moving. Health education
curricula in the schools can promote healthy lifestyles and instill health-conscious values in
children at younger ages.
GERIATRICS
The lack of physical activity is more common in the geriatric population than in any other age
group and contributes to a loss of independence in later years of life [47]. The reduction in endurance
and strength often attributed to aging is partly the result of reduced physical activity. Research has
demonstrated that diet and exercise training improve physical function and ameliorate frailty in
older adults who are obese [48]. It is recommended that exercise programs be instituted under the
supervision of a qualified healthcare professional for elderly patients who are obese and have
concomitant medical problems, with the long-term goal of a self-monitored, independent exercise
regimen. Physical therapists are experts in developing appropriate exercise programs to address
impairments and functional limitations in patients with cardiovascular, neurological, or musculo-
skeletal disorders. An assessment of strength, range of motion, function, balance, and endurance
should be performed and an exercise program designed to address the deficits found.
Appropriately designed exercise programs can reduce the risk of falls and facilitate a more
active lifestyle through improved mobility and function. Strength training is beneficial for seniors
as it prevents loss of bone mass and sarcopenia frequently observed in the elderly. Extension
exercises are particularly important to consider for older adults to improve flexibility due to their
tendency to develop flexed postures and tightness in hip flexors, hamstrings, abdominal, and cervical
muscles. To promote compliance and minimize the risk of medical complications, exercise intensity
should start low and progress gradually to a moderate level based on tolerance and heart-rate
parameters. It is recommended that a maximum heart rate be derived from a stress test when
prescribing exercise intensity in this population due to the variability in peak heart rate seen in the
elderly and their increased risk of underlying coronary artery disease [36]. It is also important to
take into consideration the medications that older adults are taking when prescribing and monitoring
an exercise program.
BARIATRIC SURGERY
Bariatric surgery rates are increasing, especially since surgery was recognized as a weight-loss
intervention by the National Institutes of Health for individuals who are morbidly obese (BMI of
40 or above) and have failed medical management [49]. Between 1990 and 1997, bariatric surgery
rates more than doubled from 2.7 to 6.3 per 100,000 adults in the United States [50]. Little in the
way of exercise guidelines can be found in the literature for pre- or postoperative intervention.
Individuals who are morbidly obese generally have multiple comorbidities that may affect their
ability to exercise. A study by Elkins et al. [51] that examined noncompliance after bariatric surgery
found that 40% and 41% of the 100 subjects at 6 and 12 months, respectively, were not exercising.
A New York State report, Focus on Overcoming Obesity, recommends participation in a
preoperative exercise program for a few months prior to bariatric surgery [52]. The preoperative
program at Northwest Kaiser Permanente includes the establishment of a 60- to 90-minute daily
home exercise program to improve physical fitness and prepare patients for the postoperative
weight-loss program. They recommend walking for those who are able and water aerobics or
“water walking” as a viable alternative. A bigger picture goal of the preoperative program strives
for patients to find activities they can sustain following surgery [53]. Immediately postop,
patients are at risk for blood clots and pneumonia and should be encouraged to perform ankle
pumps, deep breathing exercises, and ambulation as tolerated. In reviewing discharge instruc-
tions from various surgical programs, lifting objects greater than 15 to 20 lb is generally
prohibited for 6 weeks following invasive surgery and 3 weeks following laparoscopic surgery.
Upon discharge from the hospital, general recommendations include walking with a gradually
increase in the time and distance walked. Specific recommendations vary greatly, with little
attention being paid to the intensity of the exercise. Generally, patients need to find an activity
that they enjoy, one that is well tolerated and that they will engage in on a regular basis at a
moderate intensity. No specific contraindications for exercise have been noted in the literature,
except that individuals who undergo adjustable gastric banding should avoid the use of resisted
trunk flexion exercise equipment due to a report that a port connection had become dislodged
in one patient following this type of exercise [54].
CONSIDERATIONS FOR SPECIFIC MEDICAL CONDITIONS

(DIABETES, HYPERTENSION, OSTEOARTHRITIS)
Initiating an exercise program can attenuate some of the health risks associated with diabetes,
hypertension, and osteoarthritis. Due to the common comorbidities associated with obesity, however,
some precautions should be considered when prescribing exercise. For the person with diabetes who
is obese, exercise is contraindicated when blood glucose is over 300 mg/dL or greater than 240
mg/dL with urinary ketone bodies. At the initiation of an exercise program, blood glucose should
be monitored before, during, and after activity if insulin or oral medications have been prescribed.
Exercise has an insulin-like effect and may lead to exercise-induced hypoglycemia. A carbohydrate
snack may be needed either before or during exercise. It is important to review the signs of
hypoglycemia (dizziness, light-headedness, confusion, anxiety) with the individual. Exercise-induced
hypoglycemia can occur up to 4 to 6 hours after the cessation of exercise. Exercise should be planned
for early to midday, avoiding the evening due to an increased risk of nocturnal hypoglycemia. As
the exercise program progresses, insulin needs may change; therefore, close monitoring and follow-
up with a physician are important. People with diabetes are at risk for autonomic neuropathies
associated with silent heart ischemia or a blunted heart-rate response to exercise. It is important that
heart rate monitoring be performed in conjunction with a rating of perceived exertion scale to
determine a safe exercise program intensity level [55].
Hypertension is another common comorbidity. Exercise is contraindicated if resting systolic
blood pressure is greater than 200 mmHg or diastolic is greater than 115 mmHg. For persons on
alpha-1, alpha-2, or calcium channel blockers or vasodilators, the risk of post-exertion hypotension
exists, and the cool-down phase of the exercise program must be strictly adhered to [55].
A third common comorbidity is lower-extremity osteoarthritis. Public health records from
1971 and 2002 reveal an increase from 3% to 18% in the incidence of arthritis due to obesity in
the baby boomer population [56]. Non-weight-bearing exercises may be best tolerated by this
group. Stationary exercise cycles and water walking or water aerobics are alternatives that place
less stress on hips, knees, and ankles. If exercise produces pain, compliance will be diminished.
A recent study found that children who were overweight had a higher incidence of bone fractures,
joint and muscle pain, and abnormal knee-joint alignment [57]. This may contribute to an increase
in sedentary behaviors, requiring a recommendation for non-weight-bearing exercise and physical
activity to counteract this potential.
INFORMATION AVAILABLE ONLINE

A multitude of information is available to consumers with online access. Below is a list and summary
of Internet sites that individuals can refer to for education and to pick up tips, strategies, and
structure to improve their activity levels, overall fitness, and nutrition:
• www.shapeup.org — The mission of this not-for-profit organization is to increase

awareness of obesity as a health issue by providing evidence-based information. They
offer a 10-step program for weight loss and strategies to increase daily activity. They
advocate 10,000 steps/day.
• www.americaonthemove.org — America on the Move is a national initiative dedicated
to improving health and quality of life through healthy eating and increased activity.
Participation can be on an individual basis or as part of a larger group affiliation.
• www.americanheart.org — The American Heart Association provides tips for parents
and activities for children.
• www.mypyramid.gov — The U.S. Department of Agriculture promotes the newest food
pyramid as a guide for healthy eating and includes sections for children and health
professionals.
• www.nichd.nih.gov/msy — Media Smart Youth is a health promotion program instituted
by the NIH to help children 11 to 13 years old recognize how media influences nutrition
and activity choices.
• www.nhlbi.nih.gov/health/public/heart/obesity/wecan — The NIH’s We Can! site provides
practical tools for parents of children 8 to 13 years old to assist in healthy weight management.
• www.cdc.gov/nccdphp/dnpa/physical/recommendations/older_adults.htm — The CDC
offers recommendations for physical activity for older adults.
• www.niapublications.org/engagepages/exercise.asp — Provides access to the free
pamphlet Exercise: Getting Fit for Life from the National Institute on Aging.
• www.nia.nih.gov/HealthInformation/Publications/ExerciseGuide/ — The National
Institute on Aging provides free access to their comprehensive book, Exercise: A Guide
from the National Institute on Aging.
SUMMARY
Exercise and physical activity are fundamental components of a comprehensive weight-loss pro-
gram. The most successful exercise programs are those of low to moderate intensity and long
duration that are performed frequently. The cumulative effect of exercise over time is substantial,
and research has demonstrated a clear dose–response relationship between the amount of weekly
exercise performed and the amount of weight lost in overweight individuals [26]. Emphasizing
long-term lifestyle changes in diet and physical activity and establishing modest weight-loss goals
are key factors in successful weight-loss programs. Adherence to daily physical activity and exercise
are the greatest determinants in weight maintenance following weight loss. Healthcare professionals
need to be aware of the unique challenges posed by pediatric, geriatric, and post-bariatric surgery
patients and medically complex individuals when counseling for weight management.
THOUGHTS ON PREVENTION
Research indicates that a relatively small percentage of people who lose weight are successful in
maintaining their weight loss. It is important to implement strategies to prevent obesity in children
and adults who are overweight. It is essential that healthcare professionals consistently intervene
when dealing with overweight individuals to prevent weight progression to the level of obesity.
Successful long-term weight control requires that overweight or obese individuals value physical
activity and exercise as components of a healthy lifestyle. To effectively address the obesity
epidemic in the United States, it will be necessary to institute public policy that promotes education,
prevention, and wellness.
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18 Nutritional and Dietary

Approaches for Weight
Management: An Overview
Sanjiv Agarwal
CONTENTS
Introduction ....................................................................................................................................233
Factors Contributing to Obesity.....................................................................................................233
Hunger, Satiety, and Food Intake ..................................................................................................234
Food Factors Related to Satiety.....................................................................................................234
Novel Satiety Ingredients and Functional Foods ..........................................................................235
Functional Foods Affecting Energy Metabolism ..........................................................................235
Botanicals and Dietary Supplements for Weight Management ....................................................235
Conclusion......................................................................................................................................236
References ......................................................................................................................................236
INTRODUCTION
Obesity is a condition of excess body fat. It is one of the most rapidly evolving public health issues
in the recent years. According to the Centers for Disease Control and Prevention (CDC) [1,2] over
two thirds of Americans are overweight, one third of Americans are obese, and one sixth of American
children and adolescents are considered overweight or obese. The reported prevalence of obesity
among adolescents has nearly tripled in the past two decades [1,2]. Obesity is not only a cosmetic
issue but is also associated with several comorbidities and comortalities, including cardiovascular
disease, type 2 diabetes, many forms of cancer, gallbladder disease, and osteoarthritis [3,4]. It is
estimated that ≈400,000 deaths each year in the United States are associated with obesity [5].
FACTORS CONTRIBUTING TO OBESITY

Obesity is a multifactorial health problem arising from biological, behavioral, and environmental
sources [6–8]. Demographic factors (i.e., family history, race or ethnicity. and gender) are, to some
extent, determinant of individual’s susceptibility to obesity [6–8]. However, the preponderance of data
indicates that behavioral and environmental influences play a key role in obesity [6–8]. It is believed
that today environmental factors, such as the availability, convenience, and nature of food and behaviors
such as decreased physical activity and increased sedentary lifestyle, have contributed to this issue.
Indeed, the energy imbalance involving increased energy intake (eating too many calories), decreased
energy expenditure (not enough physical activity), or a combination of both leads to weight gain and
obesity [9]. This chapter describes some of the nutritional and dietary factors, metabolically active
agents, and functional food ingredients that are related to addressing the energy imbalance issue.
233
TABLE 18.1
Common Hormone/Peptide Signals That Control Satiety and Hunger
Site of
Satiety Signals Stimulus Production Effects
Cholecystokinin (CCK) Fat or protein Duodenum Decreases food intake by controlling the meal size
Glucagon-like-peptide 1 Carbohydrate Ileum Decreases food intake, affects mobility of nutrients from
(GLP-1) or protein stomach to intestine, and stimulates insulin secretion
Peptide YY (PYY) Meal Gut endocrine Decreases food intake, inhibits gut motility and gastric
cells emptying
Ghrelin Fasting Gut Increases food intake
Leptin — Adipocytes Decreases food intake only during energy imbalance
HUNGER, SATIETY, AND FOOD INTAKE

Food consumption in humans is a complex process regulated by a number of factors including
environmental cues, sensory stimulus, social pressures, appetite, and feelings of hunger. Physio-
logically, the regulation of food intake depends on direct and feedback signals from gut and adipose
tissue to the hypothalamus in the brain containing the hunger and satiety centers [10,11]. Food
intake is generally in distinct bouts or episodes (i.e., meals and snacks). The meals are eaten until
full (satiated) and then the next meal is not eaten for a certain time (satiety). The gastrointestinal
tract, in response to meals, generates a variety of biochemical peptide signals or satiety factors that
accumulate during eating and contribute to meal termination. These signals are transmitted to the
central nervous system and are manifested as a behavioral modification of feeding [11–14]. Some
peptide signals (anorexigenic signals) decrease food intake as they promote satiety, whereas other
peptides signals (orexigenic signals) increase food intake as they induce appetite. Table 18.1 lists
various peptide- and hormone-related signals that are generated in the gut and influence feelings
of satiety and hunger.
FOOD FACTORS RELATED TO SATIETY

Physical characteristics as well as the macronutrient composition of a meal are important determi-
nants of its satiating effects. Studies have shown that increasing the volume of a food (by adding
water or air) can improve satiety and significantly reduce the calorie intake at the next meal [15,16].
The energy density (ED) of a diet or caloric value of a food per unit weight or volume also plays
a key role in satiety. Dietary ED depends mainly on the water content of the foods eaten. As a rule,
high-ED foods are more palatable but less satiating, whereas low-ED foods are more satiating but
less palatable [17]. Lowering the energy density of a diet may also increase the fiber content of
the diet, especially if fiber-rich fruits and vegetables or whole grains are added. Studies have
demonstrated that eating low-energy-dense foods (such as fruits, vegetables, and soups) maintains
satiety while reducing energy intake [18]. Some data suggest that solid diets are more satiating
than semisolid or liquid diets, and more viscous liquid foods are more satiating than less viscous
foods [19]. The macronutrient composition of foods also appears to be a determinant of satiety
[20]. Traditionally, fats are considered to be most satiating; however, fats are most energy dense.
In isocaloric preload studies, where subjects are provided with a fat-, protein-, or carbohydrate-
based preload food and subsequently tracked for satiety over a period of time, fat was found to be
the least satiating macronutrient [21]. A strong body of evidence suggests that on a relative scale
proteins and fiber are more satiating than carbohydrates and fat [22–26].
Nutritional and Dietary Approaches for Weight Management: An Overview 235
NOVEL SATIETY INGREDIENTS AND FUNCTIONAL FOODS

Several functional food ingredients are metabolically active and help improve satiety. Many of
these novel ingredients have been known to function by activating the cholecystokinin (CCK)
mechanism. Satíse® (Kemin Industries, Inc.) is a protein extract from vegetables called “P12” and
is claimed to stimulate CCK [27]. Similarly, Satietrol® (Pacific Health Laboratories, Inc.) is a milk-
derived peptide (glycomacropeptide) and is also claimed to stimulate CCK and thus improve satiety
[28]. Satietrol also contains potato and guar fibers, as well as alfalfa, to help maintain the higher
levels of CCK longer. Olibra™ is a novel fat emulsion containing fractionated palm oil and
fractionated oat oil in water; it has been shown to have satiating effects via a fat-induced ileal brake
mechanism [29].
FUNCTIONAL FOODS AFFECTING ENERGY METABOLISM

Many functional foods have been shown to alter energy metabolism or fat partitioning by influencing
the substrate utilization or thermogenesis [30,31]. These may not influence the absorption of the
nutrients, but they act post-absorptively and increase the oxidation rate:
• Tea — Tea is a widely consumed beverage made from the leaves and buds of the plant
Camellia sinensis. The three types of tea are nonfermented green tea, semifermented
oolong tea, and fermented black tea. Tea contains high amounts of antioxidant polyphe-
nols (catechins, theaflavins, and thearubigins) [32]. Green tea and oolong tea are partic-
ularly rich in catechins and have been shown to increase fat oxidation in clinical and
animal studies. A catechin (EGCG) and the caffeine found in tea are implicated in the
thermogenic effects of tea [33,34].
• Medium-chain triglycerides (MCTs) — These are naturally occurring or commercially
prepared dietary fats containing 6- to 12-carbon fatty acid chains. Like long-chain
triglycerides (LCTs), MCTs are also digested to their medium-chain fatty acids (MCFs)
and absorbed in the gastrointestinal tract; however, they are not repackaged as MCTs in
chylomicrons for transportation through peripheral circulation like the LCTs are.
Medium-chain fatty acids from MCTs are directly transported via the portal system to
the liver for oxidation. MCTs therefore bypass the adipose tissue and do not get deposited
into adipose tissue store [35,36].
• Diacylglycerols (DAGs) — These are naturally occurring as minor components (1 to
10%) of oils. DAGs are glycerides in which the glycerol molecule is esterified to only
two fatty-acid chains. Similar to triacylglycerol (TAG), DAGs are also absorbed in the
gastrointestinal tract; however, they are transported via the portal system to the liver for
oxidation and they bypass the adipose tissue. A few human clinical studies have shown
that the replacement of TAG by DAG leads to significant weight reduction [37–39].
• Conjugated linoleic acid (CLA) — CLA is a group of naturally occurring trans-isomers
of linoleic acid. The main dietary sources are dairy products and beef. In animal studies,
CLA has been found to reduce body fat, possibly through increased fat oxidation and
decreased fat deposition in adipose tissue [40]; however, the human data available to
support the efficacy of CLA in weight management are inconsistent [40–42].
BOTANICALS AND DIETARY SUPPLEMENTS

FOR WEIGHT MANAGEMENT
Several dietary supplements and herbal products are currently being promoted for weight manage-
ment [43–46]. The potential biological mechanisms include increased energy expenditure, increased
fat oxidation, decreased fat absorption, and increased satiety (Table 18.2). Concerns have been
TABLE 18.2
List of Dietary Supplements Commonly Used for Weight
Management and Their Proposed Mechanisms
Dietary Supplement or Herbal Proposed Mechanism
Ephedra, yerba maté, caffeine Increase energy expenditure
Psyllium, guar gum, hoodia, pinnothin (pine extract) Increase satiety
Chitosan Inhibit fat absorption
Green tea, Garcinia cambogia (hydroxycitric acid) Increase fat oxidation
Chromium picolinate, ginseng Influence carbohydrate metabolism
Source: Data from Pittler and Ernst [43], Heber [45], and Lenz and Hamilton [46].
raised, however, regarding the efficacy and safety of herbal products and dietary supplements
promoted for weight management. The U.S. Food and Drug Administration (FDA) has taken
regulatory actions against a number of dietary supplements. The scientific evidence is insufficient
or conflicting, and clinical data are necessary to ensure their safety and efficacy.
CONCLUSION
Obesity has become an important health issue in the recent years. Energy imbalance is an important
etiological factor, and dietary and nutritional factors, functional food ingredients, and dietary
supplements may help address this issue. Readers are advised, however, to be sure of the safety
and efficacy of functional food ingredients and dietary supplements before using them.
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19 Gender Differences
in Body Fat Utilization
During Weight Gain,
Loss, or Maintenance
Gabriel Keith Harris and David J. Baer
CONTENTS
Introduction ....................................................................................................................................239
Fat Distribution ..............................................................................................................................240
Metabolic Rate ...............................................................................................................................240
Food Intake.....................................................................................................................................240
Exercise Effects..............................................................................................................................241
Conclusions ....................................................................................................................................242
References ......................................................................................................................................243
INTRODUCTION
During the late nineteenth and throughout the twentieth century, numerous experiments were con-
ducted to determine the effects of diet on health in humans. Notable examples include the work of
Goldberg [2], who studied the effects of diet on pellagra in prisoners, and of Keys [1], who examined
the effects of starvation and refeeding on conscientious objectors during the Second World War.
Without delving into the ethical dilemmas associated with those studies, one thing is clear: The
majority of these early studies were conducted on men, but the results were often extrapolated to
both men and women. Now, at the beginning of the twenty-first century, it is becoming increasingly
apparent that men and women differ considerably in their response to diet, physical activity, and other
factors that may affect changes in body fat. The increasing prevalence of obesity throughout the world
is often referred to as an “obesity epidemic” [3]. One example of this increase in obesity can be found
in the 1999–2000 National Health and Nutrition Examination Survey (NHANES), which reported
that an estimated 30.5% of U.S. citizens were obese, as defined by excessive weight for a given
height, compared to 22.9% from the 1988–1994 survey [4]. Regardless of the source of the data, it
appears that an increasing proportion of the world’s population is now overweight and overfat. The
primary concern is not obesity itself but the increased disease risk associated with it. Although the
problem of obesity seems to be an exceedingly simple one to solve (do not consume more calories
than necessary for proper development or weight maintenance), controlling obesity has proven to be
exceedingly difficult. One facet of this problem that has received little attention is the role that gender
plays in obesity and fat gain or loss. The purpose of this chapter is to outline the known differences
in fat gain, loss, and maintenance between men and women and, perhaps more importantly, highlight
how little is known about the subject. To this end, we discuss the reported effects of gender differences
on body fat distribution, fat use as an energy source, and exercise-related fat loss.
239
FAT DISTRIBUTION
One of the most obvious distinctions between men and women is the difference in body fat
distribution. Although there is an equally obvious continuum of fat distribution among the genders,
men tend to store fat in the abdominal region to a greater degree than women. Conversely, women
tend to store fat in the gluteal and femoral (thigh) areas. Less obvious is that men have a greater
tendency to store visceral (internal, organ-associated, abdominal) fat, whereas women tend to store
fat in subcutaneous tissues (between skin and muscle). In both genders, visceral fat as a percentage
of total body fat tends to increase with age, but this effect is especially apparent in men [5].
Gender-based differences in fat distribution appear to be due, at least partially, to the tendency
to store fat in or recruit stored fat from distinct areas; for example, men tend to recruit more free
fatty acids from the thigh region than women during weight loss and exercise. Under the same
conditions, total body fat mobilization from upper body stores appears to be similar between
genders, although men tend to recruit a larger percentage of that fat from subcutaneous tissue [6].
The net result is a protection of subcutaneous lower body fat in women. This effect is clearly
evident in male and female bodybuilders, where body fat loss is essential to display maximum
muscularity. Male competitors tend to display an equal degree of upper and lower body leanness,
but female competitors tend to retain more lower body fat [7]. A study comparing lipolysis
(conversion of stored triglycerides to glycerol and fatty acids) rates in the subcutaneous abdominal
fat of morbidly obese men and women undergoing bariatric surgery found that lipolysis rates were
only elevated in women. This finding may indicate that women have an increased resistance to the
accumulation of abdominal fat relative to men, even in cases of extreme obesity [8]. In summary,
gender-specific differences in body fat storage and mobilization tend to favor the preservation of
lower body and subcutaneous fat in women and of abdominal and visceral fat in men.
METABOLIC RATE
In addition to differences in fat distribution, men and women also differ with respect to basal
metabolic rate and the use of macronutrients as energy sources. Basal metabolic rate is primarily
influenced by fat free mass [9]. Because men tend to possess more muscle mass both in absolute
terms and as a percentage of body weight, they also tend to burn more calories at rest than women.
Women appear to use stored body fat differently than men, both at rest and during exercise. At rest
and in a fed state, women tend to use a smaller percentage of fat as an energy source than men.
Conversely, during exercise, women have been reported to use twice as much fat as a fuel source
than men [10,11]. In the fasted state, men and women use fat similarly, although women appear
to switch more quickly from the use of glucose to fat as an energy source [12]. Because energy
burned at rest (basal metabolic rate) represents the majority of total daily energy expenditure in
Western societies, the overall effect of these gender differences on metabolic rate and macronutrient
usage appears to be a tendency toward body fat conservation in women [9]. With that said, the fact
that the “obesity epidemic” is not restricted to women indicates that a great number of both men
and women in many countries around the world are consuming an excess of energy, not exercising
enough, or both.
FOOD INTAKE
In addition to gender differences in the use of stored body fat as an energy source, men and women
have also been reported to differ with regard to responses to food consumption in general. Not
surprisingly, food intake tends to reduce the use of stored fat as an energy source in both genders.
This feeding effect is more pronounced in women than in men, because men continue to use small
amounts of stored fat as an energy source even in a fed state. The result of this gender difference
is a greater tendency to maintain established fat stores in women [13]. In keeping with previously
Gender Differences in Body Fat Utilization During Weight Gain, Loss, or Maintenance 241
mentioned differences in body fat distribution, men tend to store a higher percentage of dietary
fatty acids in visceral tissue after meals, whereas women tend to store relatively larger percentages
of dietary fat in subcutaneous tissues [6]. Overconsumption of food would thus appear to favor
greater total body fat gains in women, primarily in subcutaneous tissues, and a greater degree of
visceral fat gain in men than in women.
With regard to the effects of specific macronutrients, a recent study reported that the ratios of
dietary carbohydrate and fat have been reported to be related to body fat levels in women, but not
men. In women, carbohydrate intake was reported to be negatively associated with percent body fat,
while fat intake was reported to have a positive association with body fat percentage. The reasons for
the association between fatty food consumption and higher percent body fat in women are not entirely
clear. One reason suggested for this is the high-energy density of fatty foods, making overindulgence
a stronger possibility [14]. In a separate study, carbohydrate intake was found to induce higher peak
glucose levels and higher insulin responses in women [15]. The significance of this finding with regard
to body fat stores is unclear, although one role of insulin is to facilitate fat storage. Although the data
are limited, they appear to suggest that gender-specific differences in body fat storage and utilization
is a function not only of total calories consumed but also of macronutrient ratios.
EXERCISE EFFECTS
Traditional wisdom would say that the best way to effect changes in body fat is a combination
of calorie control or restriction combined with exercise, regardless of gender. In theory, exercise
should generate a energy deficit and result in weight and fat loss, but, in fact, the association
between physical activity and body fat is not as straightforward as one might expect. For men,
increased physical activity alone does appear to be an effective means of weight loss or main-
tenance [14,16]. Exercise alone appears to be less effective as a means of fat reduction for women
than it does for men. At least three studies have examined the role of gender on fat loss in men
and women. One study reported no effect of physical activity on body fat percent in women
[14]. A second study found that exercise produced significant fat losses in men, but not women
[17]. A third study found that exercise was effective for body fat maintenance, but not fat loss,
in women [18]. This apparent gender difference in the effectiveness of exercise as a tool for fat
loss is one of the more robust findings in this body of literature, reflecting the lack of data on
gender effects on fat loss [19]. It should be pointed out that exercise has many benefits aside
from weight loss or maintenance and that both men and women benefit from regular exercise.
At least two proposed mechanisms could account for the observed lack of effect of exercise
on body fat stores in women. The first is a compensatory increase in calorie intake in response to
increased energy expenditure in women, but not in men [20,21]. The only study that measured
actual food intake did not find any compensation effect in women, however [14]. In this study,
total energy expenditure (resting energy expenditure combined with energy expended during phys-
ical activity) was positively associated with body fat in women. The same study reported that
physical activity was negatively associated with body fat in men only. Taken together, these studies
raise several interesting questions. If women do not compensate for energy used during exercise,
why does it appear to be less effective as a fat loss tool? Perhaps it is because voluntary exercise
represents a relatively small fraction of total energy expenditure relative to basal metabolic rate.
Second, why might total energy expenditure be positively associated with body fat in women? Is
this counterintuitive finding simply reflective of the increased energy expenditure associated with
weight gain? The current literature provides no obvious answers to these questions. Further studies
are needed to determine the role of exercise on fat loss in women.
A second proposed mechanism for gender differences in fat use and storage is the differential
activation of adrenergic receptors in men vs. women. Exercise causes the release of the cate-
cholamines epinephrine and norepinephrine, which interact with adrenergic receptors. In women,
only beta-adrenergic receptors, which promote fat mobilization, are activated. In contrast, both
Re st
st Fat Re
Food Food
Intake Intake
Ex
cise er
cis
er e
Ex Storage
FIGURE 19.1 Gender-specific effects of activity level and food intake on fat storage and utilization. The left
side of the figure illustrates the predominating effects in men, and the right side shows the predominating
effects in women under the same conditions. The arrows indicates the movement of fat into or out of storage,
and their size approximates the magnitude of the effect.
the pro-lipolysis beta receptors and the anti-lipolysis alpha-adrenergic receptors are activated in
men [11,22]. These gender differences appear to be due to the relative amounts of epinephrine
and norepinephrine released during exercise. Exercise-induced epinephrine (which has a greater
affinity for the anti-lipolytic alpha-adrenergic receptors) levels are twice as high in men as in
women. This difference may be one reason why women, more so than men, use fat as an energy
source during exercise. Even if exercise was definitively shown to be without effect for body fat
loss in women, this would not negate the fact that achieving a negative energy balance will result
in body weight or fat loss for both genders. It does indicate that weight loss may be more difficult
for women, even when energy expenditure is increased through exercise, via as yet to be defined
mechanisms.
CONCLUSIONS
It is important to emphasize that the findings presented in this chapter are based on limited data
and, as such, require further study. Figure 19.1 provides an overview of the gender-specific differ-
ences in fat utilization under various physical conditions. There are many unanswered questions
with regard to the effects of gender on fat metabolism. These include the interaction of gender with
long-term fat loss and with weight cycling. The majority of fat and weight loss studies are short
term in nature (less than 1 year in duration). This fact raises the possibility that the health effects
observed are a result of the process of weight loss and are not reflective of the effects of long-term
weight loss itself [8]. The effects of weight cycling (repeated gain and loss of body weight and or
body fat) on body fat percentage are unclear and are complicated by the fact that weight cycling
in men is often related to “making weight” in athletics, but in women it is most often a result of
repetitive dieting related to self-esteem and body image [23,24]. Some studies have reported a
decreased basal metabolic rate across genders as a result of weight cycling, but this result is by no
means an established fact. Based on the existing body of literature, the following conclusions may
be drawn with regard to differences in body fat changes between men and women:
• Women have lower basal metabolic rates than men due to a lower fat free mass.
• Women preferentially store subcutaneous fat; men preferentially store visceral fat.
• Visceral fat is more easily gained or lost in men than in women.
Gender Differences in Body Fat Utilization During Weight Gain, Loss, or Maintenance 243
• During fat loss, women preferentially retain lower body fat; men mobilize upper and
lower body fat more equally but tend to retain abdominal fat.
• Women more readily use fat as an energy source during exercise; men more readily use
fat as an energy source at rest.
• Exercise appears to be more effective for weight loss and maintenance in men than in
women, for reasons that are not clear.
REFERENCES
[1] Kalm, L.M. and Semba, R.D., They starved so that others be better fed: remembering Ancel Keys
and the Minnesota experiment, J. Nutr., 135, 1347, 2005.
[2] Spies, T.D., Observations on the treatment of pellagra, J. Clin. Invest., 13, 807, 1934.
[3] James, P.T. et al., The worldwide obesity epidemic, Obes. Res., 9(Suppl. 4), 228S, 2001.
[4] Flegal, K.M. et al., Prevalence and trends in obesity among U.S. adults, 1999–2000. JAMA, 288,
1723, 2002.
[5] Bouchard, C., Despres, J.P., and Mauriege, P., Genetic and nongenetic determinants of regional fat
distribution, Endocr. Rev., 14, 72, 1993.
[6] Blaak, E., Gender differences in fat metabolism, Curr. Opin. Clin. Nutr. Metab. Care, 4, 499, 2001.
[7] Sandoval, W.M., Heyward, V.H., and Lyons, T.M., Comparison of body composition, exercise and
nutritional profiles of female and male body builders at competition, J. Sports Med. Phys. Fitness,
29, 63, 1989.
[8] Lofgren, P. et al., Major gender differences in the lipolytic capacity of abdominal subcutaneous fat
cells in obesity observed before and after long-term weight reduction, J. Clin. Endocrinol. Metab.,
87, 764, 2002.
[9] Johnstone, A.M. et al., Factors influencing variation in basal metabolic rate include fat-free mass, fat
mass, age, and circulating thyroxine but not sex, circulating leptin, or triiodothyronine, Am. J. Clin.
Nutr., 82, 941, 2005.
[10] Mittendorfer, B., Horowitz, J.F., and Klein, S., Effect of gender on lipid kinetics during endurance
exercise of moderate intensity in untrained subjects, Am. J. Physiol. Endocrinol. Metab., 283, E58,
2002.
[11] Hellstrom, L., Blaak, E., and Hagstrom-Toft, E., Gender differences in adrenergic regulation of lipid
mobilization during exercise, Int. J. Sports Med., 17, 439, 1996.
[12] Mittendorfer, B., Horowitz, J.F., and Klein, S., Gender differences in lipid and glucose kinetics during
short-term fasting, Am. J. Physiol. Endocrinol. Metab., 281, E1333, 2001.
[13] Jensen, M.D., Gender differences in regional fatty acid metabolism before and after meal ingestion,
J. Clin. Invest., 96, 2297, 1995.
[14] Paul, D.R., Novotny, J.A., and Rumpler, W.V., Effects of the interaction of sex and food intake on
the relation between energy expenditure and body composition, Am. J. Clin. Nutr., 79, 385, 2004.
[15] Robertson, M.D., Livesey, G., and Mathers, J.C., Quantitative kinetics of glucose appearance and
disposal following a 13C-labelled starch-rich meal: comparison of male and female subjects, Br. J.
Nutr., 87, 569, 2002.
[16] Westerterp, K.R. and Goran, M.I., Relationship between physical activity related energy expenditure
and body composition: a gender difference, Int. J. Obes. Relat. Metab. Disord., 21, 184, 1997.
[17] Westerterp, K.R. et al., Long-term effect of physical activity on energy balance and body composition,
Br. J. Nutr., 68, 21, 1992.
[18] Donnelly, J.E. et al., Effects of a 16-month randomized controlled exercise trial on body weight and
composition in young, overweight men and women: the midwest exercise trial, Arch. Intern. Med.,
163, 1343, 2003.
[19] Donnelly, J.E. and Smith, B.K., Is exercise effective for weight loss with ad libitum diet? Energy
balance, compensation, and gender differences, Exerc. Sport Sci. Rev., 33, 169, 2005.
[20] Stubbs, R.J. et al., The effect of graded levels of exercise on energy intake and balance in free-living
women, Int. J. Obes. Relat. Metab. Disord., 26, 866, 2002.
[21] Stubbs, R.J. et al., The effect of graded levels of exercise on energy intake and balance in free-living
men, consuming their normal diet, Eur. J. Clin. Nutr., 56, 129, 2002.
[22] Lafontan, M., Berlan, M., and Villeneuve, A., Preponderance of alpha 2- over beta 1-adrenergic
receptor sites in human fat cells is not predictive of the lipolytic effect of physiological catecholamines,
J. Lipid Res., 24, 429, 1983.
[23] Saarni, S.E. et al., Weight cycling of athletes and subsequent weight gain in middleage, Int. J. Obes.
(Lond.), March 28, 2006 (Epub ahead of print).
[24] Devlin, M.J. et al., Metabolic abnormalities in bulimia nervosa, Arch. Gen. Psychiatry, 47, 144,
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3802_C020.fm Page 245 Wednesday, January 31, 2007 2:37 PM
20 Appetite, Body Weight,

Health Implications of a
Low-Glycemic-Load Diet
Stacey J. Bell, Wendy Van Ausdal, and Greg Grochoski
CONTENTS
Introduction ....................................................................................................................................245
Definition of Terms ........................................................................................................................246
Glycemic Index.......................................................................................................................246
Glycemic Load........................................................................................................................248
Glycemic Load and the American Diet..................................................................................248
Physiological Effects of a Low-Glycemic-Load Diet ...................................................................249
Early Postprandial Period .......................................................................................................249
Middle Postprandial Period ....................................................................................................249
Late Postprandial Period.........................................................................................................249
Effect of Glycemic Load on Hunger.............................................................................................250
Glycemic Load and Weight Loss ..................................................................................................251
Favorable Studies....................................................................................................................251
Unfavorable Studies................................................................................................................253
Glycemic Load and Disease ..........................................................................................................254
Meta-Analyses ........................................................................................................................254
Cardiovascular Disease ...........................................................................................................255
Epidemiological Data ......................................................................................................255
Short-Term Studies ..........................................................................................................255
Type 2 Diabetes ......................................................................................................................256
Epidemiological Data ......................................................................................................257
Short-Term Study.............................................................................................................258
Other Conditions.....................................................................................................................258
How to Eat a Low-Glycemic-Load Diet .......................................................................................259
References ......................................................................................................................................260
INTRODUCTION
Overweight and obesity pose a major public health concern in terms of increased mortality and
morbidity, which is associated with increased risk of cardiovascular disease (CVD), type 2 diabetes
mellitus, and osteoarthritis. Compared to normal-weight individuals, obesity (body mass index
[BMI] ≥ 30 kg/m2) was associated with over 110,000 excess deaths per year [22]. Inspection of
telomere length as a marker of aging showed that obesity corresponded to 8.8 years of aging; this
was similar to smoking a pack of cigarettes a day for 40 years (7.4 years of aging) [64]. It has
been postulated that only about a 10-calorie energy gap per day is the cause of obesity, so it would
245
seem that it could be readily treated [8]; however, few strategies for losing weight have been
effective, and new ones are welcome [3,46]. In contrast, strategies to get individuals to quit smoking
have been more successful, showing that behaviors can be changed to improve health.
Of the numerous strategies that exist for helping individuals lose weight, the most invasive —
bariatric surgery — is still the most effective at producing weight loss (about 61% per patient) [9].
Pharmacological agents have met with mixed results. One of the most promising nonsurgical, non-
pharmacological strategies to promote weight loss was ephedra, because it induced weight loss without
its users actually having to consciously reduce calorie intake [13]; however, in 2004, the Food and
Drug Administration (FDA) banned it from being sold, citing significant side effects, including death.
An equally promising weight-loss strategy has been the so-called low-carbohydrate diets pop-
ularized by the late Dr. Atkins [24,56]. It seemed that everyone in America knew someone who
had lost weight on the Atkins diet; however, two major clinical studies evaluating the Atkins diet
showed that, although weight loss after 6 months was greater compared to the conventional heart-
healthy, low-fat diet, the difference disappeared by 1 year [24]. Soon after the publication of these
articles, the appeal of the low-carb phenomenon waned.
A lesser known weight-loss program is the low-glycemic-load (low-GL) or low-glycemic-index
(low-GI) diet [17,38]. Of the seven leading drivers of health in the Western diet, a diet high in
glycemic load was identified as that having the greatest impact [14]. The low-GL diet is gaining
popularity among clinicians, researchers, and overweight and obese patients because it has been
shown to promote satiety, to have a sound physiological basis behind how it works, and to contain
all the essential nutrients. In addition, following a low-GL diet for both the short and long term
has been shown to promote weight loss without hunger and to reduce the risk of many chronic
diseases of aging including obesity, CVD, and type 2 diabetes.
This chapter serves as a review on the subject of the glycemic load of the diet. Beginning with
definitions of terms (e.g., GL, GI), the chapter also explores the physiological effects of glycemic
load, including its effects on satiety, as well as the health implications of following a high-GI or
high-GL diet. Finally, practical information is given on how to follow a low-GI or low-GL diet.
DEFINITION OF TERMS
The GL and GI are rating systems for evaluating the change in postprandial blood glucose levels
after consuming carbohydrate-containing foods (Table 20.1). Each is defined below.
GLYCEMIC INDEX
The concept of postprandial glucose levels was originally deemed important in the early 1980s,
when it was thought that setting limits would lead to better daily glucose management in patients
with diabetes [66,69]. The GI relates to the rate at which recently ingested carbohydrates appear
in the blood as glucose. The GI is expressed as a percentage:
Integrated increase in blood glucose level during a 2-hour period after a known
0 g of available carbohydrate) × 100
quantitty of carbohydrates is ingested (usually 50
Integrated increase in blood glucose level during a 2-hour period after a known
quantity of a reference food is ingested (usually 50 g of available carbohydrate) × 100
The values for GIs of foods typically range from 20 to 100; however, some foods that are highly
processed may exceed this upper value (e.g., cornflakes have a GI of 120).
Conceptually, a low-GL diet involves limiting the intake of foods that have the greatest impact
on postprandial blood glucose concentrations; for example, foods that are composed of mainly
protein and fat have virtually no impact on GI or GL. These include all meats, dairy products, and
fats and oils; however, too much protein produces an undesirable insulinemic effect that may
Appetite, Body Weight, Health Implications of a Low-Glycemic-Load Diet 247
TABLE 20.1
Glycemic Index and Glycemic Load of Commonly Consumed
Food Categories (Expressed as Approximate Values)
Glycemic Index
Food Category (Compared to Glucose) Glycemic Load
Dairy (milk, cheese, yogurt) 20–40 <10
Fruits 20–40 <10
Vegetables (nonstarchy) Insignificant Insignificant
Vegetables (starchy) 60–90 10–25
Legumes, nuts 25–45 <5–15
Nonsweetened and sweetened bakery 50–80 10–20
products, cereals, pasta, grainsa
Carbonated beverages (e.g., colas) 63 16
Juices 40–60 15–25
Snack foods >50 10–25+
a White and whole-wheat products differ only slightly.
Source: Based on data from Foster-Powell, K. et al., Am. J. Clin. Nutr., 76, 5–56, 2002.
promote weight gain and increased hunger [44]. Protein from either a bar (29 g) or from a shake
(15 g) had 2-hour area under the curve (AUC) insulin responses of 90% and 88%, respectively,
compared to 50 g of glucose; thus, to manage both postprandial glucose and insulin, protein and
carbohydrate intake should be controlled on a low-GL diet.
The procedures for obtaining measurements of GI are described elsewhere [66,69]. The GI of
carbohydrate-containing foods varies widely and cannot be predicted based on chemical analysis of
the carbohydrates (i.e., simple vs. complex). In fact, large differences in GIs even exist within foods
found in the same food group; for example, whole meal bread was found to have a GI of 72, and
whole meal spaghetti has a GI of only 42. Similarly, among tubers and root vegetables, parsnips
have a GI of 97, and sweet potatoes have a GI of 48. Ironically, the fiber content of foods has been
found to have very little effect on GI. Other oddities occur. For example, the GI of sucrose (glucose
and fructose), thought to be diabetogenic, is not among one of the highest foods measured, because
the GI of fructose is much lower than glucose [10]. In addition to all of the other variables, cooking
can affect the GI of a food. Precooked Russet potatoes elicited lower AUC glucose responses than
those consumed the same day they were cooked [21]; however, this same effect was not seen in
boiled white potatoes. All of these variables underscore the importance of measuring the GI of
individual foods to determine the true effect that food has on postprandial blood glucose levels.
With so many factors affecting the GI of individual foods, it is not surprising that the concept
of GI has been criticized [48]. In response, an international group of researchers recently validated
it. Seven different research groups from around the world measured the GIs of four foods: instant
potato, rice, spaghetti, and barley [67]. Locally obtained white bread served as the control. All
laboratories followed the protocol established by the Food and Agriculture Organization (FAO)/
World Health Organization (WHO) to measure the GIs. The GIs of these foods did not vary
significantly in the different centers, nor was a center and food interaction identified. The mean
between-laboratory standard deviation was small (approximately nine), and the measurements were
closer to nine when capillary, rather than venous, blood was sampled. The size of the standard
deviation confirmed the validity of the GI measurements, because most foods have GIs ranging
from 20 to 120, and a standard deviation of nine indicates the tightness of the data. Moreover, the
ease of using capillary blood compared to venous blood confirmed that this test can easily be
conducted at many facilities around the world.
GLYCEMIC LOAD
Ultimately, over 1200 GI measurements of individual carbohydrate-containing foods were con-
ducted [23]. Each was measured using the requisite 50 g of available carbohydrate (total carbohy-
drate minus fiber) in the food; however, these portion sizes do not always match up with actual
serving sizes, making the GI of limited use in meal planning. This limitation led to the development
of a methodology, called glycemic load, which takes this portion size into account. The GL is
representative of the GI of a food but is reflective of a usual serving size of a carbohydrate-containing
food [20,33,55]. The GL can be calculated as:
Glycemic load = (Glycemic index of a food × grams of carbohydrate in a serving of that food)/100
The GL values of foods typically range from 2 to 30 (Table 20.1). Each unit of the GL represents
the equivalent of 1 g of carbohydrate from white bread [39]. White bread is often used as the
standard (i.e., equal to a GI of 100). Of the carbohydrate-containing foods, nonstarchy vegetables
and legumes have the lowest GLs (<5). Fruit and dairy foods are next (around 10), followed by
unsweetened, grain-based foods (10–20), and then sweetened, grain-based foods, candy, and car-
bonated beverages (>15). Foods that have GLs in excess of 10 are typically considered to have
high GLs. Most grain-based snack foods — both salty and sweet — have GLs at or above this
value. Such foods only started creeping into the food supply within the past 100 years.
The GLs from all of the foods ingested in a single day can be summed and used to compare
dietary regimens among different populations. For example, the sum of all of the GLs for a day
when a low-GL diet has been followed is about 50 to 70 [4]. In contrast, consuming a high-
carbohydrate, heart-healthy, low-fat diet such as that outlined in the U.S. Department of Agri-
culture’s Food Guide Pyramid yields a total dietary GL for the day of at least 80, but it could
be as high as 120. In addition, the typical American diet, which includes numerous servings of
sweetened carbonated beverages, salty snacks, candy, and baked goods, could have a dietary
GL of over 200.
The GL and GI often trend in the same direction, but not always; for example, carrots have a
high GI (71) but a low GL (4) [4]. The difference comes from the fact that the 50 g of carbohydrate
used to compute the GI of carrots is more than a typical single serving of vegetables. To get 50 g
of the available carbohydrate in carrots, you would have to consume about four cups of carrots at
a sitting. Carrots are high in fiber and water, which take up space and weight, and a typical serving
does not have an appreciable effect on blood glucose concentrations. Other nonstarchy vegetables
and some fruits (e.g., berries) have this unique phenomenon, which explains their low GL. These
examples demonstrate that the GL is a better tool than the GI for meal planning, because single
servings of nonstarchy vegetables and selected fruits have minimal impact on blood glucose levels,
which drive the GI.
The GL methodology was recently validated [6]. In this two-part study, ten healthy subjects
consumed foods that were thought to have the same GL to confirm that they evoked similar effects
on blood glucose levels. In the second part, another group of ten healthy subjects consumed different
foods that were thought to produce a stepwise increase in GL. Both studies yielded predictable
results. This was the first report confirming that the GL of foods has the physiologic validity to
predict glycemic response.
GLYCEMIC LOAD AND THE AMERICAN DIET

One of the reasons why the low-GL diet concept is gaining in popularity is that the rising obesity
rates are coincident with the consumption of foods with extremely high GLs. Never before in our
evolution have foods been consumed that have such very high GIs (>100) or GLs (>10) [23]. As
more individuals eat an appreciable amount of calories from snacks, it is easy to understand why
the GL of the diet has increased. The GL of the diet of women 34 to 59 years of age rose 22%
between 1980 and 1990 [27]. During the same time, the percentage of women who were overweight
increased 38%, which may have been related to the change in the GL of the diet or the fact that
the percentage of women who smoked declined 41%. Other dietary factors improved, such as the
consumption of fewer trans fats, the increase in the ratio of polyunsaturated to saturated fat intake,
the increase in cereal fiber, and the increase in omega-3 fatty acids. None of these factors was
thought to cause the increase in body weight, except the change in the GL of the diet. These data
provide a compelling relationship between body weight and GL of the diet.
PHYSIOLOGICAL EFFECTS OF A LOW-GLYCEMIC-LOAD DIET

Ludwig et al. [35,37] and others have conducted an elegant series of studies identifying the
physiological basis for why a low-GL diet may be effective at promoting satiety, reducing body
weight, and lowering the risks of many chronic diseases of aging. Physiological changes were
characterized by their sequential effects at three stages postprandially.
EARLY POSTPRANDIAL PERIOD

Within 2 hours of ingesting a high-GL, carbohydrate-containing food or meal, blood glucose
concentrations can be more than double that of an eucaloric meal with a low GL [35,37]. (These
data were obtained from measurements from obese adolescents.) These higher blood glucose levels
trigger the release of increased amounts of insulin to reduce them. High circulating insulin levels
favor anabolism, thereby signaling the storage of all incoming nutrients (mainly lipids and carbo-
hydrates) as fat in the adipocytes (lipogenesis) or as glycogen stored in muscle and the liver
(glycogenesis). The disappearance of these substrates from the blood is rapid, and upon their
disappearance hunger sets in. The constant exposure to high-GL foods and meals may promote the
development of insulin resistance, mainly because the pancreas is required to regularly secrete high
amounts of insulin throughout the day. When circulating insulin levels are elevated, lipolysis is
inhibited, thereby making it difficult to use body fat stores for energy and to lose weight. Similarly,
glycolysis is suppressed because glucose levels are maintained at normal levels or may even be
elevated, depending on how much insulin resistance is already present. Some have argued that
habitual consumption of high-GL diets has no effect on the risk of insulin resistance [30], but others
refute this [37]. What is particularly problematic is that Americans tend to snack frequently on
high-GL foods, which causes hyperinsulinemia and creates a state of anabolism most of the time.
MIDDLE POSTPRANDIAL PERIOD

Within 2 to 4 hours after the ingestion of a high-GL meal, nutrients are almost completely absorbed
from the gastrointestinal tract [35,37]. Glucagon is the counter-regulatory hormone that is released in
response to insulin, and an elevated ratio of insulin/glucagon persists from the early 2-hour phase. This
skewed ratio may drive blood glucose concentrations down, even to the point of creating a hypoglycemic
state. Glucose serves as the primary fuel for the brain, and hunger sets in when the brain senses food
deprivation. The other major fuel source of the body is free fatty acids, which are also suppressed by
the exaggerated insulin/glucagon ratios. Thus, both of the body’s key metabolic hormones are unbal-
anced, which leads to hunger because the body is without its two major fuel sources.
LATE POSTPRANDIAL PERIOD

Within 4 to 6 hours after ingestion of a high-GL meal, the low circulating concentrations of glucose
and free fatty acids stimulate the release of counter-regulatory hormones (i.e., glucagons, epineph-
rine, cortisol, and growth hormone) [35,37]. This is the body’s attempt to release the recently stored
energy sources. Glucagon and cortisol primarily cause the release of glycogen, thereby increasing
blood glucose concentrations. Fat is mobilized from the adipocytes primarily by epinephrine and
growth hormone, which restores free fatty acids levels to normal; however, if insulin levels are still
elevated at this time, these catabolic processes are blunted, so it is possible that an individual will
remain hungry beyond the 4 hours after eating a high-GL meal. Thus, high-GL meals and snacks
promote the hunger that can lead to obesity by fostering more frequent snacking.
In contrast, a low-GL meal or snack does not induce such dramatic hormonal shifts [35,37].
Low-GL foods take longer to digest and absorb, thereby minimizing the impact on hyperglycemia
and hyperinsulinemia. In addition, the liver can undergo glycolysis and release glucose, and the
adipocytes can undergo lipolysis to release free fatty acids; thus, hunger is avoided and stored
substrates can be mobilized to promote weight loss. Also, insulin resistance is curtailed, as insulin
levels rarely go into super-physiologic range.
These glycemic and insulinemic changes seen in adolescents were confirmed in obese, adult
women [16]. In a crossover design, the subjects on separate occasions consumed low-GL and high-
GL test meals (breakfast and lunch). Glucose and insulin AUC were significantly higher following
the high-GL meals compared to the low-GL ones. Serum free fatty acids were suppressed by both
meals by 3 hours postprandially, but they were then raised significantly more in the low-GL meal
group by the fourth and fifth hour (p < 0.05); however, glucagon concentrations did not differ
significantly between the two test meals as found earlier [35]. Diaz et al. [16] speculated that
carbohydrate oxidation would be favored and fat oxidation reduced, but this did not occur. The
short-term period for the changes in insulin concentrations during this feeding study likely explained
why no differences were observed in fuel partitioning between the two dietary regimens. In contrast,
when insulin is infused in a step-wise manner at nonphysiological levels for a long time (>100
minutes), such differences in substrate utilization are observed.
EFFECT OF GLYCEMIC LOAD ON HUNGER

Hunger, satiety, and satiation have long been associated with the GI or GL of the diet [36,53].
Satiation is the sensation of fullness that develops during the process of a meal and contributes to
its termination. Satiety is the sensation of fullness between one meal and the next. Hunger is the
degree of appetite suppression between one meal and the next. Looking at the totality of the
published studies (reviewed elsewhere), all three sensations are affected by the GL and GI of the
diet. The lower the GI or GL of the day’s foods consumed, the earlier satiation occurs, the longer
satiety is, and the less of a sensation of hunger there is before each meal [36,53].
On average, total daily caloric intake was 20% greater after consumption of a high-GL meal
than after a low-GL meal [53]. To emphasize the importance of this relationship between food
consumption and GL, one laboratory has developed a validated satiety index of commonly con-
sumed foods [26] that can be used by overweight and obese individuals to make better food choices
on a weight-loss regimen. These investigators found that isoenergetic servings of a variety of foods
differed greatly for hunger and satiety, and the predictability of these effects was related to the GI
of the individual foods.
Clinical support exists for a low-GL diet in curtailing hunger and promoting satiety [1,18,36,
37,53]. Two studies have shown that less hunger occurs within 6 days of consuming a low-GL diet
compared to a high-GL diet [1,18]. In both short-term studies, subjects reported that they were less
hungry while following a low-GL diet and ate 25% fewer calories compared to when they consumed
a high-GL diet. Another group of investigators measured both hormonal changes and hunger to
confirm that the two are related [35]. Twelve obese adolescents were evaluated on three separate
occasions using a crossover design protocol. Eucaloric test meals were consumed at breakfast, but
each varied by GL (low, medium, and high). Subjects were monitored during the subsequent 5
hours, and selected blood chemistries, including relevant hormones, were measured. The voluntary
caloric intake after the test meals was 53% higher in the medium-GL meal and 81% higher in the
high-GL meal compared to the low-GL meal. The difference in energy intakes was supported by
how hungry the subjects felt. Using a 10-point analog hunger scale, subjects were consistently less
hungry following consumption of the low-GL meal, intermediate after the medium-GL meal, and
most hungry following the high-GL meal.
The researchers demonstrated that serial hormonal changes were responsible for the different
degrees of hunger [35]. The measured AUC for plasma insulin levels was 52% higher for the high-
GL meal compared to the low-GL meal. The mean plasma glucose nadir was 42% lower after the
high-GL meal compared to both the low-GL and medium-GL meals. Thus, the high-GL meal
produced the greatest adverse effect on glycemia (i.e., greatest hypoglycemia) and the greatest
insulin secretion, further exacerbating falling blood glucose levels. Plasma glucagon levels predict-
ably rose after the low-GL meal but were suppressed about 10% for the medium-GL and high-GL
meals. This was likely related to the presence of hyperinsulinemia. Finally, the serum free fatty
acids were suppressed the most after ingestion of the high-GL meal compared to the other two
diets. To compensate for this, the counter-regulatory hormones epinephrine and growth hormone
were higher following the high-GL meal compared to the low-GL meal, causing free fatty acids
to increase. These results suggest that a single meal can have an immediate and profound metabolic
consequence that can last up to 5 hours. The degree of hunger was supported by the metabolic
changes that occurred postprandially.
A subsequent study, however, did not support the relationship between changes in glycemic
and insulinemic responses and hunger [2]. Thirty-nine healthy adults consumed either high-GL
foods or low-GL foods for 8 days. Appetite sensation and blood tests were performed before and
2 hours following breakfast and lunch on days 1 and 8. The magnitude of the glycemic and insulin
responses did not differ between the diets at any time point, nor did the caloric intake between the
groups; thus, no close relationship between hunger and blood glucose and insulin levels was
observed. This study was short term, however, and was conducted in normal-weight volunteers.
The randomized prospective studies and epidemiological data would suggest a benefit of the low-
GL in controlling appetite and weight (see below).
GLYCEMIC LOAD AND WEIGHT LOSS

Several studies have confirmed that low-GL diets promote weight loss [5,19,62,68], but others have
not found a benefit [11,51].
FAVORABLE STUDIES
Short-term data showed that obese children (n = 64) who consumed a low-GL diet lost more weight
than those who followed a high-GL, low-fat, energy-restricted diet (n = 43) [62]. After 4 months,
the low-GL group experienced a –1.53 kg/m2 change in BMI, and the control group had a –0.06
kg/m2 change. In contrast to the high-GL group, the low-GL diet group was instructed to eat to
satiety and lost more weight.
The same laboratory followed 14 obese adolescents 13 to 21 years of age for 1 year [19]. The
dietary protocols were the same as above. At 12 months, both BMI (–1.3 ± 0.7 kg/m2 vs. 0.7 ± 0.5
kg/m2; p = 0.02) and fat mass (–3.0 ± 1.6 kg vs. 1.8 ± 1.0 kg; p = 0.01) decreased significantly in
the low-GL group compared to the high-GL, energy-restricted, low-fat group, respectively. Insulin
resistance, measured by means of homeostasis model assessment (HOMA), increased less in the
low-GL group. Despite no energy restriction, the low-GL group ate fewer calories at the 12-month
measurement compared to the high-GL group, respectively (1621 ± 159 kcal vs. 1439 ± 104 kcal).
Although hunger and satiety were not measured, it seemed that those in the low-GL group were
more satisfied because they lost more weight while eating fewer calories.
A couple of small pilot studies showed the ease with which a low-GL diet could be followed
by free-living overweight children and adults [5,68]. Children were recruited from a pediatrician’s
office [68]. They received a brief description of the diet and a handout categorizing the foods based
on their GI value; sample meal plans were also provided. Subjects were monitored for 12 weeks,
and calorie counts and food frequency questionnaires were obtained. Although 34 children were
enrolled in the study, only 15 completed it; of these, 14 lowered the GI scores of their diets and
decreased carbohydrate intake by 73 g compared to baseline (p < 0.02). Mean caloric intake
decreased by 292 kcal/day (p < 0.02), leading to 12 of the 15 children losing weight. The participants
and their parents described the diet as easy to understand. These promising data provided a protocol
to assist busy pediatricians with a tool to help children lose weight.
The effect of a low-GL diet to promote weight loss was assessed in free-living overweight and
obese adults living in Grand Rapids, MI [5]. All were recruited from a newspaper advertisement.
The study lasted 8 weeks, and the subjects were instructed on the diet at baseline. They were
weighed on the same scale at baseline, week 4, and week 8. At these visits, they also had their
waist circumference measured. Each in-between week, the subjects were called by the study
coordinator to assess compliance. Instructions for the low-GL diet included the following:
• Consume two servings of low-fat dairy each day.

• Eat two servings of fruit per day.
• At lunch and dinner, consume low-GL, low-starch vegetables, eating at least two cups
of different kinds at each meal.
• Eat 4 ounces of meat protein (beef, pork, veal, poultry, fish, shellfish) at lunch and dinner.
• Limit high-GL, starchy vegetables (potatoes, corn, rice), grain-based foods (breads, pasta,
salty snacks), flour-based foods (pastries, cakes, cookies, donuts), candy, and sugar-
containing beverages including juices.
• For breakfast, consume a low-GL meal replacement shake made with skim or 1% milk,
preferably including one of the day’s servings of fruit.
• Use the low-GL snack bars provided as in-between-meal snacks at least once a day.
• Take the appetite-suppressant (soluble fiber and chromium) capsules provided before
meals.
Of the 20 individuals who began the study, 17 completed 4 weeks, and 14 of those completed
all 8 weeks. The study included 6 males, of which 5 completed the entire study, and 11 females,
of which 9 completed it. All participants consumed the meal replacement shake at breakfast, and
only two participants did not use the snack bars. All used the capsules to control hunger, but most
used them only twice a day.
The entire group lost an average of 10 lb after 8 weeks, which is consistent with a good, weight-
reducing diet of about 1 to 2 lb/week (Table 20.2). Males lost more (17 vs. 5 lb) than females,
primarily because one male lost 37 lb, thereby skewing the average upward. Waist circumference
averaged a decrease of 1.75 in., with males and females being about even (–1.6 vs. –1.8 in.,
respectively). This may reflect an improvement in insulin sensitivity. Subjects in this study did not
complain of hunger after the first week, and no clinically relevant side effects were reported. The
participants reported that the diet was easy to follow. These data are consistent with earlier reports
showing that weight loss can be achieved without hunger.
The previous studies supported the notion that a low-GL diet reduces hunger, which led to
weight loss. Others have suggested that a low-GL diet may also affect energy metabolism [1]. Ten
moderately overweight subjects participated in two 8-day feeding regimens. The purpose of the
study was to determine if metabolic adaptations to energy restriction differed between eucaloric,
energy-restricted, high-GL, and low-GL diets. The subjects consumed each diet for 6 days and then
were followed for 2 more days using the same diet but without the energy restriction. Two of the
TABLE 20.2
Changes in Weight and Anthropometric Dataa
Parameter Males Females
Weights (lb)
Baseline 233 (182–322) 210 (144–318)
Week 4 change –10 (2–21) –3 (0–6)
Week 8 change –17 (1–37) –5 (0–11)
Waist circumference (in.)
Baseline 44 (39–49) 41 (33–48)
Week 8 change –1.6 (0–3.3) –1.8 (0.5–3.5)
Body mass index (kg/m2)
Baseline 33 (25–39) 34 (25–51)
Week 8 change –2.3 (0–5) –1 (0–1.8)
a Data are presented as means and ranges.
Source: Data from Bell, S.J. et al., Nutra World, 8, 50–51, 2005.
findings from this study helped explain how a low-GL diet may promote weight loss, above and
beyond hunger control [1]. First, serum leptin concentrations decreased to a greater extent between
day 0 and day 6 with the low-GL diet than the high-GL diet. This is what would have been expected,
because serum leptin concentrations and carbohydrate intake are positively associated. The low-
GL group consumed a smaller percentage of energy from carbohydrates compared to the high-GL
group (43% vs. 67%). In addition, the lower serum leptin concentrations seen in the low-GL group
were also predictable because insulin is a leptin secretagogue. The mean AUC for insulin was 50%
lower in the low-GL group compared to the high-GL group (478 ± 82.2 pmol⋅hr/L vs. 700 ± 98.4
pmol⋅hr/L; p = 0.01). Second, resting energy expenditure declined significantly less (p =.0.04) in
the low-GL (4.6%) compared to the high-GL (10.5%) diet during the energy-restricted phase. This
difference, coupled with the greater decrease in serum leptin concentrations, may help explain how
a low-GL diet could promote weight loss.
UNFAVORABLE STUDIES
Five-day food records were examined from over 179 elderly subjects (≥65 years of age) [15].
Subjects were clustered according to the GL of the diet and by gender. In both sexes, those who
followed a low-GL diet compared to those consuming a high-GL diet weighed significantly less
(p < 0.001), ate fewer grams of carbohydrates (p < 0.06), and had significantly higher Healthy
Eating Index scores (p < 0.001); however, the BMIs of the groups did not differ. It may be that all
that the low-GL regimen offers is better eating habits, with a more nutrient-rich diet. That alone
may suggest that the low-GL regimen promotes a lessening of disease risk rather than weight loss.
A couple of laboratories did not find that the low-GI diet promoted weight loss [11,51]. Fifty-
three free-living adults were randomly assigned to receive a behavioral weight loss program
(BWLP) and an energy-restricted, low-fat diet and were encouraged to exercise; another group
received all of these, plus education about the GI value of foods (BWLP+GI) [11]. In the BWLP+GI
group, despite consuming a lower-GI diet and having more knowledge about how to select low-
GI foods, no significant differences in weight, fat loss, or BMI were observed after one year;
however, the dietary GL for the day dropped in both groups, so differences would be difficult to
detect between the two treatment modalities. Also, the dietary GL for the day in the BWLP+GI
group still exceeded 100 (112.2 ± 51.7), which may not have been low enough to control appetite
and promote weight loss.
Other investigators similarly found no benefit of a low-GL diet beyond energy restriction [51].
Twenty-nine obese subjects were assigned to one of three energy-restricted dietary regimens for
36 weeks — a high-GL diet (dietary GL for the day was 272), a low-GL diet (dietary GL for the
day was 172), or a high-fat diet (40% of the calories from fat). During the first 12 weeks, all
subjects were provided their meals. During that phase of the study, each group experienced a
significant weight loss (around 10 kg) and improvement in insulin sensitivity, which was measured
by HOMA. No differences among the groups were detected within these parameters, except that
the HOMA values differed between the low-GL and high-fat regimen at week 12 (p < 0.03, with
the low-GL being significantly better). A subgroup (n = 22) continued on their assigned diet for
another 24 weeks. The groups were similar at the end of this period in that the weight loss was
maintained and insulin sensitivity continued to improve, but no benefit was observed in the low-
GL diet over the high-GL or high-fat diets. During the free-living phase, the GL of all groups was
similar [51]. All subjects reduced portion sizes, which lowered the GL of the overall diet. This is
an interesting finding in and of itself, in that it may be sufficient to concentrate on portion size
rather than GL to achieve weight loss. In addition, dietary fat intake increased in all groups and
approximated their prescreening levels. The study was small, and about one fourth of the subjects
dropped, out making it difficult to fully assess the effect of a low-GL diet. Unlike earlier studies
where insulin sensitivity was assessed, these data did not corroborate those findings [35,37].
As with most weight-loss studies, conflicting data usually appear in the medical literature. The
physiological responses to a high-GL diet were not supported in the study by Raatz et al. [51],
which will likely provoke more studies evaluating the effect of a low-GL diet on weight loss. Others
who did not find favorable results suggested that the concept of low-GL diets was only effective
at breakfast, following an overnight fast [28]. These investigators found the same variation in blood
sugar levels after consuming high-, middle-, and low-GL meals at all times during the day except
after breakfast. These similarities throughout the day were likely driven by snacking, which so
many individuals do. In addition, cortisol levels are highest in the early morning, so postprandial
blood sugar levels responded more predictably at that time (i.e., lower for the low-GL meals).
Another group [49] suggested that overweight individuals with relatively greater insulin secretion
in response to a glucose tolerance test (GTT) lost more weight than those who responded normally;
thus, patient screening by GTT response may improve the chances of losing weight. Nevertheless,
most of the previous studies showed that weight loss could be achieved without hunger and that
changes in metabolic parameters supported the change in body weight.
GLYCEMIC LOAD AND DISEASE

Unlike the relatively few studies showing that a low-GL diet promotes weight loss, many more are
available showing that following a low-GL diet for a long time (for up to 10 years) leads to risk
reduction of a whole host of medical conditions, including CVD and type 2 diabetes.
META-ANALYSES
Two meta-analyses reviewed the effect of low-GL diets on chronic conditions [7,43]. Opperman
et al. [43] included 16 studies in their analysis, which had major outcomes as the change in
markers of carbohydrate and lipid metabolism. The low-GL diets significantly reduced fruc-
tosamine by –0.1 mmol/L (95% confidence interval [CI], 0.20–0.00; p = 0.05), hemoglobin (Hgb)
A1c by 0.27% (95% CI, 0.5–0.03; p = 0.03), and total cholesterol by –0.33 mmol/L (95% CI,
0.47–0.18; p < 0.0001) and tended to reduce low-density lipoprotein (LDL) cholesterol in patients
with type 2 diabetes by –0.15 mmol/L (95% CI, 0.31–0.00; p = 0.06) compared to high-GL diets.
No changes were observed in high-density lipoprotein (HDL) cholesterol and triglyceride levels.
From this study, the use of a low-GL diet appears beneficial at reducing total cholesterol levels
and improving the overall metabolic control of diabetes. Another group of investigators [7] used
meta-analysis to evaluate the effect of low-GL diets on improving overall glycemic control in
individuals with diabetes as assessed by fructosamine or Hgb A1c. The 14 studies identified
included 356 subjects (203 with type 1 and 153 with type 2 diabetes) who were randomly assigned
to consume the low-GL or high-GL diets for 12 days to 12 months. The Hgb A1c was reduced by
7.4% more with the low-GL diet than the high-GL diet. Choosing low-GL foods had a clinically
useful effect on glycemic control in patients with diabetes.
CARDIOVASCULAR DISEASE
The incidence of CVD has declined since 1980, but dietary strategies such as the low-GL diet
continue to be explored to reduce the incidence even further [27]. The effect of a low-GL diet on
cardiovascular health is of particular interest, because for the past two decades patients with CVD
or at risk for it were provided low-fat, high-carbohydrate diets, which had inherently high GLs
[17]. Some have expressed a concern that such a diet increases the risk of CVD rather than reducing
it because of the high-GL nature of the diet. Epidemiological data and short-term studies exploring
the effect of low-GL diets on CVD risk are reviewed separately.
Epidemiological Data
A 10-year study including over 75,000 women 38 to 63 years old suggested that regular consumption
of a high-GL diet from refined carbohydrates increased the risk of coronary heart disease (CHD),
independent of other cardiac risk factors [32]. Using validated food frequency questionnaires to
compute the sum of the GL of all the foods consumed in a day (i.e., dietary GL), those in the lowest
quintile (dietary GL = 117) were assigned a relative risk (RR) of 1.0 for CHD risk. The other quintiles
had RRs of 1.01 (dietary GL = 145), 1.25 (dietary GL = 161), 1.51 (dietary GL = 177), and 1.98
(dietary GL = 206) (p for trend < 0.0001). These data reflected adjustment of age, smoking status,
and other CHD risk factors. Classifying carbohydrate intake merely according to simple or complex
did not yield significant outcomes as compared with classifying carbohydrates according to GL.
A subset of the previous population (n = 244) had high-sensitivity C-reactive protein (hs-CRP)
concentrations measured, and these were compared to the dietary GL [34]. This measurement is
an indicator of CVD risk, especially of ischemic heart disease. A significant and positive relationship
was seen between the dietary GL and hs-CRP (p for trend < 0.01). The difference in hs-CRP
between the lowest and highest dietary GL was twofold. The association was even more pronounced
when the women were segmented by BMI ≥ 25 kg/m2 or BMI < 25 kg/m2. The mean hs-CRPs
were higher at each dietary GL quintile, suggesting an added effect of body weight on CVD risk.
These data showed that a high-GL diet led to increased body weight, which was positively related
to hs-CRP, a risk factor for CVD. Both of these large-scale studies indicated a significant relationship
between the GL of the diet and the risk of CVD.
Short-Term Studies
The effect of a low-GL diet on reducing CVD risk factors was seen in young [20,47] and older
adult [18,45,60,61] subjects. During a 12-month study, 23 young adults ages 18 to 35 years
consumed either an ad libitum low-GL diet or an energy-restricted, low-fat diet (<30% of the
energy) [20]. Body weight decreased in both groups at 6 months (about 8%) and remained below
baseline at 1 year (about 6.5%); no differences were observed between the two groups. Compared
to the conventional, low-fat diet, the low-GL diet group experienced a significantly greater mean
decline in serum triglycerides (p < 0.005) and a reduction in plasminogen activator inhibitor, which
increased in the control group. These markers are associated with CVD events and should be
controlled throughout life. As CVD takes many decades to develop, a low-GL diet may be appro-
priate for young adults to reduce its risk later on.
Others observed similar changes in CVD risk markers [47]. After having lost 10% of body
weight young adults who consumed a low-GL diet experienced significant reductions in insulin
resistance (p = 0.01), serum triglyceride concentrations (p = 0.01), C-reactive protein levels (p =
0.03), and blood pressure compared to the conventional low-fat diet (as above). This study again
confirmed that the low-GL diet reduces CVD risk markers. Interestingly, these investigators deter-
mined that energy expenditure reduced less after weight loss in the low-GL diet, which theoretically
afforded an 80-kcal/day advantage compared to those consuming the low-fat diet. Whether this
caloric difference occurs long-term is unknown but worth exploring.
Middle-aged adults (average age, 47 ± 11 years) also experienced improvement in CVD
risk factors with a low-GL diet compared to the American Heart Association (AHA)-recom-
mended, low-fat diet [18]. Twelve overweight men (BMI = 33 ± 3.5 kg/m2) consumed each diet
ad libitum for 6 days, in a crossover design. Significant adverse changes occurred while
following the AHA diet: a 28% increase in serum triglycerides and a 10% reduction in HDL-
cholesterol levels, which increased the cholesterol/HDL-cholesterol ratio. During the low-GL
phase, serum triglycerides decreased 35%, peak particle LDL size increased (1.6%), and plasma
insulin levels measured either fasting or during the day were lower compared to the AHA diet.
During this part of the study, the subjects consumed 25% fewer calories during the low-GL
phase compared to the AHA diet.
These same subjects then consumed the AHA diet, but energy intake was set at the amount
consumed while following the low-GL diet in the first part of the study [18]. There was a trend
for the HDL cholesterol to decrease, leading to a significant increase in the cholesterol/HDL-
cholesterol ratio (p < 0.0001). In addition to these unfavorable effects on CVD risk, the subjects
reported an increase in hunger (p < 0.0002) and a decrease in satiety (p < 0.007) while on this diet
compared to a low-GI diet. These results support a role for a low-GL diet in reducing CVD risk
and question the role of the recommended AHA diet.
Another study in middle-aged adults showed that a low-GL diet reduced risk factors associated
with CVD [61]. During the 10-week trial, healthy, overweight subjects experienced a 10% decrease
in LDL-cholesterol levels (p < 0.05) and a trend toward reducing total cholesterol levels (p < 0.07).
Others were randomized to a high-GL group. However, unlike other studies, no differences in
energy intake, body weight, or fat mass were observed between the two dietary regimens. Regard-
less, the low-GL diet again was shown to be favorable at reducing CVD risk.
Fifty-seven middle-aged subjects (average age, 48 years) with elevated LDL-cholesterol levels
consumed either a low-fat, low-GL diet or a low-fat diet only for 12 weeks [60]. Despite a reduction
in the dietary GI and dietary GL in the low-fat, low-GL group, the blood lipids did not differ
between the groups at any time, except for HDL-cholesterol levels, which decreased significantly
in the low-fat group (p = 0.05). This blood lipid did not change in the low-fat, low-GL group.
These findings support the earlier study of Dumesnil et al. [18], which questioned the wisdom of
a low-fat diet for reducing the risk of CVD.
A small, retrospective study suggested that use of a low-GL diet preoperatively before coronary
artery bypass surgery may shorten hospital stay [45]. During the 4 weeks prior to surgery, patients
who were randomized to a low-GL diet, but not those in the high-GL diet group, had improved
glucose tolerance and greater adipocyte insulin activity at the time of surgery, which resulted in a
significantly shorter length of hospitalization (7.06 ± 0.38 days vs. 9.53 ± 1.44 days; p < 0.05).
Thus, a low-GL diet may benefit patients who already have CVD.
TYPE 2 DIABETES
More data exist in support of the use of a low-GL diet for the prevention and management of type
2 diabetes than for CVD. This makes sense because the GI and GL were developed initially to
help manage blood sugar control in these patients.
Epidemiological Data
Five large-scale studies assessed the effect of consuming a low-GL diet over extended periods of
time and in different age groups [30,50,54,55,58]. Young women, ages 24 to 44 years, were followed
for 8 years during which an assessment of their dietary intake was obtained as it related to fiber
and the GL of carbohydrates [58]. Of the 91,249 women included in the study, 741 developed type
2 diabetes. After adjustment of other factors that could predict the development of diabetes, overall
GL of the diet was significantly associated with it (p for trend = 0.001). A 59% increase in the
diabetes risk was observed between the highest quintile of GI and the lowest. Fiber from cereals
and fruits were inversely associated with the risk of diabetes, as well. These authors speculated
that the reason for this significant association was because high-GI foods produced higher blood
glucose concentrations and a greater insulin demand than did low-GI foods. It is possible that
chronically increased insulin demand results in pancreatic exhaustion that can result in glucose
intolerance. In addition, high-GI diets may directly increase insulin resistance.
An older, healthy group of women (over 120,000) were followed for 6 years to determine the
risk of type 2 diabetes [55]. Both the dietary GI and dietary GL were positively associated with
the risk of diabetes. Combining a low cereal fiber intake and a high dietary GL resulted in an RR
of diabetes of 2.50 (95% CI, 1.14–5.51); thus, the incidence of diabetes may be reduced by
incorporating more cereal fiber into the diet as well as following a low-GL diet.
Older men were also shown to be at increased risk of type 2 diabetes if they regularly consumed
a high-GL diet [50]. In another large-scale study in older men (n = 51,529), 40 to 75 years old,
the GI and GL of the diet were inversely associated with adiponectin concentrations (p for trend
= 0.005). Of this population, 780 developed type 2 diabetes during the 8-year study. A 13%
difference for GI and 18% difference for GL was found between the lowest and highest quintiles
for serum adiponectin. Adiponectin is an adipose-secreted cytokine that is present at low levels in
the plasma of patients with type 2 diabetes. In contrast to GI and GL, dietary fiber and magnesium
were associated with higher levels of this cytokine; thus, adiponectin may become a new risk factor
for type 2 diabetes, and the GI and GL appear to be positively related to it.
Large-scale, cross-sectional studies conducted in men and women revealed mixed results as to
the relationship between the GL of the diet and the risk of type 2 diabetes [30,54]. In a group of
over 75,000 non-diabetic men and women, 30 to 60 years old, GI and GL were not predictive of
developing insulin resistance as estimated by HOMA [30]. Insulin resistance developed in 5675
subjects. The risk of developing type 2 diabetes was significantly and inversely associated with
dietary fiber, which was a confounding variable that reduced the effectiveness of GI and GL on
HOMA. The results of this study differ from others but support the recommendation for increasing
fiber intake through carbohydrate-rich foods such as cereals, fruits, and vegetables to prevent insulin
resistance and to reduce the risk of type 2 diabetes.
Others found fiber intake to be a more important predictor of insulin sensitivity than GI or GL
[31]. Participants were selected from an ongoing study (Insulin Resistance Atherosclerosis Study)
and were selected based on glucose tolerance status (i.e., normal or impaired). Subjects underwent
a dietary assessment that included data on fiber intake and the GI and GL of the diet. In addition,
they underwent measurements of insulin sensitivity (Si), fasting insulin, acute insulin response (AIR),
disposition index, BMI, and waist circumference. No association was observed between GI and these
measurements. Relationships between these measurements and digestible carbohydrate and GL were
entirely explained by energy intake. In contrast, fiber intake was associated positively with Si and
disposition index and inversely associated with fasting insulin, BMI, and waist circumference, but
not AIR. This was the first report to address the relationship of GI and GL with direct measure of
insulin sensitivity. Earlier reports [55,58] had hinted at a stronger relationship between GI and GL
and insulin and blood sugar control, but with these data it appeared that fiber intake is a more
important aspect of the diet. Unfortunately, the type of fiber (soluble or insoluble) was not determined.
In contrast to the aforementioned studies [30,31], older individuals 70 to 80 years old appeared
to show a benefit of the low-GL diet in improving markers that predict type 2 diabetes [54]. From
a sample of over 3000, the number of men and women were nearly equal for those who participated
in the study. For men, the dietary GI was positively associated with 2-hour glucose levels after a
75-g challenge (p for trend = 0.04) and fasting insulin concentrations (p for trend = 0.004). It was
inversely associated with thigh intramuscular fat (p for trend = 0.02). Dietary GL was inversely
associated with visceral abdominal fat (p for trend = 0.02) only. For women, dietary GI and GL
were not significant for any markers.
This is the only study to identify differences between the genders. One of the problems with
this study is that the investigators based the GI (and thus GL) on glucose rather than on the most
commonly used standard, white bread. This produced GI and GL values that are lower than those
based on white bread and in this study may explain the lack of statistical significance for women
and for other parameters in men (i.e., fasting blood glucose, glycated hemoglobin, or visceral
abdominal fat). However, in the previous study, the investigators [30] used white bread as the
standard, and no significant relationships were found between GI and GL and diabetes risk either.
Thus, basing the GI and GL on either standard cannot fully explain the discrepancy between
these studies.
From these large-scale cross-sectional and long-term studies, the relationship between GI and
GL and the risk of type 2 diabetes cannot be ignored. Not all studies showed a positive result, but
those that did were fairly convincing in showing such a relationship.
Short-Term Study
In a 4-week study in middle-aged men (around 50 years of age) with type 2 diabetes, those who
consumed a low-GL diet improved glycemic control (fasting blood glucose and Hgb A1c) and
glucose utilization compared with when they consumed a high-GL diet [52]. The only difference
between the two dietary regimens was the GI of the carbohydrates consumed; the total grams of
carbohydrate consumed was the same. Despite the short time span and the small differences between
the groups, the study gives support for the long-term use of a low-GL diet for the management of
type 2 diabetes.
Despite the numerous studies showing the positive effects of a low-GL diet on the management
of type 2 diabetes, the American Diabetes Association (ADA) had been conspicuously absent in
saying anything on the subject until 2004 [59]. In a position statement from the ADA, these authors
reviewed the available data regarding the type or source of carbohydrate on the prevention and
management of diabetes. They asserted that the total grams of carbohydrate consumed was more
important than the dietary GL; thus, in counseling patients with diabetes about their diets, they
suggested that more importance should be placed on the amount rather than the type (low- or
high-GI) of carbohydrate. The authors conceded that GI affects blood glucose control and that its
consideration can provide benefit beyond managing dietary carbohydrate intake, but they went on
to state that the data showing that GI or GL can prevent the development of type 2 diabetes are
unclear.
Many studies exist that show the benefit of consuming a low-GL diet to prevent and manage
type 2 diabetes. Others do not show such relationships. It seems prudent to provide a low-GL diet
to reduce body weight because blood glucose control and blood lipid levels will likely improve.
OTHER CONDITIONS
The GL of the diet has been investigated for its possible effects on other diseases (Table 20.3). These
include blood pressure [65], stroke [42], colorectal cancer [39,41], pancreatic cancer [40], breast
cancer [25], cholecystectomy [63], and diseases of the eye [12,57]. Of these, the most promising
relationships were seen between women developing breast cancer or needing a cholecystectomy.
TABLE 20.3
Common Medical Conditions Affected by Dietary Glycemic Index or Glycemic Load
Effect of Dietary Glycemic Index (GI)
Medical Condition or Glycemic Load (GL) Ref.
Blood pressure No change in blood pressure was observed after ingestion Visvanathan et al. [65]
of 50 g of carbohydrate in a beverage.
Risk of stroke Neither GI or GL was significantly associated with the risk Oh et al. [42]
of stroke in over 78,000 women followed for 18 years.
Risk of colorectal cancer GL was related to risk of colorectal cancer in men (from Michaud et al. [39]
over 50,000) but not women (from over 120,000) followed
over 20 years.
Risk of distal colorectal Neither a high-GI nor high-GL diet was associated with Oh et al. [41]
adenoma colorectal adenoma in a large group of women (>34,000)
followed for 18 years.
Risk of pancreatic cancer GL was associated with an increased risk only in overweight Michaud et al. [40]
and obese women and those who were sedentary, but not
in normal weight women who were active from a large-
scale study (over 88,000) followed for 18 years.
Risk of breast cancer GL was associated with the risk of breast cancer in adulthood Frazier et al. [25]
from data collected regarding what women ate in their
teens.
Risk of cholecystectomy Higher intakes of total carbohydrate and a high-GI and high- Tsai et al. [63]
GL diet may enhance risk in women (over 120,000)
followed for 16 years.
Age-related cataract GL was not related to the risk of cataracts in men (nearly Schaumberg et al. [57]
40,000) and women (over 70,000) followed for 12 years
and 14 years, respectively.
Risk of early cortical and GI was not associated with either eye condition based on —
nuclear lens opacities 1717 women followed over 14 years.
Other conditions were not related to the GI or GL of the diet (i.e., blood pressure, stroke, age-
related cataracts, or early cortical and nuclear lens opacities). The GL of the diet was related to
the risk of colorectal cancer in men but not women and with the risk of pancreatic cancer in
overweight and obese women and in sedentary women but not normal weight women. Thus, in
contrast to the numerous reports showing a relationship between dietary GL in reducing the risk
of and in helping to manage CVD and type 2 diabetes, most other conditions do not seem to be
affected by it.
HOW TO EAT A LOW-GLYCEMIC-LOAD DIET

Some have argued that all obese patients should be counseled on a low-GL diet [4,29,46]. The
science behind the diet is complex, and teaching the diet to patients may prove challenging. To
meet all nutritional needs for macronutrients, micronutrients, and a low GL, the basic principles
shown in Table 20.4 should be followed. Using this guide, most patients should be able to grasp
these concepts and eat a healthier, more nutrient-dense diet. With this diet comes enhanced satiety,
reduced hunger, weight loss, and a reduced risk of CVD and type 2 diabetes.
TABLE 20.4
How To Follow a Low-Glycemic-Load Diet
Food Group Servings Per Day Comments
Dairy (e.g., milk, cheese) Two Use reduced-fat products to reduce energy intake.
Meat, fish, poultry, eggs 8–10 ounces/day; To reduce energy intake: (1) trim visible fat and
one egg = one ounce skin; (2) cook with minimal added fats, sauces,
and breaded coatings.
Fruits Two pieces or two 1/2-cup If using canned or frozen, choose sugar-free to
servings reduce energy intake.
Avoid dried fruits and fruit juices.
Nonstarchy vegetables Unlimited Use limited fats and sauces to reduce energy
intake.
Starchy vegetables and unsweetened 3–5 servings per day; a Use fewer servings during active weight loss than
grain-based foods serving is 1/2 cup, 1 slice, during maintenance.
or 1 whole (e.g., potato)
Sweetened grain-based foods, candy, None, or use sparingly Use none during active weight loss and sparingly
sugary beverages, salty snacks during maintenance.
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21 Beyond Obesity Prevention:

The Anti-Aging Effects
of Caloric Restriction
Kurt W. Saupe and Jacob D. Mulligan
CONTENTS
Introduction ....................................................................................................................................265
Caloric Restriction and Life Span .................................................................................................265
Causes and Effects of Caloric Restriction.....................................................................................268
Effect of CR on Stem Cells and Regenerative Potential of Tissues .....................................268
Effects of CR on Fat and Adipokines ....................................................................................269
How Does Caloric Restriction Affect a Representative
Organ System (Cardiovascular System)?....................................................................................269
Hemodynamics and Cardiac Contractile Function ................................................................270
Oxidative Damage...................................................................................................................270
Gene Expression .....................................................................................................................271
Will Caloric Restriction Work in Humans? ..................................................................................271
Effects of CR in Humans .......................................................................................................272
Caloric Restriction Mimetic Drugs................................................................................................273
References ......................................................................................................................................274
INTRODUCTION
This chapter contrasts with much of the book in that, instead of focusing on treating obesity, we
discuss the effects of lowering body mass in animals that are not overweight or obese to start. For
the purposes of this chapter, caloric restriction (CR) is defined as limiting caloric intake while
providing adequate micronutrients. It should be emphasized that we are not treating obesity but
are making relatively lean animals very lean while avoiding any malnourishment by increasing the
nutrient density of the diet. CR is unique in that it significantly increases the mean and maximal
life span of a population. An important aspect of CR is that it does not simply prolong the survival
of the organism in an aged or decrepit state; it actually confers a “young” phenotype to the organism.
No other nongenetic interventions have emerged that produce similar benefits.
CALORIC RESTRICTION AND LIFE SPAN

People throughout history have unsuccessfully looked for a “fountain of youth,” but in the early
decades of the 20th century several groups reported that life span in rodents could be significantly
lengthened by restricting the amount of food they were given [46,48,51]. Over the subsequent
years, the observation that a CR diet could extend life span was built upon with several fundamental
observations. CR has been shown to extend both mean and maximal life spans of a colony of
265
100 Non-CR
25% CR
55% CR
65% CR
75
Survival (%)
50
25
0
0 10 20 30 40 50 60
Age (months)
FIGURE 21.1 Effects of increasing levels of caloric restriction on survival in mice. Caloric restriction causes
a parallel rightward shift in the survival curve, increasing both average and maximal life span. (From
Weindruch, R. et al., J. Nutr., 116, 641–654, 1986. With permission.)
animals, causing a parallel rightward shift in the survival curve, as shown in Figure 21.1 [72].
Particularly noteworthy is the increase in survival of the oldest members of the colony. The fact
that CR does not just square off the survival curve by preventing early deaths is a strong indication
that CR actually retards aging. Subsequent studies have established that the improved survival of
CR animals appears to be caused by a delayed onset of age-associated diseases, including cancer
and neurodegenerative diseases.
The amount of life-span extension afforded by CR is related to two main dosing factors: the
age at which CR is initiated and the severity of CR. Regarding the first factor, if CR is initiated
either too early or too late in life, the beneficial effects of CR are lessened; for example, if CR is
initiated before an animal is mature (prior to weaning in a rodent), any benefits of CR may be
obscured. On the other hand, the later in life (after maturity) CR is initiated, the less life span will
be extended; for example, an equivalent level of CR (approximately 40% less than ad libitum
calories) will increase life span in a mouse by approximately 9, 6, and 3 months when it is started
at 3, 14, or 19 months of age, respectively [14,41,72]. In other words, starting CR during late
middle age yields only approximately a third of the life-span extension as does starting CR during
early adulthood. A second critical dosing factor is the degree to which food intake is restricted
[72]. It is interesting to note the generally linear increase in mean and maximal life span that occurs
as caloric intake is reduced, with no minimal point defined where further reduction in caloric intake
causes no further benefit or even harm (Figure 21.2). Although at some point a reduction of caloric
intake must decrease life span, this point (often assumed to be approximately a 65% reduction)
has not been empirically defined.
The increase in life span is not simply due to preventing obesity. Although preventing obesity
clearly has many health benefits, even when very lean mice are used as the basis of comparison
(such as the 25% restriction group in Figure 21.1), further restriction of food intake substantially
increases life span. It bears repeating that the anti-aging and life-span extension afforded by CR
Beyond Obesity Prevention: The Anti-Aging Effects of Caloric Restriction 267
60
Average Maximum
55
Life span, months 50
45
40
35
30
25
20 40 60 80 100 120 140
Food intake, K-Cal per week
FIGURE 21.2 Effects of decreasing food intake on average and maximal survival. Note the linear increase in
life span with decreasing levels of food intake; even at very low levels of food intake, life span is further increased
by lessening food intake. (From Sohal, B.H. and Weindruch, R., Science, 273, 59–63, 1996. With permission.)
are in addition to the benefits of preventing obesity. Surprisingly, the retardation of aging and
extension of life span are not due simply to maintaining a low body weight or low percent body
fat. This is most directly demonstrated by Holloszy et al. [28,29], who reported that exercise-
induced weight loss extended mean life span slightly but did not extend maximal life span. The
retardation of aging and life-span extension with CR seem to be caused by metabolic adjustments
to the chronic lack of food.
The beneficial effects of CR on life span occur in all species studied to date, including yeast,
worms, mice, rats, and large mammals. In fact, the effects of CR are so robust that even in genetically
long- or short-lived mice the effects of CR are preserved [32]. Thus, the effect of CR appears to
superimpose on animals with a wide range of genetic backgrounds (Figure 21.3). An overriding
unanswered question is to what extent CR will affect aging in long-lived mammals such as humans.
The effects of CR have rapid on and off kinetics. Dhahbi et al. [14] have recently shown that,
within the first 8 weeks of starting a CR diet, survival is improved in aged mice. They also noted
that the pattern of gene expression is altered within the first 2 weeks of CR. Thus, the key molecular
p53–/– Mouse 44%

p53+/+ Mouse 37%
C3B10RF1 Mouse 56%
Sprague–Dawley Rat 32%
F344 Rat 39%
Labrador Retriever 16%
Hereford Cow 35%
0 5 10 15
FIGURE 21.3 Effects of moderate caloric restriction on survival across mammalian species. Even in relatively
long-lived mammals and mice genetically engineered to have short or long lives, caloric restriction significantly
increases life span. (From Hursting, S.D. et al., Annu. Rev. Med., 54, 131–152, 2003. With permission.)
trigger events that ultimately lead to the CR phenotype must occur within this time window, possibly
as soon as the first restricted day. Conversely, when a CR diet is stopped and animals are allowed
to eat ad libitum, the benefits of CR disappear quickly. The rapid kinetics of CR-mediated changes
is a boost to the practicality of CR research. Depending on the endpoint being studied, it is possible
to collect meaningful data in a timely manner, rather than conducting long-term studies. In fact, a
current priority in this area of research is identifying biomarkers of longevity as surrogate endpoints
and alternatives to life span. Furthermore, the time frame of CR-mediated changes gives important
clues as to the molecular causes. It seems likely that many of the effects of CR may be similar to
those effects that follow a short-term fast.
The kinetics of CR effects is also of interest to those (both researchers and subjects) considering
CR diet as treatment. Although the rapid onset of these effects might be encouraging, unfortunately
the benefits of CR accumulate relatively slowly, and it may take many months or years on the CR
regimen to observe a noticeable impact on health. The emerging field of CR mimetic drugs, however,
may eventually decrease that time, or at least make the treatment period more feasible. CR mimetics
are discussed later in this chapter.
The increase in life span with CR can be seen using any one of a number of dietary regimens.
The key common factor is a reduction in caloric intake without sacrificing micronutrients. Inter-
estingly, some data suggest that even intermittent fasting protocols that do not produce a profound
weight loss still provide many of the benefits of CR [4,7].
Life-span extension with CR is due largely to retardation of age-associated diseases, most
importantly cancer. In rodents and other species that die largely of neoplastic disease, much of the
life-span extension can be attributed to anti-cancer effects [32,70]. This inhibitory action of CR on
carcinogenesis is effective in multiple species, for a variety of tumor types and for both spontaneous
and chemically induced neoplasms. Fortunately, even relatively mild CR (20 to 30% less calories
than ad libitum) can significantly delay and lower the incidence rate of late-life neoplasms [58,72].
Also encouraging from the standpoint of applicability to humans is the fact that CR even initiated
as late as middle age retards the development of tumors [71]. Although numerous theories as to
the molecular basis for how CR prevents and slows cancer have been proposed (see Hursting et
al. [32] and Weindruch [70] for reviews), the actual mechanisms remain unclear.
CAUSES AND EFFECTS OF CALORIC RESTRICTION

Given the difficulty of voluntarily restricting food intake, there is a great deal of interest in
understanding the molecular mechanisms underlying the effects of CR well enough to harness the
powerful effects; however, finding a clear, universally satisfying explanation for how CR works
has remained elusive. One major issue is that so many molecular and physiological variables are
altered with CR that it is difficult to tell the effects of CR from causes; for example, it has been
widely observed that chronic CR causes a decrease in core body temperature [52], but the extent
to which lowered body temperature and other CR-induced changes contribute to the CR phenotype
of retarded aging is unknown. Although many theories of aging and CR have been well discussed
over the past three decades, here we highlight two recent areas of investigation into the basis for
the CR phenotype.
EFFECT OF CR ON STEM CELLS AND REGENERATIVE POTENTIAL OF TISSUES

One theory of aging is that the loss of tissue regenerative potential with age contributes to the aging
phenotype. Aged tissues heal less effectively in response to acute injury, and a gradual decline in
regeneration regarding basal tissue maintenance occurs [13,34,59]. This has been shown in both
proliferative and postmitotic tissues [9,13,39,45]. It is thought that the decline in tissue regeneration
with age occurs when stem or precursor cell function decreases to the point where the production
of new cells can no longer match cellular turnover in the tissue, leading to a net loss of tissue
function. Aging decreases the functional capacity of circulating stem cells of the hematopoietic
and mesenchymal lineages [19,35], as well as resident tissue-specific precursors, such as the satellite
cells in skeletal muscle [13].
Recent evidence has suggested that in some types of tissue CR increases regenerative potential
or stem cell function. CR-mediated improvements in tissue function following acute injury include
rescue of cardiac function in post-ischemic hearts [2,43] and enhanced hepatic regeneration fol-
lowing toxin-induced injury [6]. In the latter study, CR was thought to enhance hepatic regeneration
by inducing apoptosis of damaged cells and promitotic signaling in healthy cells.
The effect of CR on stem or primitive cells has been studied directly. In bone-marrow-derived
hematopoietic stem cells, CR not only slowed aging of the stem cells but also enhanced function
to the extent that in a repopulation assay stem cells from old CR mice outperformed stem cells
from young mice fed ad libitum [12]. CR has also been shown to attenuate the age-associated
reduction in T-cell precursors [50], and in another study CR reduced the number of senescent
T-cells [64]. This suggests that CR may strengthen the regenerative potential of tissues in part by
increasing the potency of the progenitor-type cell population.
Recent evidence suggests that CR may exert its effects on regeneration via the circulation.
Conboy et al. [13] demonstrated that the regeneration capacity in liver and muscle from old mice
can be restored by cross-circulation with a young mouse. The simplest interpretation of this result
is that the “CR effect” is carried in the blood stream, at least the part of the effect that is involved
in enhancing cellular rejuvenation. Because CR confers a “young” phenotype on many aspects of
the hormonal milieu (decreases insulin and IGF-1), it is not surprising that CR may improve tissue
regeneration through the circulation [37]. Furthermore, hematopoietic stem cells, which are func-
tionally improved by CR, move through the circulation to sites where they may be involved in
tissue regeneration.
EFFECTS OF CR ON FAT AND ADIPOKINES

The recent recognition that white adipose tissue plays a central role in age-related pathologies such
as type 2 diabetes and cancer, combined with the fact that white adipose tissue is dramatically
remodeled by CR, has led to the suggestion that CR-induced changes in white adipose tissue may
play a key role in the CR phenotype [38,56]. Recent experimental evidence indicates that fat is a
dynamic endocrine organ that can become dysfunctional and not only secrete hormones that
contribute to pathology but also shunt lipids to be stored in other organs, resulting in insulin
resistance [24]. Our understanding of the biological significance of the peptides and other substances
secreted by adipose tissue (sometimes referred to as adipokines) and how they are affected by CR
is in its infancy.
HOW DOES CALORIC RESTRICTION AFFECT A REPRESENTATIVE

ORGAN SYSTEM (CARDIOVASCULAR SYSTEM)?
Caloric restriction has long been established as having powerful anti-neoplastic effects, but
more recently interest has grown in determining how CR affects other major causes of human
mortality, especially cardiovascular diseases. This question has become particularly important
with the dramatic increase in age-associated cardiovascular disease in recent decades. When
evaluating the effects of CR on the cardiovascular system, the large majority of studies have
been performed on rodents; however, several reports have studied non-human primates or human
subjects despite the many methodological difficulties and limitations. The findings of these
studies in rodents and primates can be divided into three broad categories with regard to the
effect of CR on: (1) systemic hemodynamics and cardiac contractile function, (2) oxidative
damage, and (3) gene expression.
HEMODYNAMICS AND CARDIAC CONTRACTILE FUNCTION

Caloric restriction has been reported to decrease blood pressure and heart rate in rodents [31,69]
and blood pressure in non-human primates [47]. This heart rate and blood pressure lowering occurs
in normotensive as well as hypertensive animal models and seems to be secondary to increases and
decreases in parasympathetic and sympathetic tone, respectively. Mager et al. [44] showed that the
decrease in heart rate and blood pressure caused by either CR or intermittent fasting was quickly
reversed by switching the animal to an ad libitum diet.
The most relevant data from humans comes from the study of a cohort that voluntarily under-
went a CR diet regimen for a mean of 6 years [49]. In this study, Meyer et al. compared 25 CR
volunteers (body mass index [BMI] = 20, percent fat [%fat] = 9) and 25 age-matched, non-obese
controls (BMI = 27, %fat = 26). The CR group had lower systolic (102 vs. 113 mmHg) and diastolic
(61 vs. 83 mmHg) blood pressure compared to the control group. Another study using similar
subjects revealed an improved blood lipid profile in the CR group [20]. CR increased high-density
lipoprotein (HDL) cholesterol (48 vs. 63 mg/dL) and decreased both low-density lipoprotein (LDL)
cholesterol (127 vs. 86 mg/dL) and triglycerides (147 vs. 48 mg/dL) compared to the control group.
It should be noted that these studies (as is true of all studies on humans) carry important limitations
— for example, small sample size and lack of strict control over subject diet intake. Furthermore,
these subjects volunteered for CR rather than being randomly placed on CR by the investigators.
This, at the very least, suggests a difference in lifestyle between the groups. Another important
limitation of this study was the age of the subjects. At the relatively young mean age of 53, neither
group would be expected to display a large age-associated decline in cardiovascular function.
The effects of CR on cardiac contractile function are most often studied in the context of testing
the ability of CR to reverse age-associated changes in left ventricular function. In rodents, CR generally
attenuated age-associated changes in echocardiographically measured left ventricular function. Spe-
cifically, CR decreased peak atrial filling velocity and fraction [67]; intermittent fasting improved
cardiac output, pressure work, and efficiency [65] and prevented the age-associated reduction in left
ventricular contractility [11]. It should be noted that in mice and rats age-associated changes in the
heart are relatively small and of unknown significance, as mice generally do not die of heart disease.
Thus, the extent to which CR-induced changes in left ventricular function contribute to life-span
extension is probably minimal. In humans, however, the age-associated decline in cardiovascular
function is a major health issue. Cardiovascular function was tested in the same voluntary CR cohort
introduced above [49]. CR had no effect on systolic function (which declines little if at all with age)
but caused improvement in diastolic function, an age-dependent parameter. Specifically, CR decreased
peak A-wave velocity (53 vs. 46 cm/s) and increased the E/A wave ratio (1.2 vs. 1.6). CR also
improved left ventricular chamber viscoelasticity and stiffness compared to control subjects.
A critical aspect of the healthy heart is its ability to mitigate and recover from stress-induced
damage. CR has proven beneficial in this regard. In rodents, CR was shown to lower heart rate
following ischemia [8,43] and swimming stress [69] and to blunt the hypertension-induced increase
in the ratio of left ventricular weight to body weight [66]. Experimentally, one way to lessen
ischemic damage is to subject the heart to short periods of ischemia prior to a prolonged period
of ischemia (ischemic preconditioning). Aged hearts are especially sensitive to damage from
ischemia and do not respond to this ischemic preconditioning [1,26]. CR has been shown to restore
the beneficial effect of pre-ischemic conditioning in the aged heart, as interpreted by improved
developed pressure recovery and increased cardiac output following ischemia [2,43]. This effect
of CR has been combined with exercise to achieve an additive result [3].
OXIDATIVE DAMAGE
A key hypothesis for the cause of cellular aging is the accumulation of oxidative damage to proteins,
lipids, and DNA. The majority of oxidative damage is caused by the production of reactive oxygen
species (ROS) in the mitochondria. It is thought that, with aging, ROS production is increased and
removal of ROS is decreased [25]. Although there is some disagreement on the details, considerable
evidence exists that CR improves control over oxidative damage in the heart; for example, the
production of ROS was shown to be decreased by 6 weeks of CR [62], although another study
showed no change after 4 months of CR [54]. There is more agreement on the expression of
enzymes that remove ROS. CR has been demonstrated to increase the levels of catalase, glutathione
peroxidase, thioredoxin reductase, and superoxide dismutase [10,16,18,60]. Oxidative damage is
also reduced by the presence of antioxidant or reducing molecules in the cell. CR corrects the age-
associated decline in reduced glutathione and coenzyme Q [10,36,57], although one study showed
a surprising decline in α-tocopherol levels with CR [36].
Importantly, CR has been shown not only to reduce ROS levels but also to reduce actual
oxidative damage to protein [42,53], lipids [16,18], and DNA [63]. Some studies showed a duration
dependence. Gredilla et al. [22] demonstrated a decrease in oxidative damage to DNA with 12
months of CR but not with 8 weeks. Forster et al. [21] showed that 12 months of CR decreased
protein oxidation, but 6 weeks was less effective. This group also showed that the CR effect was
completely lost within a few weeks of being switched back to an ad libitum diet.
GENE EXPRESSION
Two research groups have measured the effects of CR on global cardiac gene expression in
mice using microarrays. The scope of these studies makes them exceptionally useful for seeing
the larger picture of how CR affects the biochemical landscape of the heart. Lee et al. [40]
found that, of over 5000 genes analyzed in the heart, 312 were altered by at least 50% with
age, and 831 were altered by at least 50% with CR. This study revealed a gene expression
pattern that suggests that aging results in a downregulation of fatty acid metabolism (the
preferred fuel substrate in the healthy heart) and a subsequent upregulation of glucose metab-
olism. CR, however, reversed much of this age-dependent “fuel-switching” pattern. Additionally,
CR was shown to induce genes involved in DNA repair and to downregulate genes involved in
programmed cell death (apoptosis).
Recently, Dhahbi et al. [15] compared gene expression in both short- and long-term CR, and
the effect of going back to an ad libitum diet after the CR diet. Eight weeks of CR produced 19%
of the gene expression changes as 22 months of CR, in line with studies showing that, although
many changes occur quickly, the benefit of CR increases with time. Interestingly, 97% of CR-
induced changes in gene expression were completely reversed within only 8 weeks of the animals
switching back to an ad libitum diet.
In summary, caloric restriction has a profound effect on the physiology and biochemistry of
the heart. By and large, the available data suggest that this effect is a positive one; however, many
important details about how CR affects the human cardiovascular system are lacking due to the
sparse human data available, being primarily from observations of overweight subjects in experi-
ments that were not strictly controlled. Although the benefit of CR is quite robustly illustrated in
many experimental models in non-humans, more meaningful insights should come from additional
well-controlled studies in non-obese humans.
WILL CALORIC RESTRICTION WORK IN HUMANS?

One of the most frequently asked questions in the field of CR is: “Will a CR diet work in humans,
and if it does, will the sacrifices be worth it?” Much of the answer to this question depends on
whether one is discussing disease prevention or anti-aging and extension of maximal life span. It
is clear that some level of CR would provide most Americans with an important degree of disease
prevention, as the data in Table 21.1 indicate [20]; however, the question of whether CR retards
aging and extends maximal life span in humans is more complicated. Several theoretical reasons
for believing that CR will not provide these kinds of benefits to humans are discussed extensively
TABLE 21.1
Effects of Chronic Caloric Restriction on Blood Pressure and Blood
Lipids in Humans
Value
Parameter Pre-CR 1 Year CR Present
BMI (kg/m ) 2 24.5 ± 2.6 20.9 ± 2.4 19.5 ± 2.1
Total cholesterol (mg/dL) 194 ± 45 161 ± 31 157 ± 38
LDL cholesterol (mg/dL) 122 ± 36 89 ± 24 86 ± 17
HDL cholesterol (mg/dL) 43 ± 8 58 ± 13 65 ± 24
Total/HDL cholesterol ratio 4.1 ± 1 2.8 ± 0.5 2.5 ± 0.4
Total triglycerides (mg/dL) 149 ± 87 72 ± 35 54 ± 15
Systolic blood pressure (mmHg) 132 ± 15 112 ± 12 97 ± 8
Diastolic blood pressure (mmHg) 80 ± 11 69 ± 7 59 ± 5
Note: Values are means ± SD for 12 individuals.
Source: Fontana, L. et al., Proc. Natl. Acad. Sci. USA, 101, 6659–6663, 2004. With permission.
elsewhere [17,55]. They include the suspicion that humans will not be willing or able to restrict
calories to the required levels at an early enough age to garner any significant benefits. Because it
is unlikely that survival curves such as those shown in Figure 21.1 will ever be generated to directly
answer this question, we must look at available data.
Additionally, the question of “Is it worth it?” can only be answered when the costs and benefits
of various CR regimens are known. The obvious costs include nearly constant hunger, which does
not seem to dissipate with time. This issues raises the interesting philosophical question of whether
or not a person would extend his or her life by a few years if it meant being almost constantly
hungry. Clearly, various people would answer this question very differently, and the hope is that
they could make informed choices based on complete knowledge of the costs and benefits. Currently,
however, we have only a poor idea of the benefits and costs in humans. It should be recognized
that the importance of studying the basic biological causes of CR-induced retardation of aging does
not depend on a “yes” answer to the question of “Is it worth it?” because this area of research may
lead to a pharmacological way of reproducing some of the benefits of CR.
EFFECTS OF CR IN HUMANS
Recently, it has been demonstrated that humans can voluntarily submit to a CR diet in at least
two settings. The first is self-selected individuals who have decided to follow a CR diet [20,49].
Despite the obvious methodological problems, this approach has provided some intriguing data,
particularly when longitudinal data are available from before the CR was initiated in the individual
(Table 21.1) [20]. It would be difficult to argue that these changes in blood pressure and blood
chemistry are not desirable consequences of voluntary restriction of caloric intake. Note that the
pre-CR BMI is within the non-obese normal range, suggesting that these individuals reflect the
general American population prior to initiating CR in an important way. Data from these individ-
uals are intriguing but relatively uncontrolled with regard to some factors, such as composition
of the diet, that may contribute to improved cardiovascular health; however, these individuals
clearly demonstrate that at least some people can restrict caloric intake to low chronic levels with
impressive cardiovascular benefits.
A second group of individuals that has voluntarily undergone CR is composed of those involved
in a National Institutes of Health (NIH)/National Institute on Aging (NIA)-sponsored randomized
multicenter trial (Comprehensive Assessment of the Long-Term Effects of Reducing Intake of
Energy, or CALERIE) [27]. In part of this long-term research effort, 48 healthy, sedentary adults
27 to 49 years old were randomized to one of four groups: (1) controls (weight maintenance), (2)
25% CR, (3) 12.5% CR plus exercise, or (4) 890 kcal/day until 15% decrease in body weight.
Importantly, the subjects entered the study overweight (BMI = 28; %fat = 32), so some of the
effects noted may be due to normalization of body weight. Over the 6 months of the study, the CR
and CR plus exercise groups lost weight at a rate of approximately 3 lb/month, whereas the 890
kcal/day group lost approximately 23 lb in 10 weeks, after which body weight was maintained.
Several noteworthy findings arose from this study. First, under these carefully controlled circum-
stances, the highly motivated volunteers were able to tolerate a moderate degree of caloric restric-
tion. Second, some, but not all, biomarkers of CR established in rodents changed as predicted; for
example, CR did not affect blood glucose or DHEA levels as one might expect from rodent data,
whereas 6 months of CR significantly decreased insulin levels in all three groups. Intriguingly,
DNA damage, but not the levels of protein carbonyls, was decreased in all three CR groups. Longer
term studies should yield interesting additional information.
CALORIC RESTRICTION MIMETIC DRUGS

Given the above-mentioned difficulties and uncertainties regarding CR in humans, there is intense
interest in trying to reproduce some of the beneficial effects of CR pharmacologically [33,61]. As
more information about the molecular basis for the effects of caloric restriction becomes available,
the search for compounds that mimic the effects of CR becomes more rational and focused. Because
the benefits of CR are not directly linked to weight loss, a weight loss drug per se is not the goal.
In general, the two pharmacological strategies for CR mimetics are finding drugs that reproduce
the general metabolic state of food deprivation and finding agonists/antagonists of specific mole-
cules that are thought to be upstream in the pathway by which CR retards aging. In the first category
is the structural analog of glucose, 2-deoxy-D-glucose (2-DG), which acts as a competitive inhibitor
of glycolysis. Although 2-DG has shown great therapeutic potential in some settings, the extent to
which it mimics the effects of CR at nontoxic doses appears limited [33].
A second member of this category is insulin sensitizers, such as the commonly used anti-
diabetes drug metformin. The rationale for this approach centers on the observation that CR causes
a broad insulin sensitization of tissues that has been implicated in the anti-aging phenotype of CR
animals. Consistent with a central role of endocrine effects of CR, studies in species including
Caenorhabditis elegans, Drosophila, and rodents suggest that the CR-induced life-span extension
may be related to alterations in insulin or insulin-like growth factor signaling that retard cellular
aging [5,68]. Using microarray analysis of the liver, Dhahbi et al. [14] found that 8 weeks of
metformin treatment in mice produced 75% of the changes in gene expression that were produced
by long-term CR. To put this number in perspective, 8 weeks of CR produced only 71% of the
changes in expression observed during long-term CR. This dramatic mimicking of CR by metformin
was observed to a much weaker degree with other putative CR mimetics such as glipizide (16%),
rosiglitazone (17%), or soy isoflavone extract (11%). Thus, not only does metformin show great
potential as a CR mimetic, but it can also be inferred that insulin sensitization is relatively far
upstream with regard to causing the broad changes in gene expression observed with long-term CR.
In addition to drugs that reproduce the general effects of food deprivation, exciting recent
work has also focused on agonists of specific molecules. Most notably, Howitz et al. [30] found
that resveratrol (a naturally occuring polyphenol that is present in red grape skins and red wine)
increases the replicative life span of yeast by stimulating the histone deacetylase sir2 [30]. This
group also reported that resveratrol extends life span in Drosophila melanogaster and stimulates
the mammalian homolog SIRT1. The extent to which these finding are applicable to mammals
has not yet been determined. Some have speculated that the effects of CR on aging and longevity
in mammals may be caused by a CR-induced increase in SIRT1 activity [23]. While the extent
to which CR affects SIRT1 in mammals has not been clearly defined, this is an area of great
scientific interest.
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22 Dietary Supplement
Carbohydrate Digestion
Inhibitors: A Review
of the Literature
Jay Udani, Mary Hardy, and Ben Kavoussi
CONTENTS
Introduction ....................................................................................................................................280
Background .............................................................................................................................281
Carbohydrate Digestion ..........................................................................................................281
Carbohydrate Digestion Inhibitors (Starch Blockers): Mechanism of Action ......................282
Methods to Test for Carbohydrate Malabsorption .................................................................283
Hydrogen Breath Testing.................................................................................................283
Ileal Fluids .......................................................................................................................283
Blood Tests ......................................................................................................................283
Glucagon-Like Peptide 1.................................................................................................283
Glucagon ..........................................................................................................................284
Gastric Inhibitory Polypeptide ........................................................................................284
Serial Serum Acetate .......................................................................................................284
C-Peptide..........................................................................................................................284
Stool Tests for Carbohydrate Malabsorption ..................................................................284
Urine Tests for Carbohydrate Malabsorption..................................................................284
Clinical Studies for Carbohydrate Digestion and Absorption ......................................................284
Unpurified White Bean Products............................................................................................284
Carbolite Starch Blocker Study (1982)...........................................................................284
Unpublished North Dakota State Study (1982) ..............................................................285
Commercial Alpha-Amylase Inhibitor Study (1983)......................................................285
13C-Enriched Starch Tracer Study (1983) .......................................................................285
American Journal of Clinical Nutrition Study (1983) ...................................................285

Partially Purified White Bean Extract Studies .......................................................................286
Partially Purified White Bean Extract (1984) .................................................................286
Non-Kidney-Bean Alpha-Amylase Inhibitors ........................................................................287
Tendamistat (HOE 467) Study (1983) ............................................................................287
Tendamistat (HOE 467) Studies (1984)..........................................................................287
Wheat Alpha-Amylase Inhibitor (1998)..........................................................................288
279
Phase 2® White Bean Extract Studies for Reducing Glucose Excursion..............................288

University of Scranton (September 2001) ......................................................................288
University of Scranton (November 2001).......................................................................288
University of Scranton (May 2002) ................................................................................288
University of Scranton (September 2003) ......................................................................289
Glycemic Index Lowering Study (2005) ........................................................................289
Carbohydrate Digestion Inhibitor Studies for Weight Loss..........................................................289
White Kidney Bean Extracts: Partially Purified ....................................................................289
Norwegian Study (2000) .................................................................................................289
Phase 2® White Bean Extract Clinical Studies for Weight Loss...........................................289
Italian Study (2001).........................................................................................................289
Northridge Hospital Study (2002)...................................................................................291
Leiner Softchew Study (2003) ........................................................................................291
TheraSlim™ Study (2003) ..............................................................................................292
SCUHS Study (2004) ......................................................................................................292
Safety..............................................................................................................................................293
Discussion ......................................................................................................................................293
Conclusion......................................................................................................................................294
Disclosures .....................................................................................................................................294
References ......................................................................................................................................294
INTRODUCTION
The estimated prevalence of diabetes worldwide for the year 2000 was 177 million people ages 20
to 79 years, of whom 85 to 95% had type 2 diabetes [2]. The total prevalence of diabetes in the
United States for all ages in 2002 was estimated to be 18.2 million people (6.3% of the population),
of which an estimated 13.0 million people were diagnosed and the remaining 5.2 million undiag-
nosed [3]. As for obesity, it affects nearly one third of the adult American population (approximately
60 million) and remains the second leading cause of unnecessary deaths in the United States [4].
In response to these interrelated health epidemics, the medical community and the lay public have
turned to various caloric restriction strategies, both for reducing body mass to treat obesity and for
the glycemic control required in diabetes. These strategies aim to alter glucose and carbohydrate
metabolism, control insulin production, and alter the cellular response to insulin. Among these
products are carbohydrate digestion inhibitors such as alpha-amylase inhibitors and alpha-glucosi-
dase inhibitors.
The proposed mechanism of action of these products appears to stem from their ability to
partially inhibit, or delay, the breakdown of complex carbohydrates into absorbable constituents
(mono- and disaccharides). This inhibition may lead to a delay in the absorption rate of glucose,
a decrease in the subsequent insulin rise, a decrease in plasma triglycerides (TAG), an increase in
high-density lipoprotein (HDL), the prevention of adipose deposition, and the control of hunger
through a variety of mechanisms. It is also theoretically possible that these products decrease the
total number of calories absorbed from complex-carbohydrate-containing foods. Either way, and
regardless of the mechanism of action, carbohydrate digestion inhibitors have the potential to
decrease insulin resistance and possibly contribute to weight loss.
The general public is already using many other methods for weight loss and glucose control,
such as nonprescription products (herbs, vitamins, and nutritional supplements), as well as meal
replacement preparations (shakes, low-caloric frozen diners). Because scientifically rigorous studies
have not been performed on many of these products, in many cases, safety and efficacy have taken
a back seat to marketing.
Dietary Supplement Carbohydrate Digestion Inhibitors: A Review of the Literature 281
In this chapter, we review the evidence for the efficacy of a category of nutritional supplements
known as carbohydrate digestion inhibitors, or starch blockers. This has been an area of great interest
and debate since the 1980s, and we have chosen to review the clinical evidence from that time
forward to provide a historical perspective on the utilization of nutritional alpha-amylase inhibitors.
BACKGROUND
Alpha-amylase is a digestive enzyme secreted by the salivary glands and by the pancreas and is
responsible for breaking down starch for absorption. Recent interest in low-carbohydrate diets has
heightened the public’s desire to reduce their carbohydrate intake. If a substance were to compet-
itively bind alpha-amylase and inhibit its enzymatic activity, it could prevent the digestion and
subsequent absorption of complex carbohydrates. Such a product would be of particular interest
to those who have become very concerned with the carbohydrate content of their food. The purpose
of this review is to evaluate the scientific and historical background of nutritional alpha-amylase
inhibitors to determine their therapeutic value as an adjunctive treatment for diabetes and obesity.
CARBOHYDRATE DIGESTION
Dietary carbohydrates are found in three forms: plant-based starches, animal-based glycogen, and
disaccharides found in fruit, milk, and refined sugars. Of these, starch accounts for the largest
percentage of the carbohydrate found in human food. The two main sources of dietary starches are
naturally occurring starches and processed starches. Naturally occurring starches, found in vege-
tables, fruits, cereals, and legumes, are primarily complex carbohydrates. Processed starches are
derived from natural sources but are further processed, purified, or refined. They are used mainly
in convenience foods as thickeners, bulking agents, fillers, and as a base for color and flavors.
Under normal conditions, the digestion of carbohydrates begins in the mouth with amylase
produced by the salivary glands and continues in the duodenum by amylase and other enzymes
produced by the exocrine pancreas. Acids (such as HCl in the stomach) and enzymes (such as
alpha-amylase secreted by the salivary glands and by the pancreas) are responsible for digesting
carbohydrate oligosaccharides (of molecular weight >100,000) into dextrins (polysaccharides),
which get hydrolyzed to glucose (monosaccharides). The end result of carbohydrate digestion is
the production of mono- and disaccharides that are absorbed by the brush border of the small
intestine. The final conversion from disaccharides to monosaccharides occurs during absorption.
Although starch hydrolysis by amylase is the rate-limiting step in starch digestion [5], alternative
pathways of carbohydrate digestion include small-bowel wall brush border mucosal glucoamylases
and maltase [7,11]. Once absorbed, these sugars are delivered to the liver via the portal vein and
enter into intermediary metabolism. Glucose in excess of the immediate energy requirements is
converted into fatty acids and triglycerides and stored either as glycogen in the liver and skeletal
muscle or as adipose tissue.
Despite their biochemical similarities, starches vary greatly in their digestibility. Certain non-
cereal starches (potatoes and legumes) are more complex and more difficult to digest than cereal
starches. In addition, certain naturally occurring food starches, such as banana starch and 2 to 5%
of potato starch, are resistant to amylase [8]. The ingestion of easily digested highly processed,
purified, or refined starches results in a more rapid production and absorption of glucose. The
relative amount of glucose released during digestion of carbohydrate is the glycemic load, and
complex starches have a relatively low glycemic load compared to refined carbohydrates such as
sugar. The slowing of starch digestion based on the type of starch can be exploited clinically by
adding complex carbohydrate, such as fiber, to more refined carbohydrate to slow glucose absorption
and blunt the insulin response to a sharp glucose peak. Also, it has been noted that the addition of
fiber to carbohydrates is more effective in reducing the postprandial glucose curve (as measured
by the glycemic index) when incorporated into the food rather than when taken before the food [6].
It has also been noted that the pancreas continuously produces amylase in response to nutrient
ingestion [7] and that the pancreas secretes more amylase than is necessary to digest a particular
carbohydrate nutrient load [8]. Absolute levels of amylase vary with age, sex, and the health of
the pancreas, and the levels are found to be higher in the elderly, especially in women in the
third and fourth decades of life when compared with men; however, starch digestion is not
affected by pancreatic disease unless the amylase output is significantly decreased to a very low
level [9]. It has been noted that only 4% of the produced alpha-amylase is required to digest
large amounts of starch and, conversely, that greater than 96% of pancreatic alpha-amylase has
to be blocked to induce carbohydrate malabsorption and the resulting presence of undigested
carbohydrate in the gut [7].
Carbohydrates not digested and absorbed in the small bowel are fermented by the symbiotic
bacteria in the colon [10]. It is felt that anaerobic bacteria (such as bacteroides and clostridia) are
responsible for this fermentation because the addition of metronidazole can reduce the response to
a colonic sucrose load [11]. This fermentation process produces CO2 gas, short-chain fatty acids,
organic acids, and hydrogen gas [12], which can be measured by a standard hydrogen breath test
(H2BT).
CARBOHYDRATE DIGESTION INHIBITORS

(STARCH BLOCKERS): MECHANISM OF ACTION
Blocking alpha-amylase may prevent or delay the digestion of complex carbohydrates, as the
breakdown of starch into simple sugars cannot proceed without amylase. The end result of blocking
this enzyme may be a decrease in the glucose absorption rate or in the total number of calories
absorbed from carbohydrate-containing food. One strategy consists of mixing starchy staples (rice,
wheat, corn, etc.) with legumes (beans, lentils, etc.). Legumes have been shown to safely inactivate
intraduodenal alpha-amylase and reduce starch digestion. A very general study on the use of various
bean flours to lower the glycemic index of starch foods was published by Layer et al. in 1985 [13].
It found that the white kidney bean (Phaseolus vulgaris) extract had the highest salivary and
pancreatic alpha-amylase inhibition rate among legumes. The literature also indicates that the
preparation and level of grinding of bean flours have been found to affect postprandial glycemic
and insulin levels to an important degree.
White kidney bean extracts bind to alpha-amylase in noncompetitive fashion, optimally at a
pH of 5.5, forming a 1:1 molar complex [14]. Similar binding can be seen at neutral pH, as well.
White bean extracts are not expected to have any activity on the brush-border enzyme maltose/glu-
coamylase as evidenced by an in vitro study [12]. In addition to the glucose- and calorie-reducing
potential, alpha-amylase inhibitors may contribute to the control of hunger and appetite by other
mechanisms:
• Satiety — Satiety might be induced through two indirect mechanisms of action. The
white kidney bean has been shown to decrease gastric inhibitory polypeptide, which
decreases stomach motility. In addition, increasing the delivery of carbohydrates to the
ileum (small intestine) may itself cause a slowing of gastric motility [15,16].
• Insulin — By decreasing the effective glycemic index of a particular food, the alpha-
amylase inhibitor may decrease the magnitude of the insulin response, which in turn
decreases hunger.
• Leptin – Elevated triglycerides induce leptin resistance and elevate leptin levels. Lowering
triglycerides reduces leptin levels, which may induce the desired anorectic effect by
increasing leptin transport across the blood–brain barrier [17]. Alpha-amylase inhibitors
may be effective in lowering triglycerides [18], and as such they may increase the
effectiveness of leptin.
It must be noted that, according to the literature, the coingestion of saturated and monounsaturated
fats with starches raises the blood glucose response area. The insulin rise is reported by Rasmusen
et al. [67] to be significant for the coingestion of butter but less for olive oil. Reportedly, the
triacylglycerol response also increased in a dose-dependent manner with the fat content of the
meals, regardless of the type of fat. The mechanism by which saturated fatty acids increase insulin
release is not precisely known but so far appears to involve physiological mechanisms other than
that of alpha-amylase inhibition [19].
METHODS TO TEST FOR CARBOHYDRATE MALABSORPTION

Hydrogen Breath Testing
Hydrogen breath testing is an accepted method of determining carbohydrate malabsorption [20–22].

When determining carbohydrate malabsorption, orocecal transit time can be measured as well [22].
As colonic bacteria ferment carbohydrates into organic acids, CO2, and H2, a percentage of these
gaseous byproducts are absorbed into the portal blood stream and are subsequently expired through
the lungs. The lactulose H2BT is a valid measurement of the mean amount of starch that is metab-
olized in the colon by the bacterial fermentation process [23]. The large individual variations in the
amount of H2 produced are due to the large individual variations in the composition of the colonic
bacterial flora. Determining baseline levels of H2 is not as important as measuring how much the
H2 levels rise after lactulose reaches the colon. The sensitivity and specificity of the H2BT for
detecting carbohydrate malabsorption with 10 g of carbohydrate approach 100% when the increase
from baseline is considered positive at 15 ppm rather than at the traditional range of 20 ppm [21].
Approximately 15% of normal healthy subjects have colonic bacteria that do not produce
hydrogen, even in response to carbohydrate malabsorption [24]. It is possible that starch malab-
sorption is underestimated in methane producers as well [25]. In addition, methane producers have
more varied excretory patterns than non-methane producers [26]. Another study, however, demon-
strated that methane production was elevated in the presence of carbohydrate malabsorption even
when breath H2 did not change [27]. Population-based differences in the H2BT have been observed,
as well; for example, the percentage of the general population who fail to respond to a lactulose
challenge is 2% in the United States and as high as 20% in Israel. This may be due to dietary
differences [28].
Ileal Fluids
Ileal intubation or fluid from subjects with ileostomies is the most reliable source for identifying
carbohydrate malabsorption in the small bowel [10]. Data suggest, however, that the H2BT can
detect the amount of carbohydrates that enter the colon almost as well as directly measuring ileal
effluent in subjects with ileostomies [29].
Blood Tests
Several blood tests have been utilized to measure carbohydrate digestion or malabsorption. These
are indirect markers, as none of them directly measures carbohydrates. In addition, some blood
markers may be important in determining hunger and feeding behaviors that may be altered by the
white kidney bean or similar substances.
Glucagon-Like Peptide 1
Glucagon-like peptide 1 (GLP-1) is secreted after nutrient ingestion and promotes glucagonostatic
activity as part of the enteroinsular axis. A study with acarbose, an alpha-glucosidase inhibitor,
resulted in prolonged GLP-1 release in normal subjects [30].
Glucagon
Glucagon is a counter-regulatory hormone to insulin [31] that has been shown to be suppressed by
acarbose [30].
Gastric Inhibitory Polypeptide
Gastric inhibitory polypeptide (GIP) initiates stimulation of glucose-dependent insulin secretion.

This hormone has been shown to be suppressed by acarbose [30] and by a partially purified white
bean alpha-amylase inhibitor [16].
Serial Serum Acetate
Serum acetate levels have not been shown to be an effective measurement of carbohydrate malab-
sorption [10].
C-Peptide
C-Peptide is elevated in the presence of large glucose loads [16].
Stool Tests for Carbohydrate Malabsorption
Although bomb calorimeter tests in a small number of subjects showed no difference in fecal calorie
counts between white bean alpha-amylase inhibitor and placebo, this test has some limitations. If
undigested carbohydrates were to be delivered to the colon, a portion of those calories may be
fermented into gas. This would be identified by the H2BT but not by the bomb calorimeter.
Urine Tests for Carbohydrate Malabsorption
Urine ketones are present in the absence of digested carbohydrates. They may be a helpful marker
for demonstrating the absence of carbohydrate absorption.
CLINICAL STUDIES FOR CARBOHYDRATE

DIGESTION AND ABSORPTION
The studies summarized below show the evolution of data from low-dose and unpurified white
bean products through partially purified products to highly purified white bean extracts. It appears
that these products may have a dose- and purification-dependent effect. At the same time, a threshold
level of greater than 90% inhibition of amylase is required before any carbohydrate malabsorption
is seen. Below this threshold, incomplete inhibition of amylase may not have any significant effect
on carbohydrate malabsorption [32].
UNPURIFIED WHITE BEAN PRODUCTS

The earliest studies of white-bean-based amylase inhibitors utilized crude bean extracts and failed
to show effectiveness based on either fecal calorie excretion [8] or plasma glucose and insulin
responses [12].
Carbolite Starch Blocker Study (1982)
In 1982, the New England Journal of Medicine published a crossover study that tested the ability
of a crude extract to inhibit the digestion of a high-carbohydrate meal. First, the GI tracts of five
healthy subjects between the ages of 25 and 34 were cleansed using an electrolyte solution [8].
The subjects were given a standardized meal consisting of 100 g of spaghetti and 50 g of white
bread along with 1000 mg of the Carbolite starch blocker or an identical-looking placebo. They
then ate a test meal consisting of 100 g of starch which had been labeled with 51CrCl3, a non-
absorbable marker. The subjects each took a 500-mg tablet of the test product or placebo, ate half
of the meal, and then took the second tablet. Subjects then fasted for 14 hours. Stools were collected
and a bomb calorimeter was used to measure fecal calories. No differences were found in fecal
calorie excretion between those who were given the placebo and those who were administered the
test product. The authors admit that some calories may have been converted to gas and that the
calories that could not be accounted for [8] would have been better identified by the H2BT and not
by the bomb calorimeter [7].
Unpublished North Dakota State Study (1982)
Prior to a test meal, seven subjects received 500 mg of an unpurified starch blocker or a placebo
in a crossover study to test the short-term effect of the starch blocker on glucose levels. The test
meal consisted of instant mashed potatoes in the quantity of 1 g of starch per kg of ideal body
weight. Blood glucose levels were followed at 30, 60, 90, 120, and 180 minutes postprandially.
No adverse events were seen. The glucose levels of the treated subjects were significantly lower
at 60 and 90 minutes. The study reported a 38% reduction in blood glucose with treatment and
concluded that the starch-block meal resulted in 38% less starch digestion compared to the control
meal [7]. This conclusion is not supported by the evidence presented.
Commercial Alpha-Amylase Inhibitor Study (1983)
Six healthy adult males were given a commercial alpha-amylase inhibitor or a placebo in a crossover
trial with a 7-day washout between trials. The authors report no effect on the postprandial glucose,
insulin, or H2BT after a standardized starch-containing meal [33]. The amylase inhibitor was crushed
and mixed in with the meal rather than given as a capsule. It was postulated that this delivery
mechanism may have subjected the active ingredient to stomach enzymes, thereby inactivating the
ingredient [7].
13 C-Enriched Starch Tracer Study (1983)
Five obese but otherwise healthy women were sequentially given three meals of corn flour enriched
with 13C. They received one of two different starch blockers (Calorex brand or Starchex brand) or
a placebo 10 minutes before each meal. Detailed descriptions of the starch blockers were not
provided in the Materials and Methods sections to characterize the differences between the two
active products. Subjects were followed for 6 hours after each meal, and no differences were
observed in the rate of breath 13CO2 production, insulin, or glucose between the groups [34].
American Journal of Clinical Nutrition Study (1983)
Hollenbeck et al. [12] reported in 1983 in the American Journal of Nutrition the results of a
randomized, double-blind, placebo-controlled crossover study using the hydrogen breath test to
determine the efficacy of a crude bean extract (Pacific International Laboratories). In this study,
six healthy subjects were given a standardized test meal. (Eight subjects were screened for the
study, but two were dropped from the final analysis because one had been taking antibiotics and
one did not respond to the lactulose breath test.) The meal consisted of 686 kcal, of which 55%
was carbohydrate (50% starch and 50% sucrose). The subjects received either 500 mg of Phaseola-
min 2250® (white kidney bean) or a placebo with their meals and then had hydrogen breath tests
every 30 minutes for 300 minutes. The study found no differences between the treated and placebo
groups; however, it is noted that only 198 calories came from starch. The majority (71%) of the
carbohydrate load was in the form of sucrose, which is not affected by alpha-amylase; thus, this
may not have been an appropriate test meal. Glucose levels were also not found to be statistically
significant different between the treated and placebo groups.
PARTIALLY PURIFIED WHITE BEAN EXTRACT STUDIES

A research group from the Mayo Clinic developed a partially purified white bean product and
published a series of studies on this product in the 1980s. This purified bean-derived amylase
inhibitor has been shown to significantly reduce duodenal, jejunal, and ileal amylase activity by
more than 95% for 1 to 2 hours after ingestion. It has also been shown to increase postprandial
delivery of total carbohydrates (including glucose polymers) to the distal small bowel as evidenced
by increased breath hydrogen levels. In addition, this bean extract has been documented to reduce
early postprandial plasma glucose rise by 85% and to eliminate the late postprandial glucose fall
to below fasting levels. It has also been shown to reduce the postprandial plasma insulin levels [15].
Partially Purified White Bean Extract (1984)

A study of seven healthy, non-obese subjects who underwent gastroduodenal intubation demon-
strated that the increasing concentrations of a partially purified white bean extract caused the
inhibition of amylase in a dose-dependent manner. Patients were subjected to continuous infusions
of amino acids designed to stimulate the pancreatic secretions. Simultaneously, a continuous
aspiration of gastric and duodenal contents was also performed following instillation of the white
bean extract. Amylase activity was measured from these aspirations, and this study demonstrated
a 94%, 99%, and 99.5% inhibition of amylase at 2.0-, 3.5-, and 5.0-mg/mL infusions, respectively,
of the amylase inhibitor. Despite this almost complete inhibition, H2 breath testing did not change
for up to 4 hours after the infusion [14].

Four healthy, non-obese volunteers were intubated with an oroileal tube prior to ingesting 50 g of
rice starch with placebo or 5 g of white bean extract or 10 g of white bean extract. Part of the
placebo and white bean extract dose were given at the beginning of the meal to inactivate the alpha-
amylase present in the intestinal lumen before the meal. The remainder of the dosage was delivered
during the middle of the meal. The white bean extract significantly reduced duodenal, jejunal, and
ileal intraluminal amylase activity by more than 95% in as soon as 15 minutes and for as long as
2 hours. It also increased the delivery of carbohydrates to the small bowel by 22 to 24% (as
measured by oroileal tube aspiration) and increased the breath H2 concentrations significantly
between 30 and 90 minutes after the meal. Additionally, it significantly lowered the glucose, insulin,
C-peptide, and gastric inhibitory polypeptide levels [15].

Eight healthy subjects with a positive breath H2 test to lactulose (defined as >10 ppm increase over
baseline) were given 2.0 g or 2.9 g of partially purified white bean extract mixed in water with a
standardized meal. The placebo and the 2.0-g dose did not result in any change in the H2BT. The
2.9-g dose showed a significant increase in the H2BT between 45 and 180 minutes after the meal.
It was estimated that less than 2% of the meal was malabsorbed with the 2.0-g dose and that 18%
of the meal was malabsorbed with the 2.9-g dose. At 2.9 g, glucose, C-peptide, and GIP were also
significantly decreased [32].

Six type 2 diabetics were given between 4 and 6 g of partially purified white bean extract with
standardized meals (55% carbohydrate, 25% fat, and 20% protein, with 5 g fiber per day) for 3
weeks. The inhibitor significantly reduced postprandial plasma glucose, C-peptide, insulin, and
GIP levels at 7, 14, and 21 days. H2BT was significantly increased as well at 7, 14, and 21 days.
In addition, the delivery of increased amounts of carbohydrates to the small intestine caused a
decrease in GIP, which decreases insulin levels and slows gastric emptying [16]. A significant
increase in diarrhea was reported during the first week of inhibitor use which spontaneously resolved
even though the serum and breath markers still demonstrated the ongoing effectiveness of the
product to induce carbohydrate malabsorption. It was felt that this was due to changes in the
metabolism of carbohydrates by the colonic flora [16]. It was concluded as well that the overall
increased carbohydrate load to the colon caused the colonic bacteria to alter their carbohydrate
metabolism and to start producing metabolites other than short-chain fatty acids and lactic acid.
This more efficient digestion reduced the severity of the initial diarrhea symptoms seen with the
carbohydrate malabsorption [16].

After intubation with an oroileal tube, 18 healthy subjects were given a test meal, immediately
followed by infusion of the amylase inhibitor or placebo into the stomach. The amylase inhibitor
significantly reduced the absorption of complex carbohydrates from the terminal ileum. In addition,
the presence of carbohydrates in the ileum slowed gastric emptying. Significantly decreased con-
centrations of gastric inhibitory polypeptide and neurotensin were seen in the active treatment group
along with significantly decreased amounts of peptide YY [35].
NON-KIDNEY-BEAN ALPHA-AMYLASE INHIBITORS

Two non-kidney-bean extracts have been studied for amylase inhibitory effects: tendamistat (HOE
467) and a wheat-based amylase inhibitor (WAI). Tendamistat is a proteinaceous alpha-amylase
inhibitor that appears to induce antibodies that bind to porcine amylase [36]. Wheat amylase
inhibitors are a byproduct of gluten and wheat starch production, and intraduodenal animal studies
have shown that 4 mg/mL delivered to the duodenum can inhibit 90% of intraluminal amylase [37].
Tendamistat (HOE 467) Study (1983)

In 1983, six subjects participated in a randomized three-way crossover study in which they received
200 g of white bread followed sequentially by a placebo or 100 or 200 mg of tendamistat (HOE
467) [13]. The subjects’ blood was drawn serially for 3 hours after each intervention. Plasma
glucose concentrations were measured as an indirect marker of carbohydrate digestion and absorp-
tion. Both tendamistat dosages showed significant differences in plasma glucose compared with
the placebo. The difference between the 100-mg and 200-mg dosages was not significant.
Tendamistat (HOE 467) Studies (1984)

Tendamistat (HOE 467) was also utilized in two studies published by the same authors in 1984.
In the first study, nine subjects participated in a double-blind crossover study comparing the effect
of tendamistat, 5 g of guar, or a placebo when given with a 100-g maize meal (consisting of 85.5
g of starch). Serial blood draws were taken up to 3 hours after the meal to measure serum glucose
levels. The area under the curve for the treatment group was significantly decreased compared with
both the guar and the placebo groups [13]. The second study enrolled six subjects in a double-
blind crossover study in which escalating dosages of tendamistat (12.5 mg, 25 mg, and 50 mg) or
placebo were given along with a 100-g maize meal (consisting of 85.5 g of starch). Again, serial
serum glucose levels were drawn for 3 hours after each meal. The results showed statistically
significant reductions in glucose levels in all of the active groups compared with the placebo group.
The significance of the differences between dosages was not reported. One subject in the 25-mg
tendamistat group reported loose stools, but no other adverse events were reported [38].
Wheat Alpha-Amylase Inhibitor (1998)

Twelve subjects were given a wheat alpha-amylase inhibitor along with a standardized breakfast
consisting of 55% carbohydrates. The study found that the wheat amylase inhibitor delayed car-
bohydrate absorption and reduced peak postprandial plasma glucose levels in 10 of 12 subjects (p
< 0.05). Breath H2 levels were increased in 11 of 12 subjects (p = 0.02), and increases were generally
less than 20 ppm. Significant reductions were also seen in GIP levels (p < 0.05). Significant increases
were seen in peptide YY levels (p < 0.05), as well as a trend toward increases in human pancreatic
polypeptide levels (p = 0.07). There were no reports of diarrhea or bloating [37].
PHASE 2® WHITE BEAN EXTRACT STUDIES FOR REDUCING GLUCOSE EXCURSION

The following studies have all been performed on a proprietary white bean extract known as Phase
2®. The Phase 2® brand bean-extract is a water-extract of the common white bean (Phaseolus
vulgaris), which has been shown in vitro to inhibit the digestive enzyme alpha-amylase [8,12,15,39].
Phase 2® was previously sold as Phaseolamin 2250®. This product is purported to have a higher
concentration of the active component of the white bean, and the manufacturer claims that it is
different than the unpurified or partially purified white bean products described above.
University of Scranton (September 2001)

In 2001, ten healthy (non-diabetic, non-obese) subjects participated in a randomized, double-blind,
crossover, single-meal study comparing Phase 2® with a placebo. After an overnight fast, all subjects
were given a standardized meal containing 60 g of carbohydrates (white bread) with either 1500
mg of Phase 2® or a placebo. Plasma glucose was then measured every 30 minutes for 4 hours.
After 1 week, the subjects crossed over and repeated the procedure with the opposite intervention.
The Phase 2® group demonstrated lower average glucose levels at all time points after baseline and
showed an average 57% reduction in the area under the curve compared with the placebo group.
No adverse events were observed, and statistical analysis between groups was not provided [40].
University of Scranton (November 2001)

The single-meal study was repeated in 2001 with ten subjects who were required to remain sedentary
during the active portion of the study to reduce variability in orocecal transit time. The study was
modified to include serial blood draws for only 2 hours instead of 4 hours. Two of the ten subjects
did not complete the study, and four were excluded because they were classified as “poor/non-
absorbers as the area under the glucose-time curve was negative,” a potential source of bias for
this study. The results of this study were therefore limited to four known responders. The dose of
the Phase 2® remained at 1500 mg, and the 60-g carbohydrate content of the meal was from white
bread. The Phase 2® group did not demonstrate statistically significant differences at any individual
time point; however, the area under the curve was calculated to be 85% lower than the placebo
curve (p < 0.05) for a small group of responders [41].
University of Scranton (May 2002)

Seven subjects participated in a crossover study comparing 750 mg of Phase 2® with a placebo
given after a standardized meal containing 64 g of carbohydrates (including 6 g of dietary fiber
and 19 g of sugars) [42]. Serial plasma glucose levels were taken for 2 hours after the consumption
of the meal and Phase 2® or the placebo. Glucose levels were lower on average for subjects at all
time points in the Phase 2® group except at 20 minutes, where the values were equivalent. The
overall area under the curve was 28% lower in the Phase 2® group compared with placebo. Statistical
significance was not reached for any time point or for the area under the curve comparison,
presumably because the small number of subjects did not provide enough statistical power to
discriminate between groups.
University of Scranton (September 2003)

A three-arm crossover study was performed on 20 subjects comparing 515 mg of Phase 2® with 750
mg of Phase 2® (in powder form mixed in with the food) and with placebo [43]. The standardized
meal was the same as for the 2002 study (64 g of carbohydrates, including 6 g dietary fiber and 19
g sugars). Serial glucose levels were measured every 10 minutes for 60 minutes using the OneTouch®
Ultra blood glucose monitoring system. The 750-mg Phase 2® group demonstrated significantly
lower blood glucose levels at 10, 20, and 30 minutes (p < 0.01) compared with both the 515-mg
dose and with the placebo. The area under the curve was also lower in the 750-mg Phase 2® group
compared with the two other groups but did not reach statistical significance (p < 0.1). The 515-mg
Phase 2® group also showed significantly lower blood glucose at 10, 20 (p < 0.01), and 30 (p <
0.05) minutes compared with placebo.
Glycemic Index Lowering Study (2005)

An open-label, six-arm crossover study was performed following the Food and Agriculture Organi-
zation methodology for glycemic index (GI) testing. The GI of white bread was tested without and
with the addition of Phase 2® capsules and powder, each in dosages of 1500 mg, 2000 mg, and 3000
mg. Reductions were seen in the GI of white bread at all dosages and formulations except the
1500-mg capsule dose. The only dose and formulation combination to reach statistical significance
was the 3000-mg powder dose, which demonstrated a reduction of 20.23 or 39.07% (p = 0.0228) [44].
CARBOHYDRATE DIGESTION INHIBITOR

STUDIES FOR WEIGHT LOSS
WHITE KIDNEY BEAN EXTRACTS: PARTIALLY PURIFIED
Norwegian Study (2000)
One of the first studies on the use of a white kidney bean extract for weight loss was conducted
in Norway and published in 2000 [45]. This randomized, double-blind, placebo-controlled trial
utilized a test product containing a proprietary blend of 200 mg of a white kidney bean extract,
200 mg of inulin (from chicory root), and 50 mg of Garcinia cambogia. Tablets were described
as weighing 650 mg each, but the ingredients accounting for the remaining 200 mg were not
described. Forty overweight (but otherwise healthy) subjects with BMIs between 27.5 and 39 were
randomized and instructed to take 2 tablets of the test product after all 3 meals for 12 weeks.
Subjects were also instructed to follow a 1200-kcal/day, low-fat diet. A total of 7 subjects dropped
out of the study (6 in the placebo arm, 1 in the active arm); however, all of these subjects were
included in an intent-to-treat analysis. After 12 weeks, the active group lost an average of 3.5 kg
(7.7 lb; p = 0.001), and the placebo group lost 1.3 kg (2.86 lb; p > 0.05). The BMIs decreased by
1.3 kg/m2 (p = 0.01) in the active group and by 0.5 (p > 0.05) in the placebo group. Percent body
fat (as measured by bioelectrical impedance) decreased by 2.3% (p = 0.01) in the active group and
by 0.7% (p > 0.05) in the placebo. Between-group analysis was not provided for weight loss, BMI,
or percent body fat. No adverse events were reported in any group.
PHASE 2® WHITE BEAN EXTRACT CLINICAL STUDIES FOR WEIGHT LOSS

See Table 22.1.
Italian Study (2001)

A European study utilizing the Phase 2® product for weight reduction was conducted in Italy in
2001 [46]. Sixty overweight subjects (5 to 10 kg over ideal body weight) participated in a random-
ized, double-blind, placebo-controlled clinical trial consisting of a 30-day run-in phase followed
290
TABLE 22.1
Phase 2® Human Clinical Studies
Average Weekly
Number of Duration Phase 2® Total Weight Weight Loss
Study Year Subjects (weeks) Dosage Group Loss (lb) (lb/week) Statistical Significance
Italian study 2001 N = 60 4 500 mg 1×/day Active 6.45 1.61 p < 0.001, between group statistical analysis
Placebo 0.766 0.19
Northridge study 2002 N = 27 8 1500 mg 2×/day Active 3.79 0.47 p > 0.05, between group statistical analysis
Placebo 1.65 0.21
TheraSlim™ study 2003 N = 60 12 1000 mg 2×/day Active –0.96 –0.08 p = 0.4003, between group statistical analysis
Placebo 0.27 0.02
SCUHS study 2003 N = 25 4 1000 mg 2×/day Active 6.0 1.5 p < 0.0001, compared with baseline
Placebo 4.7 1.175 p < 0.0001, compared with baseline
p > 0.05, between group statistical analysis
Leiner study 2003 N = 60 12 1000 mg 3×/day Active 6.9 0.575 p = 0.029, between group statistical analysis
Placebo –0.8 –0.06
by a 30-day active phase. Subjects were between the ages of 20 and 45 and were 5 to 15 kg
overweight; their weight had been stable during the preceding 6 months. During the run-in phase,
subjects were educated to consume 2000 to 2200 calories/day with the complex carbohydrate intake
concentrated in one of the two main meals of the day. In addition, subjects were asked not to
change their current activity or exercise. Subjects received either 444.8 mg of Phase 2® or a placebo
before the main carbohydrate-containing meal of the day. The active group lost an average of 2.933
kg (6.45 lb) in 30 days compared with an average of 0.348 kg (0.766 lb) in the placebo group (p
< 0.001). Body composition was measured with bioelectrical impedance. The active group dem-
onstrated a 10.45% reduction in body fat compared with a 0.16% reduction in the placebo group
(p < 0.001). Waist and hip circumferences measured in a standard way showed the same pattern
as well. The active group demonstrated 2.93-cm and 1.48-cm reductions, respectively, compared
with 0.46-cm and 0.11-cm reductions in the placebo group (p < 0.001). No adverse events were
reported.
Northridge Hospital Study (2002)
A 2002 randomized, double-blind, placebo-controlled study of 39 obese subjects (BMIs, 30 to

43) were randomly allocated to receive either 1500 mg of Phase 2® or an identical placebo [47].
Twenty-seven subjects completed the study (14 active and 13 placebo). Subjects were instructed
to take the test product with at least 8 oz. of water at lunch and dinner each day for 8 weeks.
Subjects were also instructed to consume a controlled high-fiber/low-fat diet at the beginning of
the study that provided 100 to 200 g of complex carbohydrate intake per day. Subjects were also
directed to eat the majority of their carbohydrates during lunch and dinner, as those were the
meals at which the Phase 2® or placebo were taken. Carbohydrate intake was recommended for
the subjects on the basis of estimated daily maintenance carbohydrate requirements, and dietary
compliance was reinforced at return visits. The study results at 8 weeks demonstrated that the
active group lost an average of 3.79 lb (an average of 0.47 lb/wk) compared with the placebo
group’s average loss of 1.65 lb (an average of 0.21 lb/wk). The difference was not statistically
significant (two-tailed p = 0.35). Similar trends were seen at 2, 4, and 6 weeks. Triglyceride levels
in the Phase 2® group were reduced by an average of 26.3 mg/dL, compared with the 8.2-mg/dL
drop seen in the placebo group (p = 0.07). The trend favors treatment, but results did not achieve
statistical significance. Several secondary outcomes were measured during the study, including
body fat percentage, waist and hip circumferences, energy level, hunger, appetite, HbA1c, and total
cholesterol. For each of these secondary measures, no clinically or statistically significant differ-
ences were identified between the active and the placebo group. No adverse events occurred that
were felt to be due to the active product. Abdominal pain, bloating, and gas were experienced by
one placebo subject, and one active group subject complained of an increased incidence of tension
headaches while in the active phase of the trial. Safety data, including serum markers of electro-
lytes, kidney, and liver function, were obtained at time 0 and at 8 weeks. No clinically significant
changes were identified.
Leiner Softchew Study (2003)
An unpublished 12 week study of Phase 2® in a soft-chew formulation was completed in 2003

[48]. In this randomized, double-blind, placebo-controlled trial of 60 overweight individuals, sub-
jects were given 1000 mg of Phase 2® before each meal (6 500-mg soft chews per day). Subjects
received education on proper eating habits and the importance of exercise but were not given a
specific diet or exercise regimen. The results of this study demonstrated statistically significant
weight reduction in the active group compared with placebo at weeks 6 (p = 0.013), 8 (p = 0.031),
and 12 (p = 0.029). The amount of weight lost by the active group at 12 weeks was 6.9 lb (average
of 0.575 lb/wk), while the placebo group gained 0.8 lb. No adverse events were reported.
TheraSlim™ Study (2003)
A 24-week randomized, double-blind, placebo-controlled, crossover to open-label study was per-

formed in 2003 [49]. Sixty overweight and obese subjects were randomized to receive either 1500
mg of TheraSlim™ (1000 mg of Phase 2® and 500 mg of fennel [Foeniculum vulgare] seed powder)
or a placebo with lunch and dinner. After 12 weeks, all subjects were continued on TheraSlim™
in an open-label fashion and followed for another 12 weeks. Subjects were asked to eat a diet in
which lunch and dinner contained 100 to 200 g of carbohydrates. The primary outcomes changed
from baseline in weight, BMI, blood pressure, cholesterol, insulin, and glucose. Data analysis was
performed at the end of the 12-week, randomized, placebo-controlled trial, as well as for each of
the arms (active and placebo) as they crossed over to the open-label active arm for an additional
12 weeks.
During the randomized, placebo-controlled portion of the trial, none of the primary outcomes
demonstrated significant differences from placebo; however, both total cholesterol (–10.7 mg/dL
vs. +1.6154 mg/dL; p = 0.0693) and low-density lipoprotein (LDL) cholesterol (–10.22 mg/dL vs.
+1.5 mg/dL; p = 0.0719) showed positive trends in favor of the active product. Exploratory analysis
was performed by stratifying the groups by BMI and by compliance. In this analysis, the group
stratified as medium BMI demonstrated statistically significant weight loss compared with placebo
(–4.825 lb vs. +1.78 lb; p = 0.0341).
The active group received the product in a blinded fashion for 12 weeks then in an open-label
fashion for an additional 12 weeks. At the end of 24 weeks, this group demonstrated a significant
reduction in both systolic (–4.9 mmHg; p = 0.0403) and diastolic (–6.4 mmHg; p = 0.0002) pressure
compared with their own baseline. The placebo group that crossed over to receive the active product
during the second 12-week study period demonstrated a significant reduction in cholesterol (–10.4
mg/dL vs. +1.6154 mg/dL; p = 0.0396) and a trend toward significance in the reduction of LDL
(–8.115 mg/dL vs. +1.5 mg/dL; p = 0.066) in favor of the active product. No adverse events were
reported after 24 weeks of usage [49].
SCUHS Study (2004)

In 2003, 27 overweight subjects (BMIs, 25 to 30) participated in a 30-day randomized, double-
blind, placebo-controlled trial of 1000 mg of Phase 2 ® or an identical placebo twice a day [50].
Subjects were also given nutritional guidelines to standardize their caloric intake at 1800
kcal/day. Breakfast and lunch were provided to increase compliance. In addition, subjects met
with a personal trainer to establish an exercise program and each had a counseling session with
a behavioral psychologist to identify psychological barriers to weight loss. Twenty-five subjects
completed the study, and no adverse events were reported. At 4 weeks, the active group had
lost 6.0 lb and the placebo group 4.7 lb. Although both groups lost significant weight compared
with their baseline (active, p = 0.0002; placebo, p = 0.0016), between-group analysis was not
significant (p = 0.4235). For exploratory analysis, subjects were stratified by dietary carbohy-
drate intake. In this analysis, the tertile that took in the most carbohydrates demonstrated
significantly greater loss of body weight compared with the placebo group (8.7 lb vs. 1.7 lb;
p = 0.0412). The same tertile demonstrated a significantly greater loss in inches around the
waist (3.3 in. for the Phase 2® group and 1.3 in. for the placebo group; p = 0.01). Additional
parameters were analyzed for changes from baseline. These parameters were stratified by BMI,
total carbohydrate intake, and net carbohydrate intake, as well. None of these parameters,
including hip size, triglycerides, fasting glucose, total cholesterol, appetite control, hunger,
energy level, and percent body fat, demonstrated any significant differences between groups or
from baseline to the end of the study.
SAFETY
Starch is an inactive solute and therefore does not dissolve, absorb, or react with nutrients such as
vitamins or minerals. There is no evidence nor any reason to suspect that preventing the absorption
of starch affects the absorption of any other nutrients. It is theoretically possible that the additional
bulk of unabsorbed starch, along with the accompanying water, will pass through the gastrointestinal
tract and that it may carry with it some undigested nutrients or pills [11]. This has never been
demonstrated, but the theoretical possibility should be kept in mind as physicians consider recom-
mending this type of product.
Animal studies on acute and chronic toxicity have been performed on Phase 2® [51] and have
not demonstrated any histological or laboratory toxicities. In one study of an alpha-amylase inhibitor
based on partially purified white bean [16], there was a significant increase in diarrhea during the
first week. The diarrhea spontaneously resolved, even though the serum and breath markers still
demonstrated the ongoing effectiveness of the product to induce carbohydrate malabsorption. It
was believed that this was due to changes in the metabolism of carbohydrates by the colonic flora.
Six recent human studies utilizing carbohydrate digestion inhibitors for weight loss (n = 286)
revealed no side effects or toxicities. Anecdotal evidence [52,53] of an increase in gas and bloating
has been reported at supratherapeutic doses (three times recommended dose) of the product, but
never in a controlled clinical study.
Acarbose (Precose™) is a prescription alpha-glucosidase inhibitor approved for use in the
United States. Although no documentation suggests that acarbose and Phase 2® have any structural
or other similarities other than a similar mechanism of action, it is relevant to note that 62 incidents
(out of 3 million patient years) of liver enzyme abnormalities have been reported in diabetic patients
treated with acarbose [54]. In addition, acarbose has been shown to affect digoxin bioavailability
but not the absorption or disposition of sulfonylureas or metformin [55]. Acarbose does not increase
the risk of hypoglycemia, even in the fasted state. If side effects such as flatulence, diarrhea, or
abdominal discomfort occur, they generally diminish in frequency and intensity after the first few
weeks of therapy. The safety and effectiveness of acarbose in pediatric patients have not been
established [55].
Alpha-glucosidase inhibitors cause side effects such as diarrhea by increasing the amount of
short-chain polymers (disaccharides and trisaccharides), which accumulate in the lumen of the gut.
These polymers attract a great deal of water and cause an osmotic diarrhea. Alpha-amylase inhib-
itors, by contrast, cause the accumulation of longer chain carbohydrates, and there are fewer of
them compared with the number of short-chain polymers; therefore, they do not cause a similar
osmotic load and produce less diarrhea [32]. In addition, without the osmotic load, colonic bacteria
may be better able to metabolize large quantities of starch without producing diarrhea [16].
DISCUSSION
The current data on carbohydrate digestion inhibitors in general and alpha-amylase inhibitors in
particular demonstrate several trends. Animal and human data do not show any specific adverse-
event profiles attributed to the clinical use of these products. In addition, data from preliminary
single-meal studies suggest alpha-amylase inhibitors might be effective in decreasing the absorption
of glucose from a carbohydrate-containing meal or might increase the time period over which a
single load of carbohydrates is digested. These changes form the basis for the hypothesized
mechanism of action of alpha-amylase inhibitors in reducing the glycemic index. The benefits of
reducing the effective glycemic index of food are apparent in the diabetic population [56], as well
as in preventing diabetes [57,58] and reducing the risk of cardiovascular disease in women [59].
The potential role of a reduced glycemic index diet in weight control is intriguing [60–66] and
may account for part of the mechanism of action for the role of carbohydrate digestion inhibitors
in weight management. We previously stated that there are no substitutes for caloric restriction and
exercise in the treatment of obesity. Carbohydrate digestion inhibitors may only play an adjunctive
role in the management of glucose regulation and weight loss. Their best use may be for patients
who are trying to adhere to low-carbohydrate diets but who occasionally crave complex-carbohy-
drate-rich foods. These products may enable such patients to decrease the effective glycemic index
of these foods, which may contribute to weight management.
CONCLUSION
The dataset for carbohydrate digestion inhibition in general and alpha-amylase inhibition in par-
ticular remains promising but preliminary. Future directions in research should include studies with
larger numbers of subjects and should be run for longer periods of time. In addition, as the datasets
become available from the studies currently underway, a meta-analysis may be appropriate in the
future. These steps are necessary to confirm the glucose and weight management claims for this
potentially therapeutic product category.
DISCLOSURES
JU discloses that he has ongoing research support from Pharmachem Laboratories and has provided
consulting services to Pharmachem Laboratories. The authors do not have any financial interest in
Pharmachem Laboratories, the Phase 2® product, or any other commercial product.
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23 Prevention
Vegetarian Diets in the
and Treatment
of Obesity
Kathryn T. Knecht, Hien T. Bui,
Don K. Tran, and Joan Sabaté
CONTENTS
Introduction ....................................................................................................................................299
Studies of Vegetarian Diets and Obesity .......................................................................................300
Observational Studies .............................................................................................................300
Factors Affecting the Impact of a Vegetarian Diet ................................................................301
Intervention Studies ................................................................................................................304
Nutritional Differences Between Vegetarian and Non-Vegetarian Diets ......................................306
Possible Mechanisms for Specific Dietary Components ..............................................................307
Energy .....................................................................................................................................307
Proteins....................................................................................................................................308
Carbohydrates .........................................................................................................................309
Fiber ........................................................................................................................................309
Dietary Fats.............................................................................................................................309
Does the Decrease in BMI Associated with a Vegetarian Diet Imply Better Health?.................310
Conclusions ....................................................................................................................................310
References ......................................................................................................................................311
INTRODUCTION
Vegetarian diets of varying degrees of restriction may be adopted for cultural, religious, or health
reasons. In 2003, an estimated 2.8% of adults in the United States reported no consumption of meat,
poultry, or seafood and thus could be described as vegetarian, while 1.8% omitted all animal-derived
products (including milk, eggs, and honey) and could be described as vegan [1]. The official position
statement of the American Dietetic Association and Dietitians of Canada states that: “Appropriately
planned vegetarian diets are healthful and nutritionally adequate, and provide health benefits in the
prevention and treatment of certain diseases” [2]. Specifically, vegetarian diets have been linked with
a decrease in the risk of ischemic heart disease [3,4] and other obesity-related disorders [5]. The topic
of vegetarian diets and obesity has been reviewed by one of the authors and others; in general, body
mass index (BMI) has been found to be lower in both men and women in vegetarians vs. non-vegetarians
[3,4,6,7]. The discussion that follows in this chapter emphasizes results published within the last 5
years. This chapter first describes observational studies of populations who have self-selected either
vegetarian or non-vegetarian diets, then factors that might affect the outcome of these observational
299
studies. Subsequently, intervention studies of vegetarian diets are discussed, followed by an elaboration
of potential mechanisms by which vegetarian diets might affect body weight.
STUDIES OF VEGETARIAN DIETS AND OBESITY

OBSERVATIONAL STUDIES
In Europe, the Oxford cohort of the European Prospective Investigation into Cancer and Nutrition
(EPIC) recruited a significant proportion of vegetarians among its 57,496 subjects [8]. Categories
studied included meat-eaters (omnivores), fish-eaters (fish but no meat or poultry), lacto-ovo vege-
tarians (milk and eggs but no flesh foods), and vegans. Several analyses of these data indicated that
meat-eaters had a higher mean BMI and higher incidence of being overweight (25 > BMI > 29.9
kg/m2) or obese (BMI > 30 kg/m2), even when correction was made for non-dietary factors [9–14].
Body weight parameters for non-vegan vegetarians (e.g., lacto-ovo) or for those who eat fish but
not meat were between those for meat-eaters and vegans [10,12,13], and only the BMI of meat-
eaters was within the overweight range [9,10]. The U.K. Women’s Cohort Study, with 35,372
participants, also demonstrated a lower BMI for vegetarians than for meat-eaters, although two
groups of fish-eaters had average BMIs as low as or lower than those of vegetarians. Only the meat-
eating group had a BMI as high as the cut-off for the definition of overweight (25.0 kg/m2) [15]. In
the 5292 subjects of the Oxford Vegetarian Study, meat-eaters had a higher prevalence of being
overweight or obese than non-meat-eaters (including fish-eaters) and a higher mean BMI [16].
In a study population from the EPIC–Oxford study, all dietary groups tended to increase BMI
during a 5-year follow-up period, but vegans and fish-eating women showed less gain than did
meat-eaters. Interestingly, individuals who converted to a more vegetarian diet during the 5-year
period had the smallest weight gain, and those reverting from a more vegetarian diet had a weight
gain greater than any other group, including meat-eaters [17].
Results from the 55,459 members of the Swedish Mammography cohort also demonstrated
that omnivores were heavier than semivegetarians, lactovegetarians, or vegans, with a higher BMI
and risk of being overweight or obese; however, in none of these diet groups was the mean BMI
> 25 [18]. Alewaeters et al. [19] found that 326 male and female Flemish vegetarians had a lower
BMI than corresponding reference populations, with only the male reference cohort having mean
BMIs in the overweight range.
In the United States, studies of the Seventh-Day Adventist population have shown an inverse
correlation between vegetarianism and obesity. The teachings of this denomination endorse a healthy
lifestyle, and approximately 50% of a cohort of 34,192 Californian Seventh-Day Adventists ate meat
less than once a week. Within this population, BMI was significantly associated with diet, with only
male and female vegetarians and female semivegetarians (poultry or fish, <1×/week) having mean
BMIs below 25 [5]. Seventh-Day Adventist vegetarians in Barbados also showed a decreased risk
of obesity compared to non-vegetarian Seventh-Day Adventists [20]. A vegetarian diet is also a tenet
of Buddhism, and predominantly Tzu-Chi Buddhist nuns comprised a cohort of 49 Taiwanese
vegetarians. These women had lower BMI, body weight, and waist and hip circumference than 49
age-matched omnivorous controls who were predominantly local hospital employees [21].
Among the 459 members of the Baltimore Longitudinal Study of Aging, vegetarianism per se
was not addressed, but a diet high in fruit, vegetables, whole grains, and dairy and low in red and
processed meat was associated with the lowest baselines and smallest increases in BMI and waist
circumference over time [22]. Only this healthy diet resulted in a mean BMI that started and
remained within the normal range. Data from the 13,313 respondents in the Continuing Survey of
Food Intake by Individuals showed a decreased BMI in self-defined vegetarians vs. self-defined
non-vegetarians, with further decreases in BMI in self-defined vegetarians who did not eat meat
vs. those who did [23]. When vegetarianism in this cohort was defined by the absence of meat
(including poultry and fish) on the survey date, vegetarians so defined had a lower BMI than any
Vegetarian Diets in the Prevention and Treatment of Obesity 301
other group except for those reporting a high-carbohydrate diet adhering to the U.S. Department
of Agriculture (USDA) food pyramid [24]. A cohort of 12 American vegetarian men had a nearly
significantly lower BMI but also lower fat-free weight than 11 non-vegetarian controls [25].
In the 1817-member British Columbia Nutrition Survey, the mean BMI was 2.6 kg/m2 lower
in female vegetarians than in their non-vegetarian counterparts; BMI was only 0.8 kg/m2 lower in
male vegetarians compared to male non-vegetarians. Only the 76 female vegetarians had a mean
BMI within the normal range, and female vegetarians were found to have a lower waist circum-
ference and a lower prevalence of being overweight or obese. The 30 male vegetarians had a 0.8-cm
greater waist circumference than male non-vegetarians and a slightly greater incidence of being
normal or overweight but a decreased incidence of obesity [26] Increased exercise by the female
vegetarians may have accounted for the differences in body composition in this particular study.
The above studies focused on adult populations. Decreased BMI and decreased prevalence of
being overweight were also associated with vegetarianism in Turkish adolescents [27], although
the mean BMI was within the normal range for vegetarians and non-vegetarians, both males and
females. The BMI of 22 Polish vegetarian children was slightly lower than that of 13 omnivore
controls (15.7 vs. 16.0 kg/m2), although the vegetarian children were older [28]. A study of 51
vegetarian children in Hong Kong found an increase in the prevalence of obesity relative to
previously reported data from the local population [29], but a lack of physical activity in these
children may have been a factor.
Table 23.1 provides a summary of the previously described BMI data. Other anthropomorphic
parameters were available in some but not all studies and thus were not put into tabular form. For
male adults, a weighted average of available data resulted in mean BMI of 25.3 kg/m2 for meat-
eaters and 23.8 kg/m2 for vegetarians, with a total of 12,692 meat-eaters and 4175 vegetarians
[9,16,19,20,25,26]. For females, corresponding weighted BMIs were 24.6 and 23.2 kg/m2, with a
total of 109,715 meat-eaters and 16,948 vegetarians [9,15,16,18–21,26,31]. For both males and
females, the weighted-average BMI was 24.8 for 132,894 meat-eaters and 23.3 for 21,254 vege-
tarians [9,15,16,18–21,23,25,26,31]. In this analysis, data from only the most recent reports of the
EPIC–Oxford cohort and the Continuing Survey of Food Intake by Individuals were used [9,23].
For males 6 feet in height, the calculated average difference of 1.5 kg/m2 in BMI between vegetarians
and meat-eaters would correspond to a difference of 11 lb.
Figure 23.1 presents data from a meta-analysis conducted by one of the authors. The difference
between the BMIs of male vegetarians and non-vegetarians (24 studies) was 2.1 kg/m2, and a
difference of 1.8 kg/m2 between the BMIs of female male vegetarians and non-vegetarians (36
studies) was found. Thus, previous literature and the data presented in Table 23.1 are consistent.
FACTORS AFFECTING THE IMPACT OF A VEGETARIAN DIET

The effect of a vegetarian diet may be varied by the length of time spent on the diet, the strictness
of the diet, and the other lifestyle factors that may accompany vegetarianism; for example, it seems
plausible that the effects of a vegetarian intervention might be most clearly seen with a longer time
period. If overweight or obese individuals were to adopt a vegetarian diet in the short term as a
means of weight loss, their presence in the vegetarian cohort would be likely to increase the mean
body weight. In the EPIC–Oxford cohort and in a population of Seventh-Day Adventists in Bar-
bados, the BMI was lowest for those who had been vegan or vegetarian for more than 5 years
[14,20]. Mortality in the form of ischemic heart disease was also lower in those who had been
vegetarian for more than 5 years. Appleby et al. [16], however, found that the BMIs of non-meat-
eaters who had not eaten meat for more than 5 years were only slightly and not significantly lower
than those for individuals who had adopted a non-meat diet within the last 5 years. Similarly,
individuals becoming vegetarian as adults (>20 years) were no heavier than life-long vegetarians).
Interestingly, the BMI was higher for men and women becoming vegetarians as children than for
life-long vegetarians [9].
302
TABLE 23.1
Observational Studies on the Differences in BMI Between Vegetarian and Non-Vegetarian Diets
BMI (kg/m2)
Number of Difference,
Vegetarians/Total Meat-Eater vs.
Ref. Study Population Number Gender Meat-Eater Vegetarian Vegan Vegetarian
Adults
Rosell et al. [9] EPIC–Oxford 16,083/45,962 Male 25.2 24.3a — –0.9

Female 24.2 23.5a — –0.7
–1.4
Davey et al. [13] EPIC–Oxford 21,436/65,429 Male 24.9 23.5 22.5
–1.6
Female 24.3 22.7 21.9
–1.7
Cade et al. [15] U.K. Women’s Cohort Study 6478/35,372 Female 25 23.3a —
Appleby et al. [16] Oxford vegetarian study 284/5292 Male 23.2 22.1a — –1.1
Female 22.3 21.3a — –1.0
Newby et al. [18] Swedish mammography cohort 242/55,459 Female 24.7 23.4a 23.3a –1.3
Alewaeters et al. [19] Flemish vegetarians 326/9659 Male 25.7 22.6a — –2.1
Female 24.6 22.1a — –2.5
Fraser [5] Adventist health study 10,088/34,198 Male 26.2 24.3a — –1.9
Female 25.9 23.7a — –2.2
Brathwaite et al. [20] Seventh-Day Adventists, Barbados 177/407 Male 25.1 24.3 — –0.8
Female 27.8 27 — –0.8
Hung et al. [21] Taiwanese vegetarian women 49/98 Female 22 20.9a — –1.1
Haddad and Tanzman [23] Continuing Survey of Food Intake by 334/13,313 Male and female
Individuals Ages 6–11 18.5 17.3 — –1.2
Ages 12–19 22.3 20 — –2.3
Age ≥20 26.1 22.8a — –3.3
Kennedy [24] Continuing Survey of Food Intake by 642/10014 Male 26.4 25.2a — –1.2
Individuals Female 25.7 24.6a
— –1.1
Poehlman et al. [25] Vegetarian men 12/23 Male 24.4 22.7 — –1.7
Bedford and Barr [26] British Columbia vegetarian adults 106/1817 Male 26.7 25.9 — –0.8
Female 25.7 23.1a — –2.6
Barr and Broughton [31] British Columbia vegetarian women 90/193 Female 23.5 23.2 — –0.3
Weighted average Male 25.3 23.8 — –1.5

Female 24.6 23.2 — –1.4
All 24.8 23.3 — –1.5
Children
Bas et al. [27] Turkish adolescent vegetarians 31/1205 Male 22.9 22.1a — –0.8
Vegetarian Diets in the Prevention and Treatment of Obesity
Female 20.8 19.8a — –1.0
Ambroszkiewicz et al. [28] Polish vegetarian children 22/35 Male and female 16 15.7 — –0.3
a Statistics provided; p < 0.05 vs. meat-eaters.

303
A possible complication in analyzing the effects of a vegetarian diet is that self-defined

vegetarians may not adhere strictly to a vegetarian diet. As a practical concession, those who ate
meat or fish less than once a week or below 10 g/day have been defined as “vegetarian” [15,20].
Even so, only 18% of a study population met this requirement, although 28% considered themselves
vegetarian [15]. Newby et al. [18] found that groups of “semivegetarians,” “lactovegetarians,” and
“vegans” all consumed some animal products but further reported that these discrepancies did not
alter the conclusions of their study. Smith et al. [30] found that, of 59 self-reported college student
vegetarians, 40 had included poultry and/or fish in their diet; of 90 vegetarian women in British
Columbia, the percentages of women eating fish or other seafood, poultry, or red meat at least
occasionally were 74.9%, 57.6%, and 22.4%, respectively [26]. Barr and Broughton [31] and
Alewaeters et al. [19] reported that 5 to 14% of vegetarians ate chicken or fish. Haddad and Tanzman
[23] reported that 214 of 334 “vegetarians” ate some meat, fish, or poultry on at least one of two
dietary survey days. As they found that non-meat-eating “vegetarians” had a lower mean BMI than
meat-eating “vegetarians,” it may be that the apparent effect of vegetarianism on leanness is
weakened by the inclusion of meat-eating “vegetarians.”
Conversely, when “vegetarian” was defined as those who did not consume meat on a given
study day, the numbers of vegetarians by definition were higher than for self-defined vegetarians
in the same cohort [23]. The BMI appears to be lower in vegetarians by any definition, but the
combination of self-defined vegetarianism and the lack of meat (including poultry and seafood)
appeared to be the most effective [23].
Although decreased body weight is cited among the top reasons for choosing a vegetarian diet
[27,30], a causal effect of vegetarian diet on weight loss cannot be established from cross-sectional
studies. It may be that vegetarian populations may possess characteristics other than diet that may
influence body weight. Vegetarians in general and vegans in particular have a decreased incidence
of smoking and higher exercise levels and tend to be younger and of a higher social class [4,10–13,
15,16,19,26,31]. Vegetarians were also more likely to be female [1,26] and to have a higher
nutritional supplement use [15,26] and lower prescription medication use [19]. Alcohol use was
reported to be higher among meat-eaters relative to non-meat-eaters [4,5,10,11,16], although wine-
drinking was also reported to be higher in non-meat-eaters [23]. It may be, therefore, that vegetar-
ianism serves as a marker of a health-seeking personality and that vegetarianism per se has no
specific advantages.
Barr and Broughton [31] found that a convenience sample of 193 current, former, and non-
vegetarian women, health-conscious and demographically similar except for ethnic background and
parity, did not differ significantly with regard to BMI, weight, or self-assessed weight or health,
although only formerly vegetarian women had BMIs in the mean overweight range. Men who
became vegetarian after age 20 had a lower BMI before beginning a vegetarian diet than did a
corresponding same-age group of meat-eaters [17].
In a negative light, vegetarianism was also linked with eating disorders in Turkish adolescents,
although young vegetarians cited “taste preference” and “healthier diet” above “weight control” as
reasons for their dietary practices [27,30]. Only 24% of a cohort of college students who had ever
tried a vegetarian diet expected to lose weight, although 59% of the students who had at some
point tried a weight-loss diet expected weight loss from a vegetarian diet [30].
INTERVENTION STUDIES
A more direct analysis on the impact of vegetarian diets on body weight can be found with
intervention studies (Table 23.2). Phillips et al. [32] examined the effect on 33 volunteers of a
6-month diet excluding meat but including fish. Although weight, BMI, and waist-to-hip ratio were
not altered, significant decreases were seen in mid-upper-arm circumference, skinfold measurements,
percent body fat, and waist and hip circumferences. During a crossover study, 35 women reduced
their weight and BMIs during a low-fat vegetarian diet phase lasting two menstrual cycles [33]. As
TABLE 23.2
Direct Analysis on the Impact of Vegetarian Diets on Body Weight
Number in
Study Intervention/ Type of Change in BMI
Ref. Population Control Group Study Dietary Intervention Control Length of Study
Intervention Control
Barnard et al. [33] Premenopausal 35 Crossover Low-fat vegetarian Placebo supplement 2 menstrual cycles 0.9a 0.3
women diet phase phase
Barnard et al. [37]; Obese 29 Parallel Low-fat vegan diet National Cholesterol 14 weeks 2.1a 1.4
Turner-McGrievy postmenopausal Education Program
et al. [38] women Step II guidelines
Toobert et al. [39] Postmenopausal 14 Parallel Lifestyle intervention Usual care 24 months 1.0a 0
women including mostly
Vegetarian Diets in the Prevention and Treatment of Obesity
vegan diet
Phillips et al. [32] Recent 33 Pre/post Diet excluding meat Baseline 6 months 0.1b —
vegetarians but including fish
a Results are significantly different compared to control group.
b Other parameters of body fat show significant change.
305
with cross-sectional studies, results may be attributable to the personal characteristics of individuals
amenable to a vegetarian diet and not to the diet itself. Preference, for example, may play an
important role in the success of a diet [34]; however, Barnard et al. [33] found no demographic
differences between 35 completers and 16 non-completers of their diet intervention.
Delgado et al. [35] found that a 2-month transition from a Mediterranean diet to a lacto-ovo
vegetarian diet did not affect the body composition of 14 individuals; however, study subjects were
current or former physical education students who did not consume significant quantities of fast
food, so nutritional changes and possible room for weight improvement may have been minimal.
Barnard et al. [33] found that individuals with initial BMIs < 22.0 kg/m2 lost less weight (in kg)
than those with initial BMIs > 22 kg/m2.
One aspect of a vegetarian diet that may be of practical benefit is that long-term adherence to
a vegetarian diet may be greater than adherence to a “weight-loss” diet. Smith et al. [30] reported
that the median times a group of college students adhered to weight-loss diets and vegetarian diets
were 3 months and 24 months, respectively. Loss of interest was more commonly cited as a reason
for quitting for the weight-loss group than for the vegetarian group. The BMI was lower for students
who had been on a vegetarian diet at any time than for those who had been on a weight-loss diet
at any time (whether or not they had ever tried a vegetarian diet) or neither; mean BMIs for all
groups were within the normal range. Barnard et al. [35] reported that a vegan diet had a high
degree of acceptability among the 28 study participants.
Several studies examine the effect of randomization to a vegetarian diet. Barnard et al. [35,36]
and Turner-McGrievy et al. [37] studied 59 obese women assigned to either a low-fat vegan diet
or a diet following the National Cholesterol Education Program Step II guidelines, with limits on
fat, saturated fat, and cholesterol and percentages of energy from protein and carbohydrate at 15%
and >55%, respectively. The vegan group had a greater decrease in body weight, BMI, and waist
circumference over the 14 weeks period than did the Step II group, although the means of both
groups remained in the obese range [37,38]. In a group of 14 women assigned to a lifestyle
intervention including vegetarian diet, BMI decreased slightly but significantly more than in a group
of 11 controls [39].
NUTRITIONAL DIFFERENCES BETWEEN

VEGETARIAN AND NON-VEGETARIAN DIETS
Vegetarian and non-vegetarian diets are defined by the presence or absence of meat and other
animal products. Vegetarians presumably eat more plant-based foods to compensate for the missing
animal products; thus, the nutrient profile of vegetarian and non-vegetarian diets is likely to be
different. Table 23.3 shows differences in dietary components reported for vegetarian and non-
vegetarian diets. Vegetarian diets may facilitate weight loss for a number of different possible
reasons, presumably mediated by the differences in composition. Lower concentrations of some
dietary components and higher concentrations of others may each have their own effects. Vegetarian
diets have been found for the most part to be lower in overall energy [9,12,13,15,21,24,32,33,35–38],
protein [9,12,13,15,21,23–26,31,33,35–38], fat [12,15,21,23,25,26,33,35,36], saturated fat [9,12,13,
15,21,23,24,26,31–33,35–39], and cholesterol [26,31,33,35,36,38]. Vegetarian diets tended to be
higher in fiber [9,12,13,15,21,23,25,26,31,33,36–38] and carbohydrate [9,12,13,15,23–26,31–33,
36–38]. Omega-3 polyunsaturated fatty acids (PUFAs) in diet and plasma, in particular eicosapen-
taenoic acid (EPA) and docosahexaenoic acid (DHA), were reported to be lower in vegetarians
[3,10,23], although effects on overall PUFA levels range from decreased to unchanged to increased
[5,12,13,15,18,21,23,24,26,31,36–38]. Consumption of fish by “vegetarians” may affect omega-3
fatty acid levels [23]. Monounsaturated fatty acids were consistently lower in the diet of vegetarians
[12,15,18,23,24,31,38]. Possible roles for each of these dietary components in affecting body weight
will be discussed individually.
TABLE 23.3
Dietary Components Reported in Vegetarian Diets
Dietary Components Reported Dietary Components Reported
in Lower Concentrations in Higher Concentrations
in Vegetarian Dietsa in Vegetarian Dietsb
Energy Fiber
Protein Carbohydrate
Fat
Saturated fat
Cholesterol
Omega-3 polyunsaturated fatty acids
Monounsaturated fatty acids
a See References 3, 5, 9, 10, 12, 13, 15, 18, 21, 23–26, 31–33, 35–39.
b See References 9, 12, 13, 15, 21, 23–26, 31–33, 35–38.
POSSIBLE MECHANISMS FOR

SPECIFIC DIETARY COMPONENTS
ENERGY
The balance of energy intake and expenditure determines whether a person will gain or lose weight,
and a low-fat, lower-calorie diet (plus exercise) is a standard behavioral treatment for obesity [34].
Indeed, as described above, many analyses of vegetarian diets show a decreased energy (caloric)
content, and decreased energy was correlated with weight loss [31]. Kennedy et al. [24] suggested
that any diet sufficiently reducing energy intake should lead to weight loss.
Decreased energy intake should not be confused with consciously restricted food intake, as
total energy decreased with vegetarian diets even when food portions were not deliberately limited
[32,37,38]; rather, a vegetarian diet was associated with decreased hunger scores [36]. A fiber-rich
vegetarian diet is therefore typically less energy dense than a diet high in animal fats, and a high
energy intake would be more difficult to achieve. A fiber-rich, low-glycemic index diet, rich in
fruits and vegetables, could contribute to an earlier feeling of satiety and decreased voluntary intake
[40–44]. It should be noted that leptin, one of the hormones associated with satiety was decreased
in 22 vegetarian children ages 2 to 10 years relative to 13 omnivore controls [28]. Leptin is primarily
derived from adipocytes; thus, decreased leptin may be a consequence of decreased body fat [45].
Reports of decreased energy intake do not automatically correspond to decreased weight in
those individuals [35]. Decreased energy expenditure and resting metabolic rate may counter
decreased energy intake with vegetarian diets, negating some of the beneficial effect of energy
reduction [37]. The effects of a decrease in energy intake might be masked if heavier individuals
were to underreport intake [46], had remained on a diet for too short a time for effects on weight
to be noticed, or were within normal weight range and had no excess body fat to lose [35].
Furthermore, decreased energy intake may act in conjunction with other factors, as oily-fish-eaters
consumed more calories than meat-eaters or vegetarians but had a lower BMI than any of the other
groups [15]. Similarly, individuals lost more weight on a vegan diet than on a National Cholesterol
Education Program Step II diet, although both had decreased energy intake [37]. Vegetarians in
this latter study had less fat and more carbohydrate relative to the Step II group. It may be that
macronutrient balance is important; therefore, the effects of the three main macronutrients (i.e.,
protein, fat, and carbohydrate) are considered individually.
PROTEINS
The removal of meat from the diet is a simple modification that is easy to implement and maintain
and that produces favorable changes in body composition [30–32,36]. The absence of red meat,
primarily beef, was associated with a decreased BMI in Seventh-Day Adventists [5]. Meat contributes
significant amounts of protein as well as energy-dense saturated fat, and it may displace fiber- and
nutrient-rich plant foods in the diet. Meat may also serve as a marker for general overnourishment.
As described earlier, vegetarians typically eat less dietary protein than do meat-eaters. The
exact mechanism of how this decrease in protein might affect weight loss is unclear. With regard
to increased body weight of meat-eaters, it has been suggested that high protein early in life could
result in increased insulin-like growth factor, which might lead to adipocyte replication as well as
decreased growth hormone [47,48]; however, individuals becoming vegetarian as children were
heavier than adult-onset vegetarians, and lifelong vegetarians were no different in BMI from adult-
onset vegetarians [9].
High-protein diets have in fact been used as an approach to weight loss, and it has been reported
that the high protein content increases satiety and thermogenesis [49–52]. Protein preloads increased
satiety relative to a glucose preload and corresponded with decreases in the appetite-inducing
hormone ghrelin and increases in satiety-inducing cholecystokinin (CCK) and glucagon-like peptide
1 (GLP-1) [53,54]. Ghrelin was decreased more by a high-protein breakfast than a high-carbohy-
drate breakfast [55]. Increased satiety and decreased hunger and actual or desired food intake were
noted for 19 and 57 subjects placed on a high-protein diet, although in these subjects ghrelin was
increased [50,56]. Raben et al. [57], however, found no effect of high protein on postprandial satiety,
and Nickols-Richardson et al. [49] found no difference in actual energy intake between high-protein
and high-carbohydrate diets, although hunger scores were lower in the high-protein group.
Diet-induced thermogenesis is defined as the expenditure of energy required for absorbing,
processing, and storing nutrients. Expressed as a percentage of the energy content of each macro-
nutrient, reported values range from 20 to 30% for protein to 5 to 10% for carbohydrates and 0 to
3% for lipids [58]. A protein-rich diet, then, requires more energy to digest and store and should
therefore, in theory, generate fewer calories left over for storage. Correspondingly, it might be
expected that lower-protein vegetarian diets would be less thermogenic and more conducive to
weight increase. Accordingly, Johnston et al. [51] observed increased thermogenesis and a slightly
higher post-meal body temperature in volunteers after high-protein meals vs. high-carbohydrate
meals; Raben et al. [57] reported 17% higher thermogenesis after a protein meal than after fat or
carbohydrate meals; and Poehlman et al. [25] found a decreased postprandial thermic response in
a group of 12 vegetarian men vs. a group of 11 normal controls. Weigle et al. [50], however, found
that thermogenesis did not significantly increase with a high-protein diet, and Barnard et al. [37]
found an increased thermic effect in vegetarians compared to non-vegetarians.
Thus, there appears to be no clear mechanism by which low protein per se could lead to
decreased weight, and in fact an increased amount of protein might seem to be more effective in
weight loss; however, plant-based and meat-based diets differ in amino-acid makeup as well as
protein quantity. In particular, plant proteins contain more non-essential amino acids than do animal
proteins. A higher intake of non-essential amino acids can tend to downregulate insulin and
upregulate glucagon, thereby decreasing fat synthesis and increasing fat oxidation [47,59]. Taiwan-
ese vegetarians who consumed large amounts of soy-based proteins had greater insulin sensitivity
[21]. Relative decreases in essential amino acids have also been associated with lower levels of
insulin-like growth factor 1 (IGF-1) in vegan women [60], possibly resulting in adipocyte stimu-
lation [47]. Finally, a preload of plant protein in the form of tofu and mushroom mycoprotein had
a greater effect on satiety than did chicken protein, and study participants did not compensate for
the lower food intake at lunch by eating more at dinner [61]; however, pork protein produced higher
total daily energy expenditure than soy protein [52], possibly because soy protein was less able to
support energetically costly protein turnover.
CARBOHYDRATES
As discussed, vegetarian diets on average contain more carbohydrates than do meat-containing diets.
Carbohydrate ingestion, which results in increased blood glucose, stimulates the secretion of insulin
which in turn removes glucose from the blood and increases fat storage. Increased insulin would
also promote more rapid onset of hunger by clearing glucose from the bloodstream more quickly
[62]. In the liver, increased insulin after a high-carbohydrate meal has a fat-sparing effect, decreasing
fat oxidation [57,63]. Carbohydrates would therefore appear to promote weight gain via the effects
of insulin; however, sources of carbohydrates differ in regard to glucose release. In a vegetarian diet,
carbohydrates may be more likely to come from fruits, vegetables, and unrefined grains with a lower
glycemic index (GI) rather than from higher GI foods such as white bread [5,18,22,64]. Low-GI
carbohydrates would release glucose more slowly and therefore produce less of an insulin response.
Ad libitum use of low-GI carbohydrates in the diet appears to be associated with a lower body
weight, although in isoenergetic studies body weight was not affected by glycemic index per se
[57,65,66]. Overall, a lower glycemic load (GL), reflecting net quantity as well as quality of
carbohydrate, seems to be related to reduced body weight [62,66–68]. Dietary carbohydrate may be
better than dietary fat at suppressing postprandial ghrelin and increasing leptin. Both of these changes
would increase satiety and decrease food intake [50,69], although Raben et al. [57] found no
difference in satiety among meals rich in protein, refined carbohydrate, or fat; however, satiety effects
may be more relevant with low-GI foods.
FIBER
Dietary fiber consists of nondigestible, plant-derived carbohydrates and lignin [70] and is increased
in vegetarian diets. Data from 15 studies of 11 cohorts indicate a median increase in fiber intake
of 7.3 g for vegetarian or vegan vs. meat-containing diets, with mean total fiber intake of 24.8 g
for vegetarians [9,13,15,16,23,25,26,28,31,33,35–38]. In the Oxford Vegetarian Study, fiber was a
factor that was associated with lower BMI in both men and women [16]. Increased fiber was
associated with lower BMI in 2165 women but not 2374 men in the Continuing Survey of Food
Intakes by Individuals [70]. Fiber was inversely associated with weight gain over an 8-year period
in a prospective cohort of 27,082 men [44] and in a cohort of middle-aged women [43]. Weight
gain in men was decreased by 2.51 kg for every 20 g/day fruit fiber, by 0.81 kg for every 20 g/day
cereal fiber, and by 0.36 kg for every 20 g/day added bran [43], and an intake of 14 g/day of fiber
for 2 or more days appeared to correspond with a 10% decrease in energy intake [72].
Pereira and Ludwig [73] discuss three mechanisms by which fiber could lower body weight.
First, fiber has a low energy density. Because of its bulk and because of associated fluid, fiber in
the diet can lead to a fuller stomach and increased satiety. Increased satiety plus the lower palatability
of fiber-rich foods could subsequently decrease energy intake. Second, changes in the consistency
and movement of food in the gut can alter the generation of satiety-related hormones such as CCK,
gastric inhibitory peptide (GIP), GLP-1, and insulin. Third, fiber fermentation generates short-chain
fatty acids that can decrease hepatic glucose production and FFA, further affecting insulin secretion
and sensitivity.
DIETARY FATS
As described above, vegetarian diets on the average tend to be lower in fat than meat-containing
diets, although Fraser [5] noted that the diet of Seventh-Day Adventist vegetarians was not neces-
sarily low in fat. Low fat consumption and low fat in conjunction with fiber were associated with
a lower BMI in men and women, respectively [71]. In the EPIC–Potsdam cohort, foods high in fat
were correlated with increased weight gain in women [74]. High levels of dietary fat would not
appear to be desirable with regard to weight loss. The high energy density of fats plays an important
role in increasing energy intake and body weight [75], and fat as a palatable food suppresses satiety,
possible through insulin or leptin resistance [76]. Furthermore, a high-fat diet has little thermogenic
effect [58]. Dietary fat upregulates acyl CoA:monoacylglycerol acyltransferase (MGAT), an enzyme
involved in fat absorption and storage [77].
It may be that the type of fat is as important as total fat content. Appleby et al. [16] found that
consumption of animal fat, which is high in saturated fat, was a significant factor contributing to
low body mass in non-meat-eaters. Several studies have found that switching from saturated to
monounsaturated fat decreased body fat [78–80]. Saturated fatty acids have been reported to produce
less satiety and stimulate less fatty acid oxidation relative to unsaturated fats [81,82], although
several later studies showed no difference in satiety or energy expenditure for several different
sources of fatty acid [65,83–85]. Furthermore, saturated fat has been associated with a higher insulin
resistance relative to monounsaturated fat [80,86,87], although again this association has not been
consistently found [85,88]. Saturated fat is lower in a vegetarian diet [9,12,13,15,21,23,24,26,
31–33,35–39], but monounsaturated fatty acids have been reported to be lower as well [12,15,18,
23,24,31,38]. Omega-3 PUFAs were decreased [2,3,10,23], but effects on total polyunsaturated fats
varied [5,12,13,15,18,21,23,24,26,31,36–38]. Although several mechanisms exist by which
increased PUFA intake could lead to decreased obesity and insulin resistance [89], there is no
clearly established role for polyunsaturated fats in obesity or insulin resistance in vivo [88,90].
DOES THE DECREASE IN BMI ASSOCIATED WITH

A VEGETARIAN DIET IMPLY BETTER HEALTH?
A presumption of this discussion is that a decreased body weight represents a healthy change. A
counter-example might be the decreased body weight associated with the unhealthful practice of
smoking. Smokers, for example, tend to have lower body weight, and smoking cessation is asso-
ciated with weight gain [17], but overall the practice of smoking would not be considered beneficial.
It could also be that the lower BMIs result from reduced muscle mass; thus, the possibility must
be considered that decreased body weight in vegetarians results from inadequate nutrition that could
adversely affect health. Although vegetarian diets are considered to be appropriate and healthful
[2], a poorly planned vegetarian diet could contribute to malnutrition; for example, vegetarians can
be more likely to have dietary deficiencies in a number of micronutrients including B12 and vitamin
D [3,23,31,38,91]. Perry et al. [64], however, found that adolescent vegetarians had a healthier diet
than non-adolescent vegetarians, and vegetarian diets can be appropriately used to support athletic
performance [3,91]. Vegetarians and especially vegans have lower levels of the omega-3 PUFAs
that are considered protective in cardiovascular and other diseases, yet they have less ischemic
heart disease [3,10]. A cohort of 30 male vegetarians was more likely to report heart disease than
a comparison group of non-vegetarians; however, because they also were more likely to choose
foods based on effects on heart disease and high blood pressure, it may be that cardiovascular
problems were a cause and not a consequence of vegetarianism [26]. Vegetarians have less self-
reported illness than meat-eaters [15], higher health perception, and less prescription drug use [19],
although Barr and Broughton [31] found no differences in health assessment among health-con-
scious women with differing dietary patterns. Mortality from ischemic heart disease was decreased
in vegetarian populations [4], although the corresponding decrease in an EPIC–Oxford cohort was
not significant and all-cause mortality increased slightly [11].
CONCLUSIONS
A large body of evidence suggests that vegetarian populations have a decreased body weight
compared to corresponding populations of non-vegetarians, although the increased health con-
sciousness of individuals drawn toward vegetarianism may be a contributing factor. Intervention
studies suggested benefits from switching to a meatless diet, with the advantage that such diets
may be more easily adopted and sustained than a standard weight-loss diet. Even periods as short
as 14 weeks generated improvement; more benefit was seen at >5 years, but lifelong vegetarianism
did not appear to be necessary nor was strict adherence to a vegetarian diet required, as many
“vegetarians” admitted consuming some flesh foods, particularly fish and poultry. A number of
possible mechanisms for the benefits of a vegetarian diet have been suggested, resulting mostly
from increases or decreases in dietary macronutrients. Meat and concomitantly protein, fat, and
energy were decreased while carbohydrate and fiber were generally increased. An additional benefit
of a plant-based diet is presumably increased intake of plant antioxidants, polyphenols, and other
phytochemicals. Although these components may be secondary to macronutrients in regard to
protection from obesity, they may contribute to the cardiovascular and other health benefits reported
for vegetarian diets.
ACKNOWLEDGMENTS
The authors wish to thank Ms. Maria Knecht for assistance with references, Ms. Angela Williams
for formatting the manuscript, and Dr. Bruce Currie for editorial suggestions.
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24 The Atkins Paradigm

Ariel Robarge and Bernard W. Downs
CONTENTS
Introduction ....................................................................................................................................315
Science Spawns Commercial Opportunities..................................................................................316
Outside the Box of Conventional Dogma .....................................................................................316
The Atkins Concept .......................................................................................................................316
Ketosis: How Does It Work? .........................................................................................................317
Does Ketosis Propel Fat Loss by a Metabolic Advantage? ..........................................................317
Energy and the Metabolic Bank Account......................................................................................317
The Atkins Contribution ................................................................................................................318
Conclusions ....................................................................................................................................319
References ......................................................................................................................................320
INTRODUCTION
In the Beginning — It is important to state that this chapter is not an attempt to discredit Dr. Robert
Atkins’ theory. In fact, his observations were right on the mark in general terms. This chapter hopes
to put Dr. Atkins’ contribution, as controversial as it may be, into its correct context as a catalyst
and vehicle for a major paradigm shift in our understanding of and approach to the causes and
treatments of obesity and related disorders. Dr. Atkins was instrumental in removing our obsessive
focus on fat being the greatest enemy with regard to disease prevention and treatment; however,
to gain an understanding of the premise of the Atkins program, one must first understand in what
environment the Atkins program was created and what caused Dr. Atkins to pioneer this paradigm
at that particular time.
Recall that following World War II there was a sharp increase in refined and processed food
production and consumption. The major characteristic of these foods was that they were rich in
fats (they were also rich in sweeteners such as high-fructose corn syrup and invert sugar). This led
to a passive overconsumption of high-fat, high-calorie foods (as well as high sugar consumption).
Concomitant with this increase in high-fat foods was a significant increase in cardiovascular disease,
diabetes, and obesity. These new dietary habits were recognized as problematic by the medical and
nutrition establishment that ultimately, in response to the consequences of these dietary habits,
mandated a “low-fat” lifestyle. The experts of the time stated what they believed to be the obvious
conclusion: If we eat too much fat, we get fat; in other words, fat begets fat.
At this point, the Food Guide Pyramid was developed with an emphasis on increasing dietary
carbohydrate intake while reducing fat consumption. In hindsight, the flaw with the new guidelines
was that the carbohydrates emphasized (bread, rice, cereal, and pasta) were derived primarily from
refined processed sources, not necessarily whole, unprocessed grains. Americans were told that the
majority of their food intake should be grain derived and that fats in any shape or form were to be
avoided at all costs. All fats were thought to contribute to disease and obesity and should be avoided
as much as possible.
315
SCIENCE SPAWNS COMMERCIAL OPPORTUNITIES

Responding to the commercial opportunities created by these new official guidelines, agribusiness
and the food-processing industry jumped on the band wagon and began producing high-carbohy-
drate, low-fat refined and processed alternatives, which eventually became the dogma of mainstream
nutrition. This paradigm of low fat (high carbohydrate) became a societal mantra to the point of
being a phobia. New dietary laws regarding nutrition, health, weight management, and disease
treatment and prevention branded dietary fats as the villainous culprit responsible for a host of
pathological disorders. An increasingly fat-obsessed society, including health professionals, busi-
ness interests, and consumers alike, responded by adopting this paradigm, thus inciting the shift
to high (refined) carbohydrate consumption.
OUTSIDE THE BOX OF CONVENTIONAL DOGMA

Dr. Atkins, a cardiologist, saw that several decades of high carbohydrate consumption were accompanied
by a significant increase in insulin resistance problems (metabolic syndrome X), such as cardiovascular
disease, diabetes, hypertension, hyperlipidemia (high cholesterol, high triglycerides), and obesity. His
approach was to eliminate carbohydrates from the diet as a means of treating these disorders. Initially,
his focus was on improving health. It was not about obesity per se; rather, it was about anything that
had to do with insulin resistance and related disorders. He consistently observed remarkable improve-
ments in all of these insulin resistance problems, especially obesity, as a result of drastic changes made
to his patients’ diets. He authored Dr. Atkins’ Health Revolution in 1988 to promote this new paradigm.
To keep things in perspective, Dr. Atkins never promoted an unhealthy dietary lifestyle. Contrary to
antagonists’ assertions, he never said, “Stop eating sugar and start eating pork rinds and bacon fat.”
He simply recognized that refined carbohydrates were particularly bad for patients who suffered from
insulin resistance and heart disease. In practice, he found that by simply removing these foods from
their diet the patients had remarkable improvements in all parameters of their health.
Atkins proposed that a high-fat, high-protein diet gave a metabolic advantage that allows
individuals to eat as much as they want and still lose weight. Subsequently, some studies have
demonstrated an increase in the amount of weight lost on low-carbohydrate diets as opposed to the
traditional low-fat, high-carbohydrate diets; however, this difference apparently disappears after
the initial period of approximately 12 months [1]. Also, a careful meta-analysis of popular diets
revealed that it was more likely the adherence to the low-carbohydrate approach that gave rise to
a greater weight loss. The research has shown that when carbohydrates are reduced so drastically
people spontaneously decrease calorie intake by approximately 1000 calories a day [2].
Fat and protein intake elicits a much greater sense of satisfaction and increased ketosis, also
promoting a decrease in appetite, so the dieter is not struggling with constant hunger pains. On the
other hand, an extremely high-carbohydrate diet that is low in fat tends not to be as satisfying and
may cause swings in blood sugar that make compliance and adherence extremely difficult. This
difficulty is accentuated when the carbohydrates are primarily refined. A recent 1-year comparison
of four popular diet programs (Weight Watchers, Atkins, Ornish, and The Zone) showed that, at 1
year, weight loss was practically identical and was independent of the macronutrient ratio of the
diet. It was almost exclusively correlated with (reduced) caloric intake [3].
THE ATKINS CONCEPT

The Atkins diet is based on the theory that obesity is a result of carbohydrates and not calorie
intake per se. Atkins claimed that carbohydrates are the only catalyst for insulin release, so, if you
are eating foods that do not cause an increase in insulin levels, then you can eat all you want and
lose weight. Fat and protein are allowed in unlimited quantities, and carbohydrates are significantly
reduced depending on the phase of the diet. Atkins proposed that, because insulin is involved in
The Atkins Paradigm 317
fat storage, weight loss is simply a matter of reducing insulin; therefore, an individual who stops
eating carbohydrates will burn fat and lose weight more efficiently. This is why the initial phase
of Atkins diet is so strict. An individual is allotted only 20 g of carbohydrates per day during the
induction phase, which lasts 2 weeks. This facilitates a complete depletion of glycogen stores and
an associated water loss of 3 to 5 pounds. The body then enters a state of ketosis, where it burns
fats and proteins for energy as opposed to glucose.
KETOSIS: HOW DOES IT WORK?

When carbohydrates are eaten, they are broken down to sugar and used as energy or stored as
glycogen for later use. Insulin is released by the pancreas to carry the sugar to the cells where it
can be burned for energy or stored as glycogen, and any excess is converted to fat. Atkins proposes
that it is this chronic state of high blood sugar induced by our standard high-carbohydrate diet that
leads to diabetes and obesity. Ketosis can be induced by carbohydrate restriction. In simple terms,
the dieter switches to burning fat instead of sugar for energy. Ketones are carbon–oxygen fragments
that are released during the breakdown of fats. Most people experience ketosis when carbohydrate
intake falls below 40 g a day. Side effects include breath odor, loss of appetite, and constipation.
Liver and kidney distress can occur in extreme states of ketosis, and chronic long-term ketosis may
lead to organ distress or failure. The brain, red blood cells, and some organs, however, still rely on
glucose for energy. The minimal amount recommended for proper functioning is 120 g a day. The
body will go through a process of gluconeogenesis (conversion of proteins to glucose) to provide
the essential blood sugar for those tissues. These proteins may be obtained through food or the body
will pull proteins from lean body mass to provide the essential blood glucose. Some studies have
shown that low-carbohydrate diets may cause a greater loss of lean body mass for this reason [4].
DOES KETOSIS PROPEL FAT LOSS

BY A METABOLIC ADVANTAGE?
Atkins claimed that a metabolic advantage occurs with ketosis, in that ketones (byproducts of fat
metabolism) are excreted via the feces and urine, thus reducing metabolizable energy and allowing
for greater fat loss. Atkins concluded that it is possible to eat more and lose weight because ketosis
is metabolically efficient. Carbohydrate intake blunts ketosis because the body no longer needs to
break down fats to provide energy. This is why the Atkins program does not put a limit on total
caloric intake for the day and instead focuses on drastically reducing carbohydrate consumption.
More recent research has shown that the amount of energy lost as ketones is very minimal and
does not make a significant contribution to a metabolic advantage. A recent study compared 6
weeks of a ketogenic low-carbohydrate diet (KLC; 5% of calories from carbohydrates) to a non-
ketogenic low-carbohydrate diet (NLC; 40% of calories from carbohydrates). The authors concluded
that, although both diets resulted in similar loss of weight and reduced insulin resistance, the KLC
was associated with a number of adverse metabolic and emotional effects [5]. Although the study
duration was for only 6 weeks and may be inadequate to assess longer term effects, it does suggest
that any energy that may be lost via ketosis might not be sufficient to offer a significant enough
metabolic advantage over other alternatives, especially in light of ketosis-induced metabolic con-
sequences. Furthermore it calls into question the proposed tactical advantages that altering energy
ratios may offer in weight management.
ENERGY AND THE METABOLIC BANK ACCOUNT

Atkins also suggested that the energy cost of digesting and metabolizing a high-fat meal is greater
than a meal high in carbohydrates; however, recent research examined the effects of high-carbohy-
drate/low-fat/high-protein meals (60:10:30) compared to low-carbohydrate/high-fat/low-protein
meals (30:60:10) on 24-hour energy expenditure when consumed over a 36-hour period. The authors
found that high-carbohydrate meals induce greater energy expenditure when coupled with a relatively
higher protein intake (than fat) over high-fat/low-carbohydrate meals. In other words, higher fat
meals resulted in a reduced thermic effect compared to the meals high in carbohydrates when the
carbohydrates were accompanied by higher protein intake as well [6]. More recent research confirms
that protein intake is crucial in determining the intensity of the thermic effects [7]. The metabolic
advantage of the low-carbohydrate paradigm has been difficult to consistently verify. When patients
have been studied in a metabolic ward where energy is provided, this metabolic advantage ceases
to exist. Earlier research has shown that isocaloric amounts of proteins, fats, and carbohydrates elicit
almost identical losses in fat tissue regardless of whether those calories are derived from protein,
carbohydrate, or fat [8]. It is more likely that when people are in a state of ketosis they feel that
they are eating more and losing weight because of the significant decrease in appetite.
THE ATKINS CONTRIBUTION

It is the authors’ opinions that, among other things, Dr. Atkins’ program gave rise to recognition
of the importance of glycemic indexing (GI) as a means of evaluating the impact of carbohydrates
on blood sugar, insulin, and metabolism. It is not our purpose to delve into the details of GI but
just to note that this model of dietary management arose as a result of the awareness that carbo-
hydrates have varying effects on metabolism relative to the efficiency with which they are converted
to blood sugar. That sugar impact concept was the platform of the Atkins program and the reason
for omitting carbohydrates from the diet to reverse insulin resistance disorders. The prevailing
belief was that carbohydrates were the only macronutrient that stimulated release of insulin;
however, according to recent research, we now know that that is not entirely correct. Proteins and
fats also increased insulin production and release by the pancreas, but proteins and fats did not
induce a proportional or concomitant rise in blood sugar; for example, beef intake raised insulin
levels more than brown rice, and fish raised insulin more than pasta. Neither protein source raised
blood sugar more than the carbohydrate sources; therefore, insulin is not just responsive to only
carbohydrate consumption [9].
It is clear that the interplay of hormones, lifestyle, genetics, and metabolism are much more
complicated than once thought and that the causes and treatments for obesity cannot be evaluated
in such a simplistic one-dimensional manner; for example, an interrelationship of hormones is
involved in digestion and the regulation of metabolism. Focusing on one aspect and disregarding
other variables (especially for a short term) is not comprehensive and will not lead to optimal health,
which is required to effectively address chronic obesity. Initially, such a drastic change in diet may
yield some positive results, but this is short term because it does not address the root cause of the
initial problem. Given the multidimensional aspects of human metabolism, in addition to insulin, a
number of other hormones and neurotransmitters, such as ghrelin, leptin, cholecystokinin, serotonin,
and dopamine (to name a few), along with genetic factors, need to be simultaneously addressed and
included in the framework of a healthy metabolic and body recomposition program.
The greatest minds in medicine and science (including Atkins) have zeroed in on specific
aspects of metabolism (as the culprits or solutions) and analyzed them from the standpoint that
those aspects hold the key to unlocking the mysteries to successful obesity management. It is sort
of like the six blind men describing the structure of an elephant, with each one holding onto a
different part of the animal. Each blind man gives an accurate description of the part of the elephant
he is holding but falls short of giving a complete and totally accurate description of the whole
elephant. We in (nutrition) science tend to do the same thing.
It should be obvious that weight management, nutrition, and metabolism are interrelated and
that more than one component is contributing to the rise in obesity. Science fails to make the
correlation between multiple aspects of metabolism and instead focuses on one or two mechanisms
without addressing the whole picture. As an example, the fat phobia was supported by research
The Atkins Paradigm 319
that showed fat calories are more easily stored as fat in the body and carbohydrates are preferentially
burned for energy. This led to an interpretation that it was possible to eat as much as you wanted
as long at it was low fat. People started eating generous amounts of processed, refined, low-fat
foods (offset mainly by high-fructose corn syrup) with the false idea that these foods did not
contribute to weight gain and obesity.
Clearly, a dominant consumption of refined (nutrient deficient) carbohydrates can lead to many
unhealthy consequences. Atkins rightly condemned this type of lifestyle. In hindsight, the flaw of
the Atkins program, perhaps due more to commercial forces and requirements, was that it obsessed
almost solely on insulin and carbohydrate metabolism, missing other critical issues that contribute
both to obesity and long-term health.
Successful solutions to the obesity epidemic will have to encompass, in practical terms, man-
agement of the multifaceted aspects of human metabolism, their relationship to genetic expressions
and lifestyle (nutrition, personality profiles, stress, and environmental factors, among others), and
the symbiotic relationship among all of these elements. As indicated, this includes not only physical
laws but the emotional issues that affect digestion, metabolism, and food intake.
Our focus should be on achieving long-term holistic health that emphasizes maintaining optimal
body composition on an individual basis. There is no “one size fits all” when it comes to weight
management, and focusing on the bathroom scale as the primary assessment of one’s health is missing
the mark. The scale is a poor measure of success with regard to weight loss. Many diets cause the
loss of an excessive amount of lean body mass along with the loss of fat. Then, during the rebound
effect, metabolism slows down, the body becomes more efficient at storing fat, and brain chemicals
are altered, which leads to an increase in food cravings, irritability, and obsession with food.
Food consumed in its unprocessed whole form, as it was intended, provides the nutrients that
fund the structure and function of the body. Often, science and research fail to take into consideration
individual needs and lifestyle. The dieting cycle and severe restriction of calories commonly touted
by weight-loss programs fail to consider the long-term effects on energy metabolism, structural
competence, and health. History is showing us that drastically reducing calories or altering ratios
and percentages is short sighted and will not work in the long run. When the body is deprived of
nutrition and energy it sets up a cascade of events that leads to mood disorders, binging, and weight
cycling that leave dieters feeling powerless and out of control with regard to their weight.
Obesity can also not really be attributed to an individual’s lack of motivation or willpower.
Focusing on one aspect of dietary manipulation fails to take into account that the body requires all
nutrients for synergy and wellness of metabolism. The way to optimal and healthy body composition
is tuning into the body and providing its essential needs for protein, carbohydrates, fats, vitamins,
and minerals from whole foods. By focusing on eating a balanced diet that is primarily composed
of fresh, whole, uncontaminated, and unrefined foods and by engaging in an active and vital lifestyle
the body gets the energy, nutrients, and exercise it needs for optimal performance and is able to
rid itself of unneeded fat stores. The body is preprogrammed to work efficiently, energetically, and
effectively if it has all of its essential resources and a minimum of stressful, toxic, and burdensome
challenges that threaten to dismantle the scaffolding of health (at a greater rate than it can be
rebuilt). We are made only of food, air, water, and sunshine. The quality of our health and
metabolism is a direct result of the quality of those resources and the attitude with which we meet
life’s challenges.
CONCLUSIONS
Dr. Atkins offered a strategy of reducing insulin-resistance-induced metabolic insult caused by an
excessive consumption of the sort of carbohydrates that disturb the body’s insulin and blood sugar
metabolism. In contrast to the low-fat/high-carbohydrate paradigm popular at that time and the
juggernaut of failed tactics implementing that paradigm, as evidenced by the significant increase
in insulin resistance disorders, it can be concluded that Atkins was moving in the right direction.
The old adage that “hindsight is 20/20 vision” certainly gives us a critical advantage in perspective
over that of Atkins. More recent research reveals a few flaws in the sweeping conclusions supporting
the foundations of the Atkins paradigm; however, this does not completely dismantle the scaffolding
of his premise that chronic insulin resistance and related disorders, especially obesity, cardiovascular
disease, and diabetes, are exacerbated by the nemesis of excessive refined carbohydrate consumption
as a component of a lifestyle including other poor dietary habits. Atkins did not have the benefit
of research that has helped to improve our understanding of the many contributing factors to obesity,
some of which was spurred in response to the power and popularity of the Atkins paradigm. To
that point, Dr. Atkins was a courageous pioneer who ventured outside the box against conventional
dogma, and he spurred renewed investigations into and helped establish scientific merit for the
insulin-related issues he championed. To that extent, we owe him well-deserved accolades and a
debt of gratitude.
REFERENCES
[1] Foster, G.D., Wyatt, H.R., Hill, J.O., McGuckin, B.G., Brill, C. et al., A randomized trial of a low-
carbohydrate diet for obesity, N. Engl. J. Med., 348(21), 2082–2090, 2003.
[2] Astrup, A., Meinert Larsen, T., and Harper, A., Atkins and other low-carbohydrate diets: hoax or an
effective tool for weight loss?, Lancet, 364(9437), 897–879, 2004.
[3] Dansinger, M.L., Gleason, J.A., Griffith, J.L., Selker, H.P., and Schaefer, E.J., Comparison of the
Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a
randomized trial, JAMA, 293(1), 43–53, 2005.
[4] Noakes, M., Foster, P.R., Keogh, J.B., James, A.P., Mamo, J.C., and Clifton, P.M., Comparison of
isocaloric very low carbohydrate/high saturated fat and high carbohydrate/low saturated fat diets on
body composition and cardiovascular risk, Nutr. Metab. (Lond.), 3, 7, 2006.
[5] Johnston, C.S., Tjonn, S.L., Swan, P.D., White, A., Hutchins, H., and Sears, B., Ketogenic low-
carbohydrate diets have no metabolic advantage over nonketogenic low-carbohydrate diets, Am. J.
Clin. Nutr., 83(5), 1055–1061, 2006.
[6] Westerterp, K.R., Wilson, S.A., and Rolland, V., Diet induced thermogenesis measured over 24h in a
respiration chamber: effect of diet composition, Int. J. Obes. Relat. Metab. Disord., 23(3), 287–292,
1999.
[7] Westerterp, K.R., Diet induced thermogenesis, Nutr. Metab. (Lond.), 1(1), 5, 2004.
[8] Golay, A., Allaz, A.F., Morel, Y., de Tonnac, N., Tankova, S., and Reaven, G., Similar weight loss
with low- or high-carbohydrate diets, Metabolism, 43(12), 1481–1487, 1994.
[9] Holt, S.H., Brand-Miller, J.C., and Petocz, P., An insulin index of foods: the insulin demand generated
by 1000-kJ portions of common foods, Am. J. Clin. Nutr., 66, l264–1276, 1997.
25 Polyphenols from
Fruits and Vegetables
in Weight Management
and Obesity Control
Dilip Ghosh and Margot A. Skinner
CONTENTS
Introduction ....................................................................................................................................321
Association Between Fruit and Vegetable Consumption and Obesity .........................................322
Polyphenolics in Plants..................................................................................................................323
Fruits and Vegetables ..............................................................................................................323
Seeds, Nuts, and Culinary Herbs ...........................................................................................325
Tea ...........................................................................................................................................326
Mechanisms of Action ...................................................................................................................326
Glucose Uptake.......................................................................................................................326
Gluconeogenesis and Glycolysis ............................................................................................327
Adipogenesis and Lipolysis....................................................................................................328
Lipid Absorption and Metabolism..........................................................................................328
Appetite Control .....................................................................................................................329
Dietary Phytoestrogens ..................................................................................................................330
Food Sources...........................................................................................................................330
Role in Weight Management ..................................................................................................330
Exotic Fruits, Vegetables, and Herbs.............................................................................................330
Health Benefits for Conditions Associated with Obesity..............................................................331
Conclusion......................................................................................................................................332
References ......................................................................................................................................333
INTRODUCTION
The World Health Organization has recognized the epidemic of obesity as one of the top ten global
health problems [1]. In biological terms, obesity is the result of an imbalance between energy input
(food intake) and energy expenditure. In most individuals, obesity appears as a multigenic, multifac-
torial disease, and estimations indicate that genetic determinants account for at least 50% of the obese
phenotype, whereas the rest is due to the environment [2]. The current view of obesity indicates that
the environment in developed countries promotes overconsumption of energy in terms of food and a
reduction of energy expenditure. Obesity is related to several chronic and debilitating conditions
including coronary artery disease, metabolic syndrome, hypertension, stroke, hyperlipidemia, diabetes,
321
osteoarthritis, sleep apnea, gout, gallbladder disease, several cancers, and joint problems [3]. Recent
studies predict that one in three Americans born in the year 2000 will develop diabetes in their
lifetime [4], and a similar ominous future confronts nearly all developed nations. Drugs have been
developed to ameliorate or prevent obesity, but the costs, efficacy, and side effects must be considered.
For centuries people have used plants for healing. Written records about medicinal plants date back
at least 5000 years to the Sumerians [5]. Investigating new targets and perspectives may lead to
better methods in the prevention and treatment of obesity and related diseases.
The use of plants has the potential to keep the increasing prevalence of metabolic syndrome
in check. Many people are using natural products and plant-based dietary supplements for weight
loss. According to a recent survey, over 42% of adults in the United States reported using one or
more forms of alternative medicines or dietary supplements [6]. More than 8000 polyphenolic
compounds are found in foods of plant origin [7]; these compounds have been known for more
than 20 years for their antioxidant properties, but it is now becoming clear that they may have
other health benefits, including a role in energy control and weight management. Dietary guidelines
recommend an increase in fruit and vegetable consumption, and interpretation of epidemiological
evidence infers that this may have an effect on weight management and obesity [8,9].
ASSOCIATION BETWEEN FRUIT AND VEGETABLE

CONSUMPTION AND OBESITY
Numerous health benefits have been proposed to result from consuming a diet rich in fruits and
vegetables. The association between fruit and vegetable intake and weight management is not well
understood, and few studies have been specifically designed to address this issue. Short-term clinical
studies have shown that substituting fruits and vegetables for foods with higher energy densities
can be an effective weight management strategy [10]. Fruits and vegetables are high in water and
fiber. Incorporating them into the diet can reduce the energy density of diet, promote satiety, and
decrease energy intake [11]. Two epidemiological studies have been carried out on children and
adolescents to examine the relationship between fruit and vegetable intake and body weight. In a
3-year prospective cohort study, it was concluded that the recommendation for the consumption of
fruits and vegetables may be well founded but should not be based on a beneficial effect on
regulation of body mass index (BMI) in weight regulation [12]. In contrast, Lin and Morrison [13]
concluded from their study that a higher fruit consumption was linked with lower body weight. In
a recent review of epidemiological studies, Tohill et al. [14] tabulated and discussed 16 adult studies
as well as 2 on children and adolescents. Of the 16 adult studies, 8 reported a significant association
between higher intake of fruit or vegetables and decreased weight status, but there were confounding
effects. Of the 18 studies reviewed, only 2 examined the association between fruit and vegetable
intake and anthropometric outcome of body weight as a primary objective. The authors make
recommendations for future epidemiological studies to clarify the relationship. Another more recent
study also demonstrated that increasing the intake of fruits and vegetables may reduce long-term
risk of obesity and weight gain among middle-aged women [8]. Apple and pear intake has also
been shown to be associated with weight loss in middle-aged overweight women in Brazil [15].
Participants who consumed either of the fruits for 12 weeks had a significant weight loss compared
to controls. Overall, reasonable evidence is emerging to support the claim that a diet enriched in
fruits and vegetables may play a role in weight management. A concern, however, is that a high
intake of fruit juice could promote the development of obesity, but results have not been consistent
across studies [15,16]. Unfortunately, dietary patterns, such as combinations of different fruits and
vegetables, are extremely complex, and extensive randomized trials are necessary to assess whether
such dietary patterns will have a truly beneficial impact on weight management. More intervention
and epidemiologic studies are required to reach a conclusion regarding the relationship between
fruit and vegetable consumption and weight management.
Polyphenols from Fruits and Vegetables in Weight Management and Obesity Control 323
POLYPHENOLICS IN PLANTS
Phenolic compounds are abundant micronutrients in our diet, with an average consumption of around
1 g per day [17,18]. The polyphenolic content of fruits, vegetables, and other plant foods varies
considerably, not only between different types but also among strains of the same type, depending
on growing conditions and the time of harvest. Many are well known for their antioxidant activity.
FRUITS AND VEGETABLES

Fruits and vegetables are a particularly rich source of polyphenols. The polyphenolic contents of
some common fruits and vegetables are shown in Table 25.1. Polyphenols belong to one of the
major classes of plant secondary metabolites including phenolic acids, flavonoids, lignans, stilbenes,
coumarins, and tannins [19]. Several thousand have been discovered in edible plants, and they are
divided into different groups according to their structure and complexity [20,21] They appear to
protect the plant from stress and infection [22], which makes it not surprising that they should have
biological effects in animals and humans.
Polyphenols are a group of chemical substances characterized by the presence of more than
one phenolic group. The phenolic acids are phenols with only one ring. Those that predominate in
fruits and vegetables are derivatives of hydroxybenzoic acid and hydroxycinnamic acid and differ
by hydroxylations and methoxylations of their aromatic ring. The content of hydroxybenzoic acids
is generally low in fruits and vegetables, except in blackberry, raspberry [23], black currant, red
currant, and horseradish [24]. Hydroxycinnamic acids are common, particularly caffeic acid, which
is found in plums, apples, apricots, blueberries, and tomatoes [25]. Other predominant members
of this group include ferulic acid, p-coumaric acid (the dominant simple phenolic in citrus), and
chlorogenic acid, which is present in many common pip and stone fruits and berries [26], as well
as vegetables such as avocado, carrot, and eggplant. Defatted soy preparations also contain many
of these, with p-coumaric and ferulic acid being dominant in some preparations, but salicylic acid
being the principle phenolic acid in others [27]. Processing can alter the form and concentration
of these compounds considerably. Fruit may also contain phenolic amines, including tyramine,
dopamine, and serotonin. Banana and pineapple are examples of two fruits that are rich in serotonin.
Flavonoids are another large group of phenolic compounds; they have a basic skeleton composed
of three rings (Figure 25.1). They are classified into six families according to their substitution
pattern: anthocyanins, flavones, isoflavones, flavonols, flavanones, and flavanols. The anthocyanins
are responsible for the red, blue, and purple color of many plants — for example, the red skins of
radishes, the blue hue of blueberries, and the dark purple skin of eggplants. More than 500 different
anthocyanins have been identified in plants [7]. Generally, fruits contain from two to six different
anthocyanins, but some grape varieties can contain 16 or more [28]. The six anthocyanidins
commonly found in plants are classified according to the number and position of hydroxyl groups
on the flavan nucleus and are named cyanidin, delphinidin, malvidin, peonidin, pelargonidin, and
petunidin. Their stability during processing depends on the composition of the food as well as the
physical and chemical environment. Flavonols and flavones are generally present in foods both as
aglycones and glycosides. Commonly found flavonols include kaempferol, quercetin, and myricetin
and their derivatives. A combination of kaempferol and quercetin is most frequently found in fruits
[25], although quercetin derivatives are found in many vegetables, including potatoes, onions, and
fennel. Soybean is a rich source of isoflavones, such as diadzin and genistin (7-monoglycosides),
which during soaking may be hydrolyzed to their aglycones: daidzein and genistein. Two other
groups of flavonoids, the flavones and flavanones, are found mainly in celery, capsicum, and citrus
fruits and include derivatives of apigenin, luteolin, naringenin, and hesperidin. Catechin, a mono-
meric flavanol, is present in most fruits, with apricots, peaches, apples, and gooseberries having
the highest levels. Gallocatechin and epicatechin are also found in some fruits, particularly peaches,
red currants, black currants, and apples.
TABLE 25.1
Polyphenol Sources
Polyphenol Content
by Weight (mg/kg)
Polyphenols Source or Volume (mg/L)
Hydroxybenzoic acid Blackberry 80–270
Protocatechuic Raspberry 60–100
Gallic acid Black currant 40–130
p-Hydroxybenzoic acid Strawberry 20–90
Hydroxycinnamic acid Blueberry 2000–2200
Caffeic acid Kiwi 600–1000
Chlorogenic acid Cherry 180–1150
Coumaric acid Plum 140–1150
Ferulic acid Aubergine 600–660
Sinapic acid Apple 50–600
Pear 15–600
Chicory 200–500
Artichoke 450
Potato 100–190
Corn flour 310
Flour (wheat, rice, oat) 70–90
Cider 100–500
Coffee 350–1750
Anthocyanins Aubergine 7500
Cyanidin Blackberry 1000–4000
Pelargonidin Black currant 1300–4000
Peonidin Blueberry 250–5000
Delphinidin Black grape 300–7500
Malvidin Cherry 35–4500
Rhubarb 2000
Strawberry 150–750
Red wine 200–350
Plum 20–250
Red cabbage 250
Flavonols Yellow onion 350–1200
Quercetin Curly kale 300–600
Kaempferol Leek 30–225
Myricetin Cherry tomato 15–200
Broccoli 40–100
Blueberry 30–160
The plant polyphenols capable of precipitating proteins from aqueous solutions are known as
tannins. They may also form complexes with compounds such as polysaccharides. Depending on
their chemical structure, they are subdivided into hydrolyzable and condensed tannins. Hydrolyzable
tannins in fruits such as strawberry, raspberry, and blackberry are usually present in combination
with condensed tannins [29,30]. Condensed tannins, the proanthocyanidins, are more widely found
than the hydrolyzed tannins and can be present in the flesh of fruit but are primarily in the skin
and peel. Procyanidins isolated from fruit are dimers, oligomers, and polymers of certain flavanols
with average molecular weights ranging from 2000 to 4000 Daltons [25]. Tannins are responsible
for the astringency in many edible fruits, particularly before ripening, and tannin content may
decrease during maturation. Those present in beans and peas, which may make up to 2% of total
polyphenolics, are located mainly in the seed coat.
TABLE 25.1 (cont.)

Polyphenol Sources
Polyphenol Content
by Weight (mg/kg)
Polyphenols Source or Volume (mg/L)
Myricetin (cont.) Black currant 30–70
Apricot 25–50
Apple 20–40
Beans (green or white) 10–50
Black grape 15–40
Tomato 2–15
Black tea infusion 30–45
Green tea infusion 20–35
Red wine 2–30
Flavones Parsley 240–1850
Apigenin Celery 20–140
Luteolin Capsicum pepper 5–10
Flavanones Orange juice 215–685
Hesperetin Grapefruit juice 100–650
Naringin Lemon juice 50–300
Eriodictyol
Isoflavones Soy flour 800–1800
Daidzein Soybeans (boiled) 200–900
Genistein Miso 250–900
Glycitein Tofu 80–700
Tempeh 430–530
Soy milk 30–175
Monomeric flavanols Chocolate 460–610
Catechin Beans 350–550
Epicatechin Apricot 100–250
Cherry 50–220
Grape 30–175
Peach 50–140
Blackberry 130
Apple 20–120
Green tea 100–800
Black tea 60–500
Red wine 80–300
Cider 40
Source: Adapted from Manach, C. et al., Am. J. Clin. Nutr., 79, 727, 2004.
SEEDS, NUTS, AND CULINARY HERBS

Nuts, like beans and peas, contain characteristic arrays of phenolic acids, flavonoids, and tannins,
which again are associated with their coat or hull; for example, the bronze coloration of peanut
hulls is due to the presence of tannins, but the fruit (nut meat) is practically tannin free. In coffee
and cocoa, phenols play an important role in the formation of flavor. Green coffee beans contain
many chlorogenic acid isomers which degrade on roasting while the caffeine content remains
virtually unchanged [31]. The fermentation and drying process of cocoa also alters the content and
composition of polyphenolic compounds so the anthocyanins of unfermented purple beans are
hydrolyzed to anthocyanidins, giving fully fermented beans their brown color, and the low-molec-
ular-weight phenolics, such as epicatechin, are replaced with an enhanced content of tannins [32].
3'
2' 4'
1 B
8 1'
O 5'
7
C 2 6'
A
6 3
5 4
FIGURE 25.1 Basic skeleton structure of flavonoids. (Adapted from Zhang, J., Evaluation of Natural Oxi-
dants, Ph.D. thesis, University of Auckland, 2004.)
Many herbs and spices used to flavor food are a source of dietary phenolic compounds, although
the quantities consumed in this way are generally quite small. Among the various culinary herbs,
some species are of particular interest because they may be used for the production of raw materials
or preparations with putative health benefits as dietary supplements [33]. Many culinary herb
species, especially those belonging to the Lamiaceae family, such as sage, oregano, and thyme,
show strong antioxidant activity [34]. Rosmarinic acid is one such polyphenolic substance contrib-
uting to the antioxidant activity of rosemary, sage, mint, basil, and thyme [35]. Culinary herbs and
spices also contain many of the polyphenolics found in fruits and vegetables; for example, laurel
and juniper contain quercetin glycosides, fennel contains kaempferol, and cardamom contains
caffeic acid and p-coumaric acid [36].
TEA
Although green tea is discussed in another chapter, mention should be made of tea here, as some
of the polyphenols present in tea are also found in fruits and vegetables [37,38]. Green tea is one
of the most popular beverages consumed worldwide. Phenolic compounds constitute up to 35% of
the dry weight of tea. The major constituents are flavanols, such as epigallocatechin gallate (EGCG),
epigallocatechin (EGC), and catechin; flavonols, such as quercetin, kaempferol, and their glyco-
sides; flavones, such as vitexin and isovitexin; and phenolic acids, such as gallic acid and chlorogenic
acid [39]. Fermentation is a critical process for the production of good quality tea, and oxidation
of tea phenolics affects the color, flavor, and final polyphenolic composition.
MECHANISMS OF ACTION
Although large gaps still exist in our understanding of polyphenols and their impact on obesity and
related health conditions, the growing body of literature in this area suggests that they may confer
a substantial health benefit related to obesity beyond just lowering the energy density of the diet.
It has been shown that polyphenols may favorably affect glucose uptake and regulation, adipogen-
esis and lipolysis, lipid metabolism, and appetite control.
GLUCOSE UPTAKE
Glucose, one of the sugars produced by the breakdown of dietary carbohydrate, is central to
carbohydrate metabolism and energy control. The regulation of glucose uptake, under the control
of insulin, is important for maintaining appropriate blood glucose levels in times of feeding and
fasting. A number of flavonoids present in fruits and vegetables have been reported to be competitive
inhibitors of glucose uptake by a variety of cell types [40,41]. Phloridzin, a dietary flavonoid common
in apples, consists of a glucose moiety and two aromatic rings joined by an alkyl spacer; it has long
been known to produce renal glucosuria and block intestinal absorption of glucose [42]. Phloridzin
does this through inhibition of sodium-dependant glucose transporters (SLGTs), primarily located
in the proximal renal tubule and in the mucosa of the small intestine [43]. The SLGTs, two of which
(SLGT1 and SLGT2) have been fully characterized, carry glucose against a concentration gradient
into cells by coupling with the extrusion of sodium. Phloridzin competitively inhibits both SLGT1,
which transports two molecules of glucose for every one of sodium, and SLGT2, which transports
one molecule of each. Phloridzin is able to improve insulin sensitivity on its own simply by lowering
blood sugar [44]. Thus, the ability to block intestinal glucose absorption and renal glucose absorption,
with consequent caloric loss presumably resulting in weight loss, makes phloridzin a potential therapy
for obesity. The green tea polyphenol EGC has also been shown to markedly inhibit SLGT1 and
can also be considered as a potential therapeutic for weight management [45].
The facilitative glucose transporters (GLUTs), which transport glucose down a concentration
gradient, are expressed on virtually all cells and are not affected by phloridzin; however, removal
of the glucose moiety from phloridzin to yield phloretin, also found in apples, produces a compound
that can block GLUT-mediated glucose transport [46]. Glucose uptake by GLUT is inhibited by
many of the polyphenols present in fruits and vegetables. Genistein, quercetin, myricetin, morin,
rhamnetin, and isorhamnetin inhibit GLUT-1-mediated glucose transport through direct interaction
with the membrane protein in a variety of cell types, and evidence suggests that quercetin and
myricetin inhibit GLUT-3 activity as well [47]. GLUT-4 mediates insulin-stimulated glucose uptake
specifically in muscle and adipocytes, and glucose transport in adipocytes plays a critical role in
glucose homeostasis. Some flavanoids, including quercetin, myricetin [47], and naringenin [48],
have been shown to inhibit this type of glucose transport. Although many flavonoids can act as
tyrosine kinase inhibitors, including quercetin, these flavonoids do not appear to inhibit glucose
transport by inhibiting tyrosine kinase activity as they do not affect insulin receptor substrate 1
(IRS1) [47]. Naringenin has been shown to act by inhibiting the activity of a key regulator of
insulin-induced GLUT-4 translocation, phosphoinositide 3-kinase (PI3K), in 3T3-L1 preadipocytes.
By inhibiting PI3K, naringenin may also inhibit proliferation. It is interesting to note that naringenin
is able to inhibit insulin-stimulated glucose uptake by 20% in adipocytes at physiologically attain-
able doses of 6 µM [48]. Inhibition of glucose uptake in the gut and into adipocytes will have
beneficial effects on weight management and obesity, but similar inhibition into muscle could
potentially lead to the blood glucose effects associated with diabetes.
GLUCONEOGENESIS AND GLYCOLYSIS

The process of energy storage and transfer relies on the storage of glucose as glycogen in the liver.
Glucose can also be oxidized via the Kreb’s cycle or can undergo glycolysis for the synthesis of
fatty acids. Amino acids arising from protein are converted to glucose via the Kreb’s cycle in a
process known as gluconeogenesis. Effects of quercetin on both glycolysis and gluconeogenesis
have been reported [49] using perfused rat liver. It was concluded that quercetin can inhibit both
glucose degradation and production with suggestions that reduction of oxidative phosphorylation,
inhibition of Na+–K+–ATPase, and inhibition of glucokinase and glucose-6-phosphatase could all
contribute to the overall effect. Oral administration of quercetin to diabetic rats resulted in a decrease
in the levels of blood glucose and ameliorated diabetes-induced changes in oxidative stress [50].
Quercetin has also been shown to effectively reduce postprandial hyperglycemia in diabetic rats,
reflecting its ability to increase carbohydrate metabolism in the small intestine [51]. The major
green tea polyphenolic constituent, EGCG, has been shown to mimic some of the effects of insulin
in a cell culture system by reducing gene expression of rate-limiting gluconeogenic enzymes [52],
and more recently this has been demonstrated in vivo [53]. Similarly, red wine polyphenolic extracts
[54] and grapeseed-derived procyanidins [55] have been shown to exert antidiabetic effects in
streptozotocin-induced diabetic rats. Grapeseed procyanidin extracts have recently been shown to
have insulinomimetic properties in the 3T3-L1 adipocyte cell line, activating both glycogen and
lipid synthesis [56].
ADIPOGENESIS AND LIPOLYSIS

Adipocyte dysfunction is strongly associated with the development of obesity and insulin resistance.
Adipocytes synthesize and secrete biologically active molecules called adipokines (e.g., leptin),
which reduce food intake and increase energy expenditure. Drugs that target regulation of adipocyte
function, in particular the peroxisome proliferator-activated receptor γ (PPARγ), have effects on
adipocyte differentiation, cause an increase in fatty acid oxidation, and ameliorate hyperglycemia
without stimulating insulin secretion. They are used as a therapy for obesity-related metabolic
disease. There are fewer studies on the effects of flavonoids in adipocytes than on other cell types,
but some interesting results are emerging. Quercetin and fisetin have been shown to potentiate
epinephrine-induced lipolysis in isolated rat adipocytes and appear to increase membrane phos-
pholipid methylation, which correlates with cellular accumulation of cyclic AMP [57]. Shisheva
and Shechter [58] found that quercetin blocked insulin-mediated lipogenesis by preventing the
insulin receptor tyrosine kinase from phosphorylating substrate. These potentially lipolytic and
antilipogenic effects in rat adipocytes, coupled with antiproliferative activity in a number of cell
lines, suggest that flavonoids may decrease adipose tissue mass or inhibit the signals that promote
adipogenesis. Recently, Harmon and Harp [59] showed using 3T3-L1 cells that both genistein and
naringenin inhibited proliferation of preconfluent preadipocyte cells, but only genistein was able
to inhibit proliferation of postconfluent preadipocytes at the induction of differentiation and their
subsequent differentiation into mature adipocytes. In mature adipocytes, again genistein, but not
naringenin, was shown to strongly induce lipolysis, both alone and in combination with epinephrine
[59]. These findings in cultured adipose cells suggest that dietary flavonoids, particularly genistein,
may have inhibitory effects on adipose tissue enlargement. The few animal studies that have
evaluated the effects of genistein treatment on lipid metabolism or body weight support the findings
with isolated cells [60]. Genistein holds promise for nutrient-mediated regulation of body fat through
its effects on preadipocyte replication, differentiation, and lipolysis.
The study of gene expression, particularly using microarrays of RNA from adipocytes, has
revealed some additional interesting effects of polyphenols. Comparison of obese and lean human
omental adipose tissue has demonstrated a general tendency in obese tissue to blunt lipolysis inducer
genes and a global downregulation of genes encoding growth factors. Downregulation of growth
factors and upregulation of mitogen-activated protein kinases (MAPKs) may indicate an attempt
to restrain adipocyte proliferation and differentiation [61]. Dietary anthocyanins have been shown
to normalize hypertrophy of adipocytes in epididymal white adipose tissue, ameliorate hypergly-
cemia induced by a high-fat diet, and suppress development of obesity in mice [62]. In isolated rat
adipocytes, anthocyanins have been shown to upregulate adipokine-specific gene expression and
secretion without activation of PPARγ [63]. It has just recently been shown that they also upregulate
genes involved in lipid metabolism and signal transduction, leading to upregulation of hormone-
sensitive lipase and enhancement of lipolytic activity [64]. The anthocyanins used in the latter study
were cyanidin-3-glucoside and cyanidin, and the general conclusions regarding responsive genes
whose function is important in obesity and diabetes were similar for both studies.
LIPID ABSORPTION AND METABOLISM

Lipase inhibitors are good candidates for the treatment of obesity, and one of the latest drugs for
obesity, XENICAL® (orlistat), belongs to this class of compounds. They inhibit the key enzyme
that breaks down fat in the gut, resulting in lower fat absorption. Some natural products are lipase
inhibitors (for example, flavanol extracts from Cassia nomame [65]), and recently some of the
major polyphenols of tea (e.g., EGCG and oolong tea polymerized polyphenols) have been shown
to inhibit pancreatic lipase. Catechin, however, was shown to be ineffective in this study [66].
Lipase-inhibiting substances in fruits, related to their condensed tannins, have also been reported
[67]. In an in vitro experiment, Moreno et al. [68] showed that a grapeseed extract rich in polyphenol
compounds inhibited the fat-metabolizing enzymes pancreatic lipase, lipoprotein lipase, and hor-
mone-sensitive lipase, and consequently the authors described it as a safe, natural, and cost-effective
weight control treatment.
The regulation of cholesterol absorption and metabolism is important in obesity, as enhanced
intake may lead to cardiovascular disease. Green tea catechins have hypocholesterolemic effects
[67,70] and suppress the intestinal absorption of cholesterol [70,71]. Moreover, the tea polyphenol
EGCG has been shown to have an inhibitory effect on acetyl-CoA carboxylase, which is essential
for fatty acid biosynthesis in vitro [72], and anti-obesity effects at high doses in rats [73,74]. On
analyzing the effect of catechin on intestinal lipid metabolism, Valsa et al. [75] detected an increase
in the concentration of cholesterol in the duodenum and jejunum along with an increase in the
hydroxy-3-methyl glutaryl CoA (HMGCoA) reductase activity. The authors suggested that this
increase in enzyme activity could be due to the binding of catechin to cholesterol in the lumen.
De-alcoholized red wine contains resveratrol (a stilbene, with estrogen-like activity); the flavonoids
catechin, epicatechin, and quercetin; and phenolic acids, such as gallic acid, which have been shown
to increase HMGCoA reductase mRNA and low-density lipoprotein (LDL) receptor binding activity
relative to controls in the HepG2 liver cell line. De-alcoholized red wine also increased LDL
receptor gene expression, suggesting that red wine polyphenolics regulate major pathways involved
in lipoprotein metabolism [76]. By using de-alcoholized wine, the confounding effects of alcohol
were removed. In a human trial, it was demonstrated that there was a significant delay in fat
absorption after the consumption of red wine phenolics [76].
Green tea extracts, rich in catechins, have been shown to have thermogenic properties, increas-
ing 24-hour energy expenditure and fat oxidation in people beyond that expected by their caffeine
content [38]. In a trial on Japanese females, oolong tea was shown to increase energy consumption,
whereas green tea did not have a significant effect. The effect of the oolong tea may have been
due to polymerized polyphenols; in comparison with green tea, oolong tea contained approximately
half the caffeine and EGCG, while polymerized polyphenols were double [77]. Tea also contains
caffeine and theanine, which can have effects on weight management. Zheng et al. [78] showed
that, although caffeine and theanine were the constituents of green tea powder responsible for a
suppressive effect on body weight increase and fat accumulation, they also demonstrated that
catechin and caffeine were synergistic in anti-obesity activities.
APPETITE CONTROL
Appetite can be viewed as a bridge between energy intake and expenditure that should aid in
coupling the two. Several studies indicate that incorporating cayenne pepper into the diet may help
people to lose weight by reducing hunger after meals and calories consumed during subsequent
meals. Capsaicin and a closely related compound, dihydrocapsaicin, are responsible for many of
the red pepper effects. They have the ability to bind to the capsaicin (or vanilloid) receptors in a
subpopulation of primary afferent sensory neurons. Oregano, cinnamon, and cilantro also contain
this type of compound but at much lower concentrations. Red pepper and coffee consumption can
significantly reduce cumulative ad libitum energy intake and increase energy expenditure [79],
indicating that their consumption can induce a considerable change in energy balance when indi-
viduals are given free access to foods. It was suggested that these effects are mediated by an increase
in the ratio of sympathetic nervous system vs. parasympathetic nervous system activity as measured
by power spectral analysis of heart rate. Previously, the same group had conducted two studies to
investigate the effects of red pepper on feeding behavior and energy intake [80]. The results indicated
that the ingestion of red pepper decreases appetite and subsequent protein and fat intakes in Japanese
women and energy intake in Caucasian men. Moreover, this effect might be related to an increase
in sympathetic nervous system activity in Caucasian men. The maximum tolerable dose of red
pepper was found to be necessary to have a suppressive effect on fat intake [81]. In another study,
the effects of dietary hot red pepper on energy metabolism at rest and during exercise were examined
in long-distance male runners [82]. Significantly higher plasma epinephrine and norepinephrine
levels in those that were fed red hot pepper were found. These results suggested that hot red pepper
ingestion stimulates carbohydrate oxidation at rest and during exercise.
DIETARY PHYTOESTROGENS
Phytoestrogens are a group of biologically active plant substances with chemical structures related
to that of estradiol, the principal endogenous estrogen in humans. These structural elements account
for the ability of phytoestrogens to bind to estrogen receptors in various cells [83,84] and exert
estrogenic or antiestrogenic effects.
FOOD SOURCES
Phytoestrogens are found in various plants consumed by humans, including legumes, seeds, and
whole grains. The three major classes of phytoestrogens are isoflavones, lignans, and coumestans.
The most abundant food sources of isoflavones (genistein and daidzein) are soybean and soybean
products. Other beans, lentils, and peas contain a small quantity of isoflavones. Common food
sources of lignans include seeds, whole grains, legumes, and vegetables. Major sources of plant
lignans include cereals, cereal brans, oil seeds, and fruit. Coumestrol is the most important
coumestan consumed by humans, with the major food sources being alfalfa sprouts, dry round split
peas, and other legumes.
ROLE IN WEIGHT MANAGEMENT

Substantial data from epidemiological surveys and nutritional intervention studies in humans and
animals suggest that the consumption of plant-based foods rich in phytoestrogens may benefit
human health. They have been shown to have benefits in protection against menopausal symptoms
and in a variety of disorders, including cardiovascular disease, cancer, hyperlipidemia, osteoporosis,
and various forms of chronic renal disease [85–88]. Evidence is emerging that consumption of
foods rich in phytoestrogens may have a beneficial effect on obesity and diabetes [89]. Nutritional
intervention studies performed in animals and humans suggest that the ingestion of isoflavones
associated with soy protein and flaxseed rich in lignans improves glucose control and insulin
resistance. Phytoestrogens have been shown to have a beneficial effect by improving serum lipids
and modifying LDL oxidation, the basal metabolic rate, and insulin-stimulated glucose oxidation.
Several lines of evidence suggest that phytoestrogens may favorably affect glucose homeostasis,
insulin secretion, and lipid metabolism [60,90–92]. Thus, phytoestrogens appear to have favorable
biological effects of benefit in weight control, obesity, and diabetes.
EXOTIC FRUITS, VEGETABLES, AND HERBS

The activity of flavonoids and tannins in exotic fruits, vegetables, and herbs and their seeds, leaves,
stems, and roots have been exploited in many traditional medicines. They will not be dealt with in
detail in this chapter, but a few interesting examples are mentioned. In Brazil, a phytomedicine
obtained from the fruits of Solanum lycocarpum St. Hill (Solanaceae) has been widely employed for
the management of diabetes and obesity and to decrease cholesterol levels. The presence of flavonoids
[93] and tannins [94] was found to be responsible for such activity. Polyphenol fractions prepared
from the leaves of Salix matsudana were shown to reduce the elevation of rat plasma triacylglycerol
and hepatic total cholesterol content after oral administration of a high-fat diet alone [95]. Furthermore,
three flavonoid glucosides enhanced norepinephrine-induced lipolysis in fat cells [96]. In his herbal
handbook The Green Pharmacy, Duke [97] quotes Russian researchers as having found that the
weight-loss effect of plantain is related to polyphenols in this plant. Some tentative evidence supports
a potential role for plantago in reducing short-term appetite, fat, and energy intake [98–101].
St. John’s wort (Hypericum perforatum) is a flowering plant indigenous to much of Europe,
the Americas, New Zealand, and Australia. It is reported by some that these extracts have seroton-
ergic activity [102]. Due to its presumed serotonergic action, St. John’s wort is thought to have the
potential to suppress appetite and cause weight loss, but animal studies to support this claim are
lacking. An open-label study that used a combination of Ma huang and St. John’s wort has been
published only in abstract form [103]. In a patent application, Haveson [104] cited three additional
studies of St. John’s wort and Ma huang used in combination for controlling weight loss.
Herbal preparations known as “YGD” contain yerba maté (leaves of Ilex paraguayensis),
guarana (seeds of Paullinia cupana), and damiana (leaves of Turnera diffusa var. aphrodisiaca);
they have long been used in South American folk medicines for weight management. Tannins are
the major polyphenolics present in this preparation, plus it also contains caffeine. In one double-
blind, placebo-controlled parallel trial, the YGD preparation significantly delayed gastric emptying,
reduced the time to perceived gastric fullness, and induced significant weight loss over 45 days in
overweight patients treated in a primary healthcare context [105]. The maintenance treatment given
in an uncontrolled context resulted in no further weight loss; however, the mechanisms involved
have yet to be published.
HEALTH BENEFITS FOR CONDITIONS

ASSOCIATED WITH OBESITY
Over the last decade, researchers and food manufacturers have become increasingly interested in
polyphenols, due to their antioxidant properties and their potential health benefits with regard to
diabetes, cancer, and cardiovascular and neurodegenerative diseases [21,106], some of which are
associated with obesity. Epidemiological data are beginning to support the association between a
high intake of fruits and vegetables and a low risk of chronic diseases [107]. The total dietary
intake of polyphenols can be as high as 1 g/day, which is much higher than any other class of
phytochemicals and known dietary antioxidants.
Despite their wide distribution in plants, the health effects of dietary polyphenols have come
to the attention of nutritionists only rather recently. The main factor that has delayed research
on polyphenols is the considerable diversity and complexity of their chemical structures. Current
evidence is beginning to support a contribution of polyphenols to the prevention of cardiovascular
diseases, cancers, and osteoporosis and suggests a role in the prevention of neurodegenerative
diseases and diabetes mellitus [17]. Obesity is clearly associated with some of these diseases
and is the dominant modifiable risk factor for type 2 diabetes. Some evidence suggests that
adequate fruit and vegetable consumption may lower the risk of developing diabetes [108–111].
Despite the presence of dietary fiber and minerals in fruits and vegetables, some research suggests
that antioxidant compounds such as carotenoids, flavonoids, vitamins, phenolic acids, and indoles
could have favorable effects on the pathogenesis of diabetes [112–115]. Treatment of rats,
rendered diabetic with streptozotocin, with ethanol-free polyphenols from white wine has been
shown to reduce the plasma antioxidant capacity associated with the diabetic state [116]. As
insulin resistance and diabetes are associated with increased oxidative stress [117], these bene-
ficial effects of fruit and vegetable polyphenolics could result from their antioxidant properties
as well as the other effects that these compounds have on glucose transport, fat absorption, and
carbohydrate and fat metabolism.
Our knowledge, however, still appears too limited for formulation of recommendations for
general population or for particular populations at risk of specific diseases. Evidence for a reduction
of disease risk by flavonoids was considered “possible” for cardiovascular disease and “insufficient”
for cancers in a recent report from the World Health Organization [118]. Significant progress has
been made in the field of cardiovascular disease, and today it is well established that some
polyphenols, administered as supplements or with food, do improve health status, as indicated by
several biomarkers closely associated with cardiovascular risk [119–121]. Limited epidemiologic
studies tend to confirm the protective effects of polyphenol consumption against cardiovascular
diseases [122]. In contrast, evidence for the protective effects of polyphenols against cancers,
neurodegenerative diseases, and brain function deterioration is still largely derived from animal
experiments and in vitro studies [123,124]. We have to wait for the discovery of predictive biom-
arkers for such diseases or large intervention studies, similar to those performed with nonphenolic
antioxidants [125].
CONCLUSION
The majority of the world’s population relies on plants as their source of medicines. Crude
botanical drugs or plant extracts are utilized primarily by lay persons as a form of alternative
therapy for the treatment of disease states, often of a chronic nature, or to attain or maintain a
state of improved health. The first documented dietary prescription in the treatment of presumed
diabetes appeared in the Papyrus Ebers, written around 1500 B.C., and the use of wheat grains,
grapes, honey, and berries has been advocated for this disease more recently [126]. To understand
whether the effect of consumption of fruits and vegetables on obesity and weight control is
simply due to a substitution of high-calorie foods with those of low-calorie and high-fiber
content or whether phytochemical constituents such as polyphenols are involved in the observed
effects requires carefully planned and controlled feeding trials, which have yet to be carried
out. Although the effects of the polyphenolic compounds present in fruits and vegetables on
cellular and biochemical mechanisms related to energy control and weight management are
beginning to be understood, a better understanding of their interactions with the cell membrane
and of their uptake and metabolism is necessary to understand the effects of these compounds
in the various cell types and tissues [127]. As evidence emerges that fruit and vegetable
constituents aid in weight management and obesity control, the opportunity arises to develop
functional foods in this area. These may include food products that help in the management of
hunger or increase the satiety or foods that contribute to more inefficient use of ingested energy
(i.e., foods that stimulate energy expenditure more than would be expected from their energy
content). As the concept of insulin sensitivity becomes generally more accepted by healthcare
professionals and the public, foods may be targeted toward maximizing insulin sensitivity and
the prevention of diabetes. Foods that have an impact on body weight may include foods that
affect the glucose or insulin levels that are seen either following the ingestion of food or later
in the day. As synergistic interactions between different food constituents are discovered [128],
it may be possible to develop foods that target one or more of the physiological processes
involved in weight control in a way that is better than having them on their own.
The current evidence for protective effects of polyphenols against diseases has generated
new expectations for improvements in health, with great interest from the food and nutritional
supplement industry regarding the promotion and development of polyphenol-rich products;
however, it is still impossible to evaluate individual needs and recommendations of foods tailored
for an individual genotype. Nutrigenomics will lead to the development of new foods for
individualized health and nutritional benefit. As we begin to understand the genetic components
of weight management and obesity, it should be possible to apply personalized nutrition in this
area. In the future, we can look forward to novel functional foods containing fruits and vegetables
as wellness foods that may assist in weight management and have associated health benefits
that keep obesity at bay.
ACKNOWLEDGMENTS
Thanks to Bob Elliott, Daryl Rowen, Steve Skinner, Jingli Zhang, and David Stevenson for critically
reading the manuscript.
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26 Chromium (III) in
Promoting Weight Loss
and Lean Body Mass
Manashi Bagchi, Harry G. Preuss, Shirley Zafra-Stone,
and Debasis Bagchi
CONTENTS
Introduction ....................................................................................................................................339
Consequences of Chromium (III) Deficiency ...............................................................................339
Dietary Sources of Chromium (III) and Recommended Dietary Intake ......................................340
Glucose Tolerance Factor...............................................................................................................340
Bioavailability of Chromium (III) Complexes ..............................................................................341
Chromium (III) Supplementation, Metabolic Syndrome, and Weight Loss.................................341
Safety of Chromium (III) Complexes ...........................................................................................344
Conclusion......................................................................................................................................345
References ......................................................................................................................................345
INTRODUCTION
A large number of biochemical, pharmacological, and toxicological studies have established
selected chromium (III) complexes as novel micronutrients for ameliorating the components of the
metabolic syndrome via enhancing glucose–insulin sensitivity [1–6]. Early studies showed that the
biologically active form of chromium (III) in Brewer’s yeast forms a glucose tolerance factor (GTF)
that prevents diabetes in experimental animals by impeding the action of insulin and modulating
protein, fat, and carbohydrate metabolism, resulting in significantly reduced plasma glucose levels
in diabetic animals [1–7].
CONSEQUENCES OF CHROMIUM (III) DEFICIENCY

A strong association exists between chromium deficiency, high blood insulin, atherosclerosis, and
elevated blood cholesterol levels. In rats, chromium deficiency has been reported to increase serum
cholesterol levels and formation of aortic plaques [4]. In humans, it has been well demonstrated
that chromium deficiency can lead to impaired insulin function, obesity, and cardiovascular dys-
function [4]. This is unfortunate, because many elderly people, diabetics, and pregnant women
suffer from chromium deficiency. Athletes, too, suffer from chromium deficiency, as a major cause
of chromium loss is strenuous exercise [1,2]. On the positive side, chromium (III) supplementation
has been shown to prevent the formation of aortic plaques and the rise of serum cholesterol [2].
339
DIETARY SOURCES OF CHROMIUM (III)

AND RECOMMENDED DIETARY INTAKE
Chromium (III) is available in various food sources, including whole-grain products, high-bran
breakfast cereals, egg yolks, coffee, nuts, green beans, broccoli, meat, Brewer’s yeast, and selected
brands of beer and wine. Chromium (III) complexes are also found in many mineral or multivitamin
supplements. According to the National Research Council (NRC), the Estimated Safe and Adequate
Daily Dietary Intake (ESADDI) for chromium (III) is 50 to 200 µg/day, corresponding to 0.83 to
3.33 µg/kg/day for an adult weighing 60 kg [8]. The U.S. Food and Drug Administration (FDA)
has selected a Reference Daily Intake (RDI) of 120 µg/day for chromium (III).
GLUCOSE TOLERANCE FACTOR

Chromium (III), in the form of the naturally occurring dinicotinic acid–glutathione complex, or
glucose tolerance factor (GTF), significantly enhances the effect of exogenous insulin on glucose
metabolism [2,3]. GTF influences the action of insulin and potentiates the actions of protein, fat,
and carbohydrate metabolism [2,3]. GTF is safe, absorbable, and known to stabilize blood glucose
levels; furthermore, GTF has access to biologically important chromium storage depots in the fetus
and placenta [2–4]. The most abundant and naturally occurring form of GTF is found in Brewer’s
yeast [2–4]. The O-coordinated chromium (III)–dinicotinic acid complex is biologically active,
which suggests that a trans configuration of pyridine nitrogen atoms resembles that part of the
GTF structure that is recognized by the receptors or enzymes and is involved in the expression of
the biological effect [2,3]. The body’s ability to convert simple chromium (III) compounds into the
GTF form declines with advancing age and is impaired in diabetes and probably in hyperlipidemic
and atherosclerotic patients as well [2,3,9–11]. Unfortunately, naturally occurring GTF represents
less than 2% of the available chromium in Brewer’s yeast [2,3].
Several studies demonstrate that the biologically active form of chromium (III) in Brewer’s
yeast promotes GTF and prevents diabetes in experimental animals by impeding the action of
insulin to enhance protein, fat, and carbohydrate metabolism and significantly reduces plasma
glucose levels in diabetic mice [2,3,9–11]. A clinical investigation on diabetic patients showed a
highly favorable response (i.e., increased insulin sensitivity) to chromium supplementation via
Brewer’s yeast. Twenty-two participants (8 males and 14 females; mean age, 51 years) with fasting
values of total cholesterol and glucose from 3.21 to 6.90 and 4.3 to 6.2 mmol/L, respectively, were
evaluated. After a 9-hr fast, an oral glucose load (75 g) was administered before chromium (III)
supplementation, and blood was drawn before and at 30, 60, 90, and 120 min after the glucose
load [11,12]. Subjects were given either Brewer’s yeast or torula yeast (10 g yeast powder) daily
for 12 weeks. Brewer’s yeast demonstrated a beneficial effect by decreasing serum triacylglycerol
values in subjects. In an oral glucose tolerance test, an increment at 0 min and significant decreases
at 60 and 90 min were shown. In subjects given torula yeast, glucose values increased at both 0
and 30 min after glucose load and 12-week supplementation. Brewer’s yeast and torula yeast
significantly altered glucose concentrations at 60 min after glucose dosage. Brewer’s yeast had
significant decreasing effects on insulin output both at 90 and 120 min after glucose load; likewise,
in subjects given torula yeast, serum insulin contents decreased at 90 min. Brewer’s yeast supple-
mentation had beneficial effects both on serum triacylglycerol and on the 60- and 90-min glucose
values of oral glucose tolerance test [11,12].
A complex of chromium (III) and nicotinic acid was demonstrated to facilitate insulin binding
similar to the GTF found in Brewer’s yeast. Urberg et al. [11] showed that humans’ inability to
respond to chromium (III) supplementation resulted from suboptimal levels of dietary nicotinic acid
to serve as a substrate for GTF synthesis. In a controlled clinical trial, 16 healthy elderly volunteers
were given 200 µg chromium (III), 100 mg nicotinic acid, or 200 µg chromium (III) + 100 mg
nicotinic acid daily for 28 days and evaluated on days 0 and 28. Fasting glucose and glucose tolerance
Chromium (III) in Promoting Weight Loss and Lean Body Mass 341
were unaffected by either chromium (III) or nicotinic acid alone. In contrast, the combined chro-
mium–nicotinic acid supplement caused a 15% decrease in a glucose area integrated total (p < 0.025)
and a 7% decrease in fasting glucose.
BIOAVAILABILITY OF CHROMIUM (III) COMPLEXES

The mechanism of trivalent chromium absorption and action has been studied extensively. After
absorption in the gastrointestinal tract, chromium is transported to cells bound to the plasma protein
transferrin. Insulin initiates chromium (III) transport into the cells, where it is bound to the oligopeptide
apochromodulin. Apochromodulin, combined in a tetra-nuclear assembly of four chromium (III)
atoms, forms the low-molecular-weight oligopeptide chromodulin (MW, ~1500 Da), which is impor-
tant in amplifying the insulin signaling effect. After binding to insulin-activated receptor, chromodulin
increases tyrosine kinase activity and forms a part of the intracellular portion of insulin receptor [13].
In a study conducted by Clodfelder et al. [14], the biomimetic cation [Cr3O(O2CCH2CH3)6(H2O)3]+
was found to imitate the ability of oligopeptide chromodulin to stimulate the tyrosine kinase activity
of insulin receptor, to increase insulin sensitivity, and to decrease plasma total concentrations, low-
density lipoprotein (LDL) concentrations, and triglycerides concentrations, as shown in healthy and
type 2 diabetic rat models. In addition, due to the stability and solubility of the biomimetic cation, a
greater magnitude of absorbability was demonstrated [14].
Olin et al. [15] investigated the absorption and retention of CrCl3, niacin-bound chromium
(NBC), and chromium picolinate over a 12-hr period. Male rats (150 to 170 g) were gavaged with
44 µCi (1 mL each or 2.7 nmol) chromium as CrCl3, NBC, or chromium picolinate. At 1, 3, 6, and
12 hr post gavage, rats were anesthetized and killed. Cardiac blood and urine (at 6 and 12 hr) were
collected, and liver, kidneys, pancreas, testes, and gastrocnemius were removed, weighed, and
assayed to calculate the chromium absorbed/retained. Results reveal that the highest percent of
absorbed/retained counts was observed in urine, followed by the muscle, blood, and liver. The average
percent chromium (III) retained in the tissues was higher in NBC-gavaged rats than in CrCl3– or
chromium-picolinate-gavaged rats for the majority of the time points. One hour post gavage, NBC
rats had retention percentages 3.2- to 8.4-fold higher in the tissues collected compared to the
chromium picolinate and CrCl3 groups. Three hours post gavage, NBC-treated rats had blood, muscle,
and pancreatic chromium retentions that were 2.4 to 8 times higher compared to chromium-picoli-
nate-gavaged rats. By 6 and 12 hr post gavage, the levels of absorbed/retained chromium in tissues
were 1.8 to 3.8 times higher in the NBC-treated group compared to rats receiving chromium
picolinate. These results demonstrate significant differences in the bioavailability of the different
chromium compounds, with NBC exhibiting superior bioavailability (see Table 26.1 and Table 26.2).
CHROMIUM (III) SUPPLEMENTATION,

METABOLIC SYNDROME, AND WEIGHT LOSS
Obesity is a highly prevalent health problem in the United States and around the world [16,17].
Obesity is associated with a broad spectrum of degenerative diseases, including certain forms of
cancer. Existing elements of insulin resistance, lipid disturbances, glucose intolerance, obesity, and
hypertension have been characterized by the term metabolic syndrome [16–18]. Suboptimal chro-
mium (III) intake, common in the global scenario, can contribute to these metabolic disorders
[17,18]. Studies have shown that novel chromium (III) complexes are efficacious in maintaining
proper carbohydrate and lipid metabolism in both humans and animals. The insulin signaling
potential of trivalent chromium has demonstrated its effects on body composition, including reduc-
tion of fat mass and enhancement of lean body mass. Previous studies have focused on the use of
the dietary chromium (III), especially niacin-bound chromium, due to its increased absorption and
retention [15].
342
TABLE 26.1
Percent of 51Cr Dose Absorbed/Retained in the Liver, Pancreas, and Kidney Tissues
Liver Pancreas Kidney
1 hr 3 hr 6 hr 12 hr 1 hr 3 hr 6 hr 12 hr 1 hr 3 hr 6 hr 12 hr
51 CrCl3 0.295± 0.769± 0.724± 0.231± 0.077± 0.085± 0.014± 0.029± 0.153± 0.459± 0.209± 0.179±
0.082a 0.210 0.473 0.039ab 0.057ab 0.044 0.005a 0.022 0.034a 0.079 0.039a 0.033a
51 NBC 1.869± 0.668± 0.353± 0.378± 0.309± 0.265± 0.030± 0.028± 0.696± 0.441± 0.476± 0.355±
0.433b 0.116 0.101 0.086a 0.158a 0.231 0.007b 0.010 0.144b 0.107 0.133b 0.090b
51 CrPic 0.250± 0.345± 0.201± 0.155± 0.021± 0.031± 0.008± 0.013± 0.146± 0.571± 0.156± 0.137±
0.046a 0.068 0.032 0.029b 0.008b 0.016 0.002a 0.002 0.025a 0.338 0.034a 0.029a
a,b Each data point represents mean ± SEM at 1, 3, 6, and 12 hr post gavage. Values with non-identical superscripts are significantly different (p ≤ 0.05).
TABLE 26.2
Percent of 51Cr Dose Absorbed/Retained in the Muscle, Blood, and Urine
Muscle (Gastrocnemius) Blood Urine
1 hr 3 hr 6 hr 12 hr 1 hr 3 hr 6 hr 12 hr 1 hr 3 hr 6 hr 12 hr
51 CrCl3 1.53± 1.910± 1.879± 0.801± 0.346± 0.681± 0.338± 0.229± — — 3.05± 4.35±
0.42 0.857 1.227 0.134 0.085a 0.134ab 0.052a 0.037a 0.67a 0.86ab
51 NBC 12.62± 2.158± 1.910± 1.503± 2.575± 1.180± 0.629± 0.381± — — 8.91± 6.25±
6.67 0.948 0.618 0.474 0.756b 0.346b 0.187b 0.070b 2.54b 1.36a
51 CrPic 4.01± 0.855± 0.591± 0.594± 0.450± 0.497± 0.347± 0.183± — — 2.95± 3.00±
1.81 0.325 0.157 0.083 0.115a 0.103a 0.080a 0.036a 0.83a 0.54b
a,bEach data point represents mean ± SEM at 1, 3, 6, and 12 hr post gavage. Values with non-identical superscripts are significantly different (p ≤ 0.05).
Clinical studies have consistently reported that chromium supplementation in overweight people
induces loss of fat mass and/or increases lean body mass. Crawford et al. [19] reported that
supplementation of 600 µg per day of elemental chromium (III) as NBC over a period of 2 months
by African-American women, combined with a moderate diet and exercise regimen, favorably
influenced weight loss and body composition. In a randomized, double-blinded, placebo-controlled,
crossover study, 20 overweight African-American women received placebo t.i.d. during the control
period and 200 µg NBC t.i.d. during the verum period and engaged in a modest diet and exercise
regimen for 2 months. Group 1 subjects (n = 10) received placebo first then NBC; group 2 subjects
(n = 10) received NBC first then placebo later. Body weights and blood chemistries were measured
by routine clinical methodology. Fat and non-fat body masses were estimated using bioelectrical
impedance (electrolipography). In women receiving NBC after the placebo period (group 1), body
weight loss was essentially the same, but fat loss was significantly greater and non-fat body mass
loss was significantly less with chromium (III) intake. There was a significantly greater loss of fat
in the placebo period compared to the verum period of group 1; however, the ability of chromium
supplementation to augment fat loss and decrease lean body mass loss was carried over into the
placebo period even after a 1-month wash-out period. No changes in blood chemistries were
observed in either group. To summarize, results confirmed that NBC given to African-American
women in conjunction with moderate diet and exercise caused a significant loss of fat and spared
muscle compared to placebo, and this effect can be carried over for months [19].
Grant et al. [20] studied the effects of chromium (III) supplementation (400 µg elemental
chromium per day) as NBC and chromium picolinate, with or without exercise training, in young,
obese women. Exercise training combined with NBC supplementation resulted in significant weight
loss and lowered the insulin response to an oral glucose load. In contrast, chromium picolinate
supplementation was associated with a significant weight gain. Accordingly, exercise training with
NBC supplementation is beneficial for weight loss and lowers the risk of diabetes.
Recently, NBC in combination with HCA-SX and a standardized Gymnema sylvestre extract
was evaluated in a weight loss study of moderately obese subjects [21–23]. A randomized, double-
blind, placebo-controlled human study was conducted in 60 moderately obese subjects (ages 21 to
50 yr, body mass index [BMI] > 26 kg/m2) for 8 weeks. One group was administered a combination
of 4 mg NBC, 4667 mg HCA-SX, and 400 mg Gymnema sylvestre extract, while another group
was given placebo daily in three equally divided doses 30 to 60 min before meals [22,23]. All
subjects received a diet of 2000 kcal per day and participated in a supervised walking program. At
the end of 8 weeks, body weight and BMI decreased by 5 to 6%. Food intake as well as total
cholesterol, LDL, triglycerides, and serum leptin levels were significantly reduced, while high-
density lipoprotein (HDL) levels and excretion of urinary fat metabolites increased [22,23]. In
another related study, 30 moderately obese subjects received the same combination of NBC,
Gymnema sylvestra extract, and HCA-SX or placebo daily in 3 equally divided doses 30 to 60 min
before each meal for 8 weeks [22,23]. Subjects also received a diet of 2000 kcal day and underwent
a 30-min/day supervised walking program, 5 days a week, as in the previous study. Results
demonstrated that, at the end of 8 weeks, the chromium-combination-supplemented group had
reductions in body weight and BMI of 7.8 and 7.9%, respectively. Food intake was reduced by
14.1%. Total cholesterol, LDL, and triglyceride levels were reduced by 9.1, 17.9, and 18.1%,
respectively, while HDL and serotonin levels increased by 20.7% and 50%, respectively. Serum
leptin levels decreased by 40.5%, and enhanced excretion of urinary fat metabolites increased by
146 to 281%. No significant changes were observed in the placebo group [22,23].
In another study, moderately obese women participated in a 12-week exercise program that
investigated the effect of chromium picolinate supplementation on body composition, resting
metabolic rate, and selected biochemical parameters [24]. In this double-blind study, 44 women
(ages 27 to 51 years) received either 400 µg/day of elemental chromium (III) as chromium picolinate
or a placebo and participated in a supervised weight-training and walking program 2 days per week
for 12 weeks. Body composition and resting metabolic rate were measured at baseline and at 6
and 12 weeks. Body composition and resting metabolic rate were not significantly changed by
chromium picolinate supplementation. Overall results demonstrated that 12 weeks of chromium
picolinate supplementation (400 µg elemental chromium (III) per day) did not significantly affect
body composition, resting metabolic rate, plasma glucose, serum insulin, plasma glucagon, serum
C-peptide, or serum lipid concentrations.
The effects of daily chromium supplementation (200 µg elemental chromium as chromium
picolinate) were investigated in football players during spring training for 9 weeks in a double-
blind study [25]. Subjects receiving chromium picolinate demonstrated urinary chromium losses
five times greater than those in the placebo group, and the chromium picolinate supplementation
was ineffective in bringing about changes in body composition or strength during a program of
intensive weight-lifting training. Another double-blind, randomized, placebo-controlled study
assessed the effects of 14 weeks of chromium picolinate supplementation, during a preseason
resistance and conditioning program, on body composition and neuromuscular performance in
NCAA Division I wrestlers [26]. Twenty wrestlers from the University of Oklahoma were assigned
to a treatment group (n = 7; 20.4 yr ± 0.1) receiving 200 µg elemental chromium (III) as chromium
picolinate daily, a placebo group (n = 7; 19.9 yr ± 0.2), or a control group (n = 6; 20.2 yr ± 0.1)
using a stratified random sampling technique based on weight classification. Body composition,
neuromuscular performance, metabolic performance, and serum insulin and glucose were measured
before and immediately following the supplementation and training period. Repeat measures by
ANOVA indicated no significant changes in body composition for any of the groups. Aerobic power
increased significantly (p < 0.002) in all groups, independent of supplementation. The results from
the above two studies demonstrated that chromium picolinate supplementation coupled with typical
preseason training programs does not enhance body composition or performance variables beyond
improvements seen with training alone, at least at the relatively low doses used.
In another double-blind, placebo-controlled study, the efficacy of chromium picolinate as a fat-
reduction aid for obese individuals enrolled in a physical exercise program was investigated for 16
weeks [27]. Participants were healthy, active-duty Navy personnel who exceeded the Navy’s percent
body fat standards of 22% fat for men and 30% for women. Mean age was 30.3 years, and
comparisons between the subjects who completed the study (n = 95; 79 men, 16 women) and
dropouts (n = 109) revealed no significant differences in demographics or baseline percent body
fat. The physical conditioning programs were held a minimum of 3 times per week for at least 30
minutes of aerobic exercise. On a daily basis, subjects were given either 400 µg elemental chromium
(III) as chromium picolinate or a placebo. At the end of 16 weeks, the group as a whole had lost
a small amount of weight and body fat; however, the chromium-picolinate-supplemented group
failed to show a significantly greater reduction in either percent body fat or body weight or a greater
increase in lean body mass compared to the placebo group.
Livolsi et al. [28] examined the effect of chromium picolinate supplementation on muscular
strength, body composition, and urinary excretion in women softball athletes. Fifteen women softball
athletes were randomly divided into two groups: chromium picolinate (500 µg elemental chromium
per day; n = 8) and placebo control (n = 7). Results demonstrated that no significant (p < 0.05)
differences in muscular strength or body composition were found after 6 weeks of resistance training.
A 16-month, longitudinal, double-blind, randomly assigned intervention study of 33 female obese
subjects combined supplementation of 200 µg elemental chromium (III) as chromium picolinate
with a very low energy diet (VLED) during the first 2 months. Results showed that chromium
picolinate intake did not result in significant changes in blood parameters and body composition [29].
SAFETY OF CHROMIUM (III) COMPLEXES

Numerous studies have been conducted to evaluate the safety of chromium (III) complexes available
in the marketplace. In a comparative evaluation, the toxicities of chromium chloride, chromium
picolinate, and NBC were examined. At equal and physiological relevant doses, chromium picolinate
demonstrated mutagenic potential at the hypoxanthine (guanine) phosphoribosyltransferase locus

in Chinese hamster ovary cells, while chromium chloride and NBC exhibited no mutagenicity [30].
In a separate study, chromium picolinate was again found to produce chromosome damage in
Chinese hamster ovary cells, but no chromosome damage was observed following treatment with
similar doses of NBC or nicotinic acid [31]. This damage was concluded to be due to the picolinate
ligand, as picolinic acid alone resulted in some chromosomal damage, nephrotoxicity, and clasto-
genicity [30–32]. A number of published studies demonstrated the neurological effects (both
beneficial and deleterious) associated with chromium picolinate supplementation [33–35]; however,
chromium picolinate has recently received self-affirmed Generally Recognized as Safe (GRAS)
status [36]. Based on the results of extensive safety studies (acute oral, acute dermal, primary
dermal, and eye irritation studies; 90-day subchronic toxicity; Ames’ bacterial reverse mutation
assay; and mouse lymphoma mutagenicity assay), NBC also has received self-affirmed GRAS
status [37,38]. No significant toxic effect of chromium chloride has been reported. No detailed
safety studies have been reported on other trivalent chromium complexes.
CONCLUSION
The novel chromium (III) micronutrients have been demonstrated to help insulin metabolize fat,
favorably influence glucose and insulin metabolism, maintain healthy lipid profiles and blood sugar
levels, turn protein into muscle. and convert sugar into energy [1–5,39]. Also, novel chromium (III)
complexes may play a role in regulating appetite, reducing sugar cravings, and increasing lean
body mass [1–5,39]. Trivalent chromium levels are known to decrease with advancing age and
pregnancy, and marginal chromium deficiencies appear to be widespread [1–5,39–41]. In summary,
based on extensive scientific research on chromium (III), it may be concluded that supplementation
of well-researched, safe, novel chromium (III) complexes may promote lean body mass and regulate
obesity. Research studies have demonstrated the superior safety, bioavailability, and efficacy of
NBC over other chromium (III) complexes.
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27 An Overview on
(–)-Hydroxycitric Acid
in Obesity Regulation
Shirley Zafra-Stone, Manashi Bagchi, Harry G. Preuss,
Gary J. Grover, and Debasis Bagchi
CONTENTS
Introduction ....................................................................................................................................349
(–)-Hydroxycitric Acid, a Natural Extract from Garcinia cambogia (Family Guttiferae) ..........350
Pharmacognosy .......................................................................................................................351
Chemistry ................................................................................................................................351
Isolation Techniques and Physicochemical Properties...........................................................352
Structural Characterization of a Calcium/Potassium Salt of (–)-Hydroxycitric Acid...........352
Bioavailability of (–)-Hydroxycitric Acid ..............................................................................353
Safety of (–)-Hydroxycitric Acid...................................................................................................354
Animal Studies...............................................................................................................................355
Clinical Studies ..............................................................................................................................360
Benefits of Ca2+ and K+ in HCA-SX in Weight Management......................................................364
Molecular Mechanisms of Serotonin and Neuropeptide Y in Appetite Suppression...................365
Regulation of Genes by HCA-SX .................................................................................................365
Conclusion......................................................................................................................................366
References ......................................................................................................................................367
INTRODUCTION
Obesity has become a worldwide epidemic and a major challenge to health professionals. In fact,
a new term, globesity, has been coined to describe the recent upsurge of overweight and obesity
in the global population. Today, obesity rates in the United States have reached epidemic proportions
— 58 million Americans are overweight with a body mass index (BMI) of 25 or greater, 40 million
are obese, and 3 million are morbidly obese (BMI ≥ 30); 8 out of 10 U.S. adults over 25 years of
age are overweight [1,2]. These changes in rates of overweight and obesity are primarily attributed
to overeating and a sedentary lifestyle. A recent survey found that 25% of Americans lead sedentary
lifestyles, while 78% of Americans do not meet basic activity level recommendations. A 76%
increase in type 2 diabetes in adults 30 to 40 years old has occurred since 1990 [1,2]. According
to the World Health Organization (WHO), more than 1 billion adults are overweight and at least
300 millions are clinically obese worldwide. The International Obesity Task Force estimated that
22 million of the world’s children under 5 are overweight or obese [1,2]. Obesity has been shown
to be associated with a broad spectrum of degenerative diseases, including metabolic disorders and
349
certain forms of cancer. It has been reported that 80% of the cases of type 2 diabetes, 70% of
cardiovascular diseases, and certain forms of cancer such as breast and colon (42%) are related to
obesity [1,2]. Also, obesity is the major cause of 30% of gallbladder surgery, and 26% of obese
people have high blood pressure. Among children diagnosed with type 2 diabetes, 85% are obese [2].
Globesity has generated an unlimited array of weight-loss strategies [1,2]. Fundamental changes
have been made to the Food Guide Pyramid, and new strategies to readdress the consequences of
excessive refined-carbohydrate consumption are emerging. In addition to drug therapy, numerous
procedures suggested to promote weight loss include reduced caloric intake (such as meal-replace-
ment products), special weight-loss diets (e.g., grapefruit diet or cabbage soup diet), increased
caloric expenditure (via exercise or stimulants), reduced-fat diets, increased water consumption,
increased fiber consumption, reduced carbohydrate consumption and glycemic indexing (e.g.,
Atkins’ Diet, South Beach Diet, The Zone Diet, Cave Man Diet), appetite suppression, fat blockers,
fat burners, starch/sugar blockers, bariatric and other surgeries (e.g., liposuction or stomach reduc-
tion), acupuncture, hypnotism, support groups, and body wraps, all of which are supported by
products, programs, and services designed to help the consumer achieve desired results. Rapid-
weight-loss products and programs dominate the focus of marketers and consumers alike; however,
rapid weight loss is potentially unhealthy and disturbs metabolic setpoint homeostasis, inducing
undesirable rebound weight-gain consequences.
Several synthetic drugs and phytopharmaceuticals have been demonstrated to help in weight
management; however, concerns about exaggerated unsubstantiated benefit claims, undesirable side
effects, and federal regulatory intervention regarding dietary supplements are increasing. Conse-
quently, the search has intensified for products backed by credible scientific research that promote
healthy body composition and body mass redistribution but do not stimulate the central nervous
system, elevate blood pressure, cause nervousness, interfere with sleep, or block nutrient absorption
(e.g., fat, starch, and sugar blockers). Outside of significant and permanent lifestyle changes,
previously acceptable conventional methods alone or in combination have not resulted in sustained
success. In some cases, these regimens resulted in undesirable side effects or serious consequences,
such as the use of ephedrine and phenylpropanolamine (PPA), which have prompted regulatory
scrutiny and intervention. At the same time, adverse side effects have been demonstrated for
synthetic drugs. Thus, it is very important to develop a strategic therapeutic intervention using safe,
novel natural supplements supported by credible research. This chapter demonstrates the role of
(–)-hydroxycitric acid derived from the fruit rind of Garcinia cambogia in weight loss.
(–)-HYDROXYCITRIC ACID, A NATURAL EXTRACT

FROM GARCINIA CAMBOGIA (FAMILY GUTTIFERAE)
The fruit of Garcinia cambogia is valued for its dried rind, which is used extensively in Southern
India for culinary purposes and particularly as a condiment, in place of tamarind or lemon, for
flavoring curries and meat and seafood dishes. The fruit extract also serves as a unique flavor
enhancer for beverages, as a gourmet spice, and as a postprandial carminative. The fruit has also
been used for centuries to make meals more filling [3,4]. The dried rind of G. cambogia, which
contains (–)-hydroxycitric acid (HCA), is also used in pickling fish [5,6]; the commercial pickling
of fish is called Colombo curing [5,7]. The organic acids present in the fruit are responsible for
the bacteriostatic effect of the pickling medium by a simple lowering of the pH. In addition to the
flavoring and preservative effects of the fruit extract, in the traditional system of herbal medicine
in India (Ayurveda), Garcinia is considered to be a prime herb beneficial for health. A decoction
of the fruit rind is given for rheumatism and bowel complaints. In veterinary medicine, the extract
is employed as a rinse for some diseases of the mouth in cattle [8]. HCA, the organoleptically
characterizing ingredient of G. cambogia, is a popular component of several dietary supplements
marketed under various trade names. It has been reported that the calcium salts of HCA, which
An Overview on (–)-Hydroxycitric Acid in Obesity Regulation 351
COOH COOH
HO – C – H H – C – OH
HO – C – COOH HOOC – C – OH
H– C – COOH H– C – COOH
H H
a. (–)-Hydroxycitric acid b. (+)-Hydroxycitric acid
COOH COOH
HO – C – H H – C – OH
HOOC – C – OH HO – C – COOH
H– C – COOH H– C – COOH
H H
c. (+)-allo-Hydroxycitric acid d. (–)-allo-Hydroxycitric acid
FIGURE 27.1 Chemical structures of the stereoisomers of hydroxycitric acid.
are typically less than 50% soluble, are less bioavailable compared to the readily soluble calcium/
potassium salts of HCA. As a dietary supplement in the United States, HCA is regulated under the
Dietary Supplement Health and Education Act (DSHEA) of 1994 [9].
PHARMACOGNOSY
Garcinia is a large genus of approximately 180 species of polygamous trees or shrubs distributed
in tropical Asia, Africa, and Polynesia. Approximately 30 species of Garcinia are found in India
and Southeast Asia. One of the species, G. cambogia, found commonly in the evergreen forests of
southwest India, is a small or medium-sized tree with a rounded crown and horizontal or drooping
branches. The leaves are dark green and shiny, elliptic obovate, 5 to 12 cm long, and 2 to 7 cm
broad. The tree flowers during the hot season, and fruits ripen during the rainy season. The fruit,
which is the source of HCA, is ovoid and 5 cm in diameter; it ranges in color from yellow to
orange or red when ripe and has six to eight grooves. The fruit has six to eight seeds surrounded
by a succulent aril. The G. cambogia fruit is included in the U.S. Department of Agriculture’s
inventory of perennial edible fruits of the tropics [10]. The fruit contains approximately 10 to 30%
acid calculated as citric acid on a dry-weight basis [7]. In some early studies, the organic acids
present in the fruits were mistakenly identified as tartaric and citric acids. In subsequent studies,
the major acid in the fruit of G. cambogia was identified as HCA [11,12]. HCA-SX, derived by a
novel patented process from the dried fruit rind of G. cambogia, contains approximately 95%
calcium/potassium salt of (–)-hydroxycitric acid. The calcium/potassium salt contains approxi-
mately 60% HCA, as characterized by high-performance liquid chromatography (HPLC).
CHEMISTRY
Hydroxycitric acid (1,2-dihydroxypropane-1,2,3-tricarboxylic acid) has two asymmetric centers;
hence two pairs of distereoisomers or four different isomers are possible (Figure 27.1). All four
isomers, (–)-HCA, (+)-HCA, (–)-allo-HCA, and (+)-allo-HCA, have been chemically synthesized
starting from trans-aconitic acid [12,13]. Of these isomers, (–)-HCA is the principal constituent of
HCA-SX, occurring in Garcinia (Figure 27.1a), while the (+)-HCA isomer is found in Hibiscus
species (Figure 27.1b) [12,13]. (–)-HCA is the principal acid in the highly acidic fruit of G. cambogia.
The absolute configuration of (–)-HCA was determined from Hudson’s lactone rule, optical rotatory
dispersion curves, circular dichromism curves, and calculation of partial molar rotations [14]. By
employing x-ray crystallography, Glusker et al. [15,16] determined the structure and absolute
configuration of calcium hydroxycitrate and HCA lactone. The acid is present at a level of 10 to
30% in the dried fruit rind of G. cambogia. The acid can be isolated in its free form, as a mineral
salt (Ca2+ salt, Na+ salt, K+ salt, Mg2+ salt, Ca2+/K+ double salt, Mg2+/K+ double salt, and others
formed after extraction), or as a lactone by various methods. Lowenstein and Brunengraber [17]
estimated the hydroxycitrate content of the fruit of G. cambogia by gas chromatography (GC).
During concentration and evaporation, free HCA leads to the formation of HCA lactone. Based on
information submitted to the U.S. Patent Office, several investigators have reported the preparation
of HCA concentrate from Garcinia rinds with 23 to 54% HCA and 6 to 20% lactone [18,19].
Recently, Jayaprakasha and Sakariah [20,21] developed HPLC methods for the estimation of organic
acids in the fruits of G. cambogia and commercial samples of G. cambogia extracts. Using these
methods, dilute extracts can be quantified without concentration, drying, or derivatization. An
additional advantage of these methods is that the HCA and its lactone can be quantified separately.
Loe et al. [22] reported a gas chromatography/mass spectrophotometry (GC/MS) method for
quantitative determination of blood hydroxycitrate levels.
ISOLATION TECHNIQUES AND PHYSICOCHEMICAL PROPERTIES

Lewis and Neelakantan [11] reported a method for the large-scale isolation of HCA from the dried
rinds of G. cambogia. In this method, the acid was extracted by heating the raw material with water
under pressure. The extract was then concentrated and pectin was removed by precipitation with
alcohol. The clear filtrate was neutralized and the acid was recovered after passing through cation-
exchange resin. The recovered acid was concentrated, dried, and recrystalized to small, needle-
shaped crystals of lactone. Using another method, Lewis [12] isolated HCA from dried Garcinia
fruit rinds using acetone. The acetone extract was concentrated, and the acid was extracted in water.
The water extract was evaporated to yield lactone. In yet another process, aqueous extract of HCA
was passed through an anion-exchange column for adsorption of HCA. The adsorbed HCA was
eluted with sodium/potassium hydroxide. The free acid was prepared by passing it through a cation-
exchange column. In recent years, several manufacturers have employed different procedures
(patented) to prepare salts of HCA with improved solubility and bioavailability. Among the number
of HCA salts available in the marketplace are Ca2+ salt, Na+ salt, K+ salt, Mg2+ salt, Ca2+/K+ double
salt, and Mg2+/K+ double salt. The solubility of these HCA salts, which can affect bioavailability,
ranges from less than 50 to 100%. Furthermore, different salts have different physicochemical
characteristics, including color, taste, and odor. Extensive research has been conducted on a novel,
patented calcium/potassium salt of 60% HCA extract (HCA-SX, known commercially as Super
CitriMax®), which is tasteless and odorless as well as 100% water soluble.
STRUCTURAL CHARACTERIZATION OF A CALCIUM/POTASSIUM

SALT OF (–)-HYDROXYCITRIC ACID
A typical compositional analysis of HCA-SX reveals that it contains 60% (–)-hydroxycitric acid
in its free form, 1.0% (–)-hydroxycitric acid in its lactone form, 10% calcium, 15% potassium,
0.5% sodium, 0.05% total phytosterols, 0.3% total protein, 4.5% moisture, and 8.5% soluble dietary
fiber (by difference). It also contains 0.1% magnesium, 0.03% iron, and trace amounts of manga-
nese, copper, zinc, selenium, total fat, and total sugar. HCA-SX provides approximately 150 calories
per 100 g and exhibits an optical rotation [α]D20 = –17.55 (c = 1.0 H2O), as measured in a Rudolph
AUTOPOL II Polarimeter (Hackettstown, NJ) using a 10-cm cell at 589 nm.
Using HPLC, HCA-SX was detected by injecting a 20 µL solution of HCA-SX (sample

concentration 1.6 mg/mL) in water (pH 2.1, adjusted with sulfuric acid) on a Shimadzu HPLC
(Tokyo, Japan) equipped with LC-10AT pumps, SCL-10A system controller, SIL-10A auto injector,
SPD-M10AVP detector (detector was set at 210 nm), CLASS-M10A software, and a 5-µ Altima
C18 column (250 mm × 4.6 mm) (Alltech Associates, Inc.; Deerfield, IL) at a flow rate of 1 mL/min
in an isocratic mode using a mobile phase of 0.05-M sodium sulfate in water (pH 2.3, adjusted
with sulfuric acid) at 25 ± 2°C. The retention time for HCA was noted at 4.78 min, which was
reconfirmed by spiking with an authentic standard of HCA (Wako, Japan).
When the ultraviolet (UV) spectra of HCA-SX were recorded on a Varian Cary 50 UV–VIS
spectrometer (Mulgrave, Victoria, Australia), the UV spectra (H2O) exhibited a shoulder at λmax
210 nm. The infrared (IR) spectra of HCA-SX were recorded on a PerkinElmer Spectrum BX
FT-IR spectrometer (Norwalk, CT) with the following results: IR (KBr pellet, cm–1) 3403.20 (OH),
1599.39 (asymmetric C=O stretching band), 1397 (symmetric C=O stretching band), 1295.93 (C–O
stretch), 1099.74, 1061.98 (alcoholic C–O absorption), 905.99, 837.40 (C–C stretching), and 627.11
(C–C bending). The proton nuclear magnetic resonance (NMR) spectrum (300 MHz, D2O) was
recorded on a JEOL JNM-LA (Lambda) NMR spectrometer (Tokyo, Japan), and the chemical shift
values were expressed in ppm. 1H NMR data of HCA-SX showed H-2 at δ 3.98 s, H-4a at δ 2.53
d (J = 16.5 Hz), and H-4b at δ 2.69 d (J = 16.5 Hz). The 13C NMR spectrum (75 MHz, D2O) was
recorded on a JEOL JNM-LA (Lambda) NMR spectrometer (Tokyo, Japan), and the chemical shift
values were expressed in ppm. The 13C NMR spectrum of HCA-SX exhibited C-1, C-5, and C-6
at δ 181.0, 179.7, and 178.7 ppm, and C-2, C-3, and C-4 at δ 42.4, 79.8, and 77.1, respectively.
The mass spectrum was recorded on an Agilent 1100 Series liquid chromatograph (LC)/mass
selective detector (MSD) (Palo Alto, CA) under electrospray ionization (ESI), negative ion mode
conditions. In electrospray ionization, the mass spectrum contains abundant pseudomolecular ions
(M+1, M+23, etc. in positive-ion mode and M–1 in negative-ion mode). These ions were used to
confirm the molecular weight of the compounds. The peak at m/z 207 (M–1) in the mass spectrum
of HCA-SX corresponds to the pseudomolecular ion of HCA (molecular weight 208) [22].
BIOAVAILABILITY OF (–)-HYDROXYCITRIC ACID

Loe et al. [23] conducted a study utilizing a simple method that requires minimal sample preparation
and is able to measure trace amounts of HCA with accuracy and precision using [U-13C] citrate
(CA*) as the internal standard to account for losses associated with the isolation, derivatization,
and measurement of HCA. These authors developed a new GC/MS method to measure HCA levels
in blood. HCA and CA* were derivatized with BSTFA + 10% TMCS and analyzed using positive
chemical ionization (PCI) GC/MS (HCA, m/z 553; CA*, m/z 471). Plasma HCA concentration
was measured over a 3.5-hr period in four subjects who had ingested 2 g of HCA-SX. Their plasma
HCA concentrations were 0.8 and 8.4 µg/mL 30 min and 2 hr after ingestion, respectively. These
results demonstrated that, when taken acutely, HCA is absorbed yet present in small quantities in
human plasma. In a separate study, these authors assessed the bioavailability of HCA-SX in both
fasting and fed states in humans [24]. HCA-SX concentrations peaked 2 hr after administration
and were not completely cleared after 9 hr (Figure 27.2). Feeding appeared to hinder HCA-SX
absorption, as the peak concentration was approximately 60% lower than for absorption in the
fasting state. HCA-SX absorption was detectable in the urine and was used to determine relative
HCA-SX absorption [23,24]. A recent pharmacokinetics study was conducted on HCA-SX in
Sprague–Dawley rats. HCA-SX was given orally at 912 mg/kg by gavage. Blood samples were
collected at 0.25, 0.5, 1, 2, 4, 6, 8, and 24 hr, and plasma concentrations of HCA-SX were measured.
HCA-SX was absorbed in a time-dependent manner, and the Tmax value (1 hr) suggests fairly rapid
absorption of HCA-SX. After achieving Cmax, the HCA-SX levels rapidly declined, suggesting that
this compound is rapidly metabolized. By 8 to 24 hr, it had disappeared from the plasma. The
plasma half-life was between 1 and 2 hr. Key pharmacokinetic profiles are shown in Table 27.1.
9
Fasting (n=3)
8
Plasma HCA Concentration (µg/mL) Fed (n=3)
7
0
1 2 3 4 5 6 7 8 9
Time (hr)
FIGURE 27.2 Plasma HCA (mg/mL) concentrations in fasted and fed human subjects over a period of 9 hr
following a single oral administration of HCA-SX (2.0 g).
SAFETY OF (–)-HYDROXYCITRIC ACID

An extensive safety evaluation was conducted on HCA-SX. Acute oral, acute dermal, primary
dermal irritation, and primary eye irritation toxicity studies have demonstrated the safety of
HCA-SX [25]. The LD50 of HCA-SX was found to be greater than 5000 mg/kg body weight when
administered once orally via gastric intubation to fasted male and female Albino rats. No gross
toxicological findings were observed under the experimental conditions. The dermal LD50 of
HCA-SX was found to be greater than 2000 mg/kg body weight when applied once for 24 hr to
the shaved, intact skin of male and female albino rabbits. No evidence of acute systemic toxicity
was observed among rabbits that were dermally administered HCA-SX at 2000 mg/kg body weight.
In the dermal irritation study, no deaths or significant body weight changes were observed during
the study period. HCA-SX induced very slight erythema on one animal [25]. No edema or other
dermal findings were noted, and all irritation was reversible and had completely subsided by the
end of day 1. The primary dermal irritation index (PDII) was calculated to be 0.0. Based on these
observations, HCA-SX received a descriptive rating classification of nonirritating. In the eye
irritation study, no deaths or remarkable changes in body weights occurred during the study period.
The results indicate that HCA-SX causes ocular irritation with the production of inflammatory
exudate in some animals. Positive iridal and conjuctival reactions were present in all animals and
subsided within 48 hr. A total maximum score of 110 is possible, and a score of 15 was obtained
in the study, indicating mild irritation [25].
Sprague–Dawley rats were used to assess the dose- and time-dependent effects of HCA-SX on
body weight, selected organ weights, hepatic lipid peroxidation and DNA fragmentation, hematol-
ogy, and clinical chemistry over a period of 90 days (subchronic study) [26,27]. Furthermore, a
90-day histopathological evaluation was conducted. The animals were treated with 0, 0.2, 2.0, and
5.0% HCA-SX of feed intake and were sacrificed at 30, 60, or 90 days of treatment. The body
weights and selected organ weights were assessed and correlated as a percentage of body weight
and brain weight at 90 days of treatment. A significant reduction in body weight was observed in
treated rats as compared to control animals. An advancing age-induced marginal increase in hepatic
TABLE 27.1
Key Pharmacokinetic Values
for HCA-SX in Rats
Pharmacokinetic Estimate Value
Half-life (hr) 1.3
Tmax (hr) 1
Cmax (µg/mL) 384.0
AUC0-t (hr*µg/mL) 1336
Volume of distribution (mL/kg) 1286
Clearance (mL/hr/kg) 683
lipid peroxidation was observed in both male and female rats, while no such difference in hepatic
DNA fragmentation was observed as compared to the control animals. Furthermore, selected organ
weights individually and as a percentage of body and brain weights at 90 days of treatment exhibited
no significant difference between the groups. No difference was observed in hematology and clinical
chemistry or the histopathological evaluation. Taken together, these results show that 90-day
treatment of HCA-SX results in a reduction in body weight and does not cause any changes in
major organs or in hematology, clinical chemistry, and histopathology [26,27].
Ames’ bacterial reverse mutation studies and mouse lymphoma tests have shown that
HCA-SX does not induce mutagenicity [27]. Five histidine-dependent strains of Salmonella
typhimurium (TA98, TA100, TA1535, TA 1537, and TA102) were used to evaluate the mutagenic
potential of HCA-SX (up to 5000 µg/plate) in both the presence and absence of metabolic
activation (±S9). No mutagenic potential of HCA-SX was observed. The mutagenic potential
of HCA-SX (up to the recommended dose level of 5000 µg/plate) was assessed in the mouse
lymphoma assay using L5178Y mouse lymphoma cells, clone –3.7.2C (ATCC #CRL-9518,
American Type Culture Collection; Manassas, VA). HCA-SX did not induce mutagenic effects
in the mammalian cell gene mutation test on L5178Y mouse lymphoma cells TK+/–, with or
without metabolic activation [27].
In an independent study, Saito et al. [28] demonstrated that diets containing 51 mmol HCA
per kg diet (389 mg HCA per kg body weight per day) or less did not cause any adverse effects.
Accordingly, 51 mmol HCA per kg diet (389 mg HCA per kg body weight per day) was deemed
to be the no-observed adverse effect level (NOAEL) [28].
The structure, mechanism of action, long history of use of HCA, and other toxicity studies
indicate that HCA-SX is unlikely to cause reproductive or developmental effects. In several placebo-
controlled, double-blind trials employing up to 2800 mg/day HCA, no treatment-related adverse
effects were reported. Sufficient qualitative and quantitative scientific evidence, including animal
and human data, suggest that the intake of HCA at levels up to 2800 mg/day is safe for humans [29].
ANIMAL STUDIES
Since 1970, a number of animal studies conducted with hydroxycitrate, singly and in combination
with other ingredients, have demonstrated beneficial effects for weight and fat loss. Early studies
showed that (–)-hydroxycitrate is a potent competitive inhibitor of ATP citrate lyase, the extra-
mitochondrial enzyme that supplies most of the acetyl coenzyme A for lipid synthesis [30,31].
Hydroxycitrate was also shown to inhibit the conversion of carbohydrate and its metabolites into
lipid by reducing the acetyl coenzyme A pool, the substrate for fatty acids and cholesterol. Studies
in the 1970s on HCA supplementation in rats demonstrated evidence of decreased lipogenesis levels
and appetite suppression. Lowenstein [32] demonstrated that (–)-hydroxycitrate is a highly effective
inhibitor of fatty acid synthesis by rat liver in vivo. Hepatic fatty acid synthesis was inhibited
strongly by sodium (–)-hydroxycitrate. An i.p. dose of as little as 0.1 mmol per kg body weight
inhibited fatty acid synthesis by 25 to 30% (equivalent to about 2.9 mg of (–)-hydroxycitrate per
150 g rat). Inhibition of 50% and 75% was obtained with an i.p. dose of 0.28 and 1 mmol per kg
of body weight, respectively. The results also demonstrated that inhibition of fatty acid synthesis
remained strong between 50 and 95 min after administration of hydroxycitrate. Additional exper-
iments showed that inhibition of fatty acid synthesis remained strong up to 2 to 3 hr after admin-
istration of hydroxycitrate [32].
Sullivan et al. [33] determined the effect of the hydroxycitrate stereoisomers on the rate of
lipogenesis in rat liver. Inhibition of lipogenesis by administration of (–)-hydroxycitrate, (+)-
hydroxycitrate, (–)-allo-hydroxycitrate, and (+)-allo-hydroxycitrate stereoisomers i.v. or i.p dem-
onstrated that only (–)-hydroxycitrate significantly decreased the rates of lipid synthesis in both
studies. The in vivo rate of lipogenesis was markedly decreased for 150 minutes following the
administration of (–)-hydroxycitrate. Fatty acid and cholesterol synthesis was also significantly
inhibited by the oral administration of (–)-hydroxycitrate when the compound was given before
the feeding period [33]. In another study, oral administration of (–)-hydroxycitrate in female rats
was shown to depress the in vivo lipogenic rates in a dose-dependent manner in the liver, adipose
tissue, and small intestine [33]. Hepatic lipogenesis was significantly inhibited during the 8 hr
period in the (–)-hydroxycitrate treated animals and was 11% less than controls. Rats receiving
(–)-hydroxycitrate also consumed less food than the untreated controls [34]. Although this decreased
caloric intake was not responsible for the drug-induced depression of hepatic lipogenesis (as shown
by studies in pair-fed rats), a separate pair-feeding study demonstrated that the reduction in food
intake accounted for a decrease in weight gain and body lipid observed with (–)-hydroxycitrate
treatment [34,35]. In this study, a significant reduction in body weight gain, food consumption,
and total body lipid was observed in female rats with a chronic oral administration of (–)-hydroxy-
citrate for a period of 11 to 30 days. An equal amount of citrate administration did not have any
effects. Pair-feeding studies demonstrated that these effects on weight and body lipids were due to
the decreased caloric intake produced by (–)-hydroxycitrate [35].
In another in vivo study, Sullivan et al. [36] examined the influence of (–)-hydroxycitrate on
weight gain, appetite, and body composition in several obese rodent model systems: mature normal
rat, the goldthioglucose obese mouse, and the ventromedial-hypothalamic-lesioned obese rat. In
all models, food intake and body weight gain were reduced significantly by the chronic oral
administration of (–)-hydroxycitrate (52.6 mmol/kg of diet, a dose approximately equivalent to
2.74 mmol/kg body weight) as part of the dietary admixture. The dietary admixture was a G-70
diet that consisted of 70% glucose, 23% vitamin-free casein, 5% Phillips and Hart salt mixture,
and 40 g/kg of cellulose [36].
Hamilton et al. [37] investigated the influence of (–)-hydroxycitrate on serum triglyceride and
cholesterol levels, as well as the in vitro and in vivo rates of hepatic fatty acid and cholesterol
synthesis in normal and hyperlipidemic rat model systems. (–)-Hydroxycitrate reduced equivalently
the biosynthesis of triglycerides, phospholipids, cholesterol, diglycerides, cholesteryl esters, and
free fatty acids in isolated liver cells. In vivo hepatic rates of fatty acid and cholesterol synthesis
determined in meal-fed normolipidemic rats were suppressed significantly by the oral administration
of (–)-hydroxycitrate for 6 hr, when control animals exhibited maximal rates of lipid synthesis.
Results also demonstrated that serum triglyceride and cholesterol levels were significantly reduced.
In two hypertriglyceridemic models — the genetically obese Zucker rat and the fructose-treated
rat — elevated triglyceride levels were due, in part, to enhanced hepatic rates of fatty acid synthesis.
(–)-Hydroxycitrate significantly reduced the hypertriglyceridemia and hyperlipogenesis in both
models. The marked hypertriglyceridemia exhibited by the triton-treated rat was only minimally
due to increased hepatic lipogenesis. This study showed that (–)-hydroxycitrate significantly inhib-
ited both serum triglyceride levels and lipogenesis in this model [37].
In another in vivo study conducted by Greenwood et al. [38], (–)-hydroxycitrate treatment in

growing lean Zucker rats resulted in a decrease in the percent of body fat in the carcass and a
significant decrease in fat cell size. Young Zucker lean (Fa/–) and obese (fa/fa) female rats were
fed the fatty acid synthesis inhibitor (–)-hydroxycitrate as a dietary admixture for 39 days. In the
lean rats, (–)-hydroxycitrate treatment decreased body weight, food intake, percent of body fat, and
fat cell size. In the obese rat, food intake and body weight were reduced, but the percent of body
fat remained unchanged. Throughout the treatment period, obese rats maintained a fat cell size
equivalent to their obese controls. Although a reduction in fat cell number in the obese rats occurred
during the treatment period, marked hyperplasia was observed during the post-treatment period.
The results of this study indicate that the obese rat, despite a substantial reduction in body weight
produced by (–)-hydroxycitrate, still defends its obese body composition [38].
Rao et al. [39] evaluated the effects of (–)-hydroxycitric acid in male albino Winstar rats fed
a lipogenic diet for a period of 15 days. A control group was fed a lipogenic diet without HCA.
Analysis results from blood, liver, and epididymal fat demonstrated that inclusion of (–)-hydroxy-
citrate in the diet significantly reduced food intake, body weight, epididymal fat, and serum
triglyceride in animals. A decrease in the feed efficiency ratio was also observed. The effect of
HCA was dose dependent [39].
In another study, body weight gain was decreased and fat deposition was inhibited by (–)-
hydroxycitrate, but no difference in cumulative food intake was observed [40]. In a study conducted
by Vasselli et al. [40], growing male Sprague–Dawley rats (n = 5) were fed (–)-hydroxycitrate ad
libitum as a dietary admixture for 28 days. A separate experiment tested the ability of (–)-hydroxy-
citrate to alter 24-hr energy expenditure (EE) in rats (n = 6) fed a mixed high-carbohydrate diet
(75% CHO, 3.90 kcal/g) known to stimulate lipogenesis in humans. EE was measured in whole
body respirometers during days 1 through 5 of a 28-day test period, and the final weights of 3 fat
depositions were determined. Results of the first experiment demonstrated that (–)-hydroxycitrate
inhibited body weight gain (–48.9 g, p < 0.01) and cumulative food intake (control, 675.7 ± 23.5 g;
(–)-hydroxycitrate, 622.5 ± 44.6 g; p < 0.05). The second experiment showed that (–)-hydroxycitrate
increased 24-hr EE by 12.6% (no change in respiratory quotient was observed). Results in the
(–)-hydroxycitrate group included the following: body weight gain, 73.8 ± 7.1 g (p < 0.02); EE
(kcal/24 hr), 62.59 ± 5.41 (p < 0.02); cumulative food intake, 614.7 ± 27.8 g; and total pad weight,
16.04 ± 1.28 g (p < 0.01). The results for the control group included the following: body weight
gain, 91.5 ± 12.7 g; EE (kcal/24 hr), 55.67 ± 2.43; cumulative food intake, 629.1 ± 8.8 g; and total
pad weight, 21.45 ± 2.57 g [40].
Ishihara et al. [41] conducted a study on hydroxycitrate and male Std ddY mice. Mice were
divided into three groups (n = 60, 54, and 12) of equal body weights. The first group of mice
(n = 60) were placed in metabolic chambers to measure respiratory gas. Diet and water were
prohibited from 0930 hr; at 1000 hr, they were administered orally 10 or 30 mg of a 0.48 mol/L
hydroxycitrate solution or water, and the respiratory gas was analyzed. The same procedures
were applied in the second mice group (n = 54). Blood was collected 30 or 100 min after
administration of the hydroxycitrate to measure serum variables. The effect of hydroxycitrate on
glycogen accumulation was evaluated in the gastrocnemius muscle and liver tissue in the final
mice group (n = 12). In a separate experiment, mice (n = 18) were forced to swim to exhaustion
at a flow rate of 8 L/min twice a day for a preliminary period of 1 week. They were then divided
into three groups and orally administered 10 or 30 mg of 0.48 mol/L hydroxycitrate or 10 mg
water (control); also, they were given free access to commercial diet and water. Following the
treatment, the mice swam until fatigue every day at the same flow rate, and the maximum
swimming time was measured. The mice were administered hydroxycitrate orally every day after
swimming. Finally, in another experiment, mice (n = 18) were divided into two groups of equal
mean body weights. They were orally administered 10 mg of 0.48 mol/L hydroxycitrate or water
(control) twice a day for 25 days. At day 26, each mouse was placed in a treadmill chamber and
allowed to rest for 1 hr, followed by a 1-hr run at a speed of 15 m/min while respiratory gas
was monitored. Body weight and food intake were taken every day until termination. The authors
demonstrated that oral administration of 10 mg hydroxycitrate elevated serum free fatty acid
concentration and increased muscle glycogen concentration in mice at rest. Mice that were
chronically (twice daily for 25 days) administered hydroxycitrate had a significantly reduced
respiratory exchange ratio (RER) at rest and during running exercise. Lipid oxidation was
increased and carbohydrate utilization was less in the early stages of the running exercise. These
results indicated that the enhancement of exercise endurance by orally administered hydroxyci-
trate in mice might have occurred by attenuation of glycogen consumption caused by the
promotion of lipid oxidation during the running exercise [41].
In a series of experiments, 24 male rats were fed restrictively (10 g/day) for 10 days and then
given ad libitum access to one of four different diets: high sucrose (HI-Suc), high glucose (HI-
Glu), grounded standard rat chow (Chow), and high glucose + fat (HI-Glu+fat), which varied in
the content of fat and low-molecular-weight carbohydrates for 10 days. In the other rats (n = 12),
the ad libitum diet was supplemented with 3% (w/w) HCA. HCA reduced body weight regain with
all diets except Chow. HCA also reduced food intake temporarily with three of the four tested diets.
The suppressive effect of HCA on food intake was particularly strong in the HI-Glu+fat diet group
(fat = 24% of energy). For the HI-Glu and HI-Glu+Fat diets, HCA reduced the feed conversion
efficiency (cumulative body weight regain [g]/cumulative food intake [MJ]) during the 10 ad libitum
days, suggesting that it also increased energy expenditure. This effect seemed to be positively
related to the glucose content of the diet [41].
Two experiments were performed in 23 and 24 adult male Sprague–Dawley rats [42,43]. Initial
body weights for experiment 1 and 2 were 663 ± 12 g and 616 ± 7 g, respectively. Both groups
were fed only 10 g powdered standard rodent chow for 10 days before being divided into groups.
Rats were divided into two groups (n = 11 or 12) for each experiment and matched for body weight
loss and given one of two diets ad libitum for 22 days. The diet of one group was always
supplemented with 3 g/100 g hydroxycitrate (85 mmol/kg diet). In experiment 1, rats in both groups
were given a 1% (g/100 g) fat diet = 81% carbohydrate, 10% protein, and 1% fat. In experiment
2, rats in both groups were given a 12% (g/100 g) fat diet = 76% carbohydrate, 9% protein, and
12% fat. Rats lost 72 ± 3 g and 75 ± 2 g body weight, respectively, during the 10-day restrictive
feeding in experiments 1 and 2. Hydroxycitrate reduced body weight regain in rats fed both diets
throughout the period of ad libitum consumption. In experiment 1 (1% fat diet group), the cumu-
lative body weight regain in rats fed hydroxycitrate was significantly less than in controls on ad
libitum day 2 (control, 17 ± 1 g; hydroxycitrate, 12 ± 1 g). On day 22, the control rats had regained
70 ± 6 g body weight, and the hydroxycitrate rats had regained 48 ± 3 g body weight (overall p <
0.01). Thus, the hydroxycitrate-fed rats regained only 68 ± 4% of the control group’s body weight
regain. HCA did not affect any metabolic variables examined. In experiment 2 (12% fat diet group),
after day 22 the control group and had regained 81 ± 7 g while the hydroxycitrate group had
regained 49 ± 6 g (overall p < 0.01). The latter was 61 ± 8% of the control group’s body weight
regain. As in experiment 1, the control group had compensated the body weight loss on ad libitum
day 22 (body weight loss, 75 ± 3g; body weight regain, 81 ± 3g), whereas the hydroxycitrate group
had not (body weight loss, 75 ± 3g; body weight regain, 49 ± 6 g; p < 0.01). Hydroxycitrate had
no effect on plasma β-hydroxybutyrate but reduced plasma triacylglycerol and increased liver fat
concentration. The suppressive effect of hydroxycitrate on body weight regain, which was main-
tained for at least 3 weeks, appears to be independent of the dietary fat content; yet, the fat content
of the diet seemed to be important for the long-term suppressive effect of hydroxycitrate on feeding
[42,43]. Hayamizu et al. [44] evaluated the effects of 3.3% Garcinia cambogia extract on 10%
sucrose loading in mice for 4 weeks. The authors demonstrated that G. cambogia extract efficiently
improved glucose metabolism and displayed leptin-like activity.
The dose- and time-dependent effects in rats of HCA-SX (Super CitriMax®, 60% calcium/potas-
sium salt of HCA) were evaluated with regard to body weight, selected organ weights, hepatic lipid
peroxidation and DNA fragmentation, hematology and clinical chemistry, and histopathological
evaluation [45]. Male and female Sprague–Dawley rats (male rats, 251 to 320 g; female rats, 154
to 241 g) were treated with HCA-SX at 0, 0.2, 2.0, and 5.0% of feed intake and were sacrificed
on 30, 60, or 90 days of treatment. The body weight and selected organ weights were assessed and
correlated as a percentage of body weight and brain weight at 90 days of treatment. A 90-day
histopathological evaluation was also conducted. A significant reduction in body weight was
observed in treated rats as compared to control animals. An advancing age-induced marginal
increase in hepatic lipid peroxidation was observed in both male and female rats, but no such
difference in hepatic DNA fragmentation was observed as compared to the control animals. Selected
organ weights individually and as a percentage of body weight and brain weight at 90 days of
treatment exhibited no significant differences between the groups. No differences were observed
in hematology and clinical chemistry or the histopathological evaluation. Taken together, these
results show that 90-day treatment of HCA-SX results in a reduction in body weight and does not
cause any changes in major organs or in hematology, clinical chemistry, and histopathology [26,27].
Roy et al. [45] determined the effects of low-dose oral HCA-SX on the body weight and
abdominal fat gene expression profile of Sprague–Dawley rats. At doses relevant for human
consumption, dietary HCA-SX significantly reduced body weight growth. This response was
associated with lowered abdominal fat leptin expression. Other genes, including vital genes tran-
scribing for mitochondrial/nuclear proteins which are necessary for fundamental support of the
tissue, were not affected by HCA-SX. Under the current experimental conditions, HCA-SX proved
to be effective in restricting body weight gain in adult rats. Functional characterization of HCA-SX-
sensitive genes revealed that upregulation of genes encoding serotonin receptors, as well as fat and
carbohydrate metabolism, represent a distinct effect of dietary HCA-SX supplementation.
In another study, 24 male Sprague–Dawley rats were fed restrictively (10 g/day) for 10 days
and then given ad libitum access to a high-glucose diet supplemented with 3% hydroxycitrate for
6 days [46]. Controls received the same diet without the supplement. The respiratory quotient (RQ)
and energy expenditure (EE) were measured during ad libitum days 1, 2, and 6. An oral glucose
tolerance test was performed on ad libitum day 4 or 5. Hydroxycitrate decreased RQ and EE during
ad libitum days 1 and 2. In all probability, these findings reflect a decrease in de novo lipogenesis.
On ad libitum day 6, RQ and EE did not differ between treatment groups. Hydroxycitrate suppressed
food intake during the first 3 days ad libitum, but overall body weight regain was not decreased in
the hydroxycitrate group. The oral glucose tolerance test showed that hydroxycitrate significantly
decreased the increase in plasma glucose from baseline and tended to decrease the area under the
curve for glucose. The area under the curve for insulin did not differ between the groups. These
results indicate that, in this animal model, hydroxycitrate suppressed de novo lipogenesis and may
improve glucose tolerance.
Leonhardt et al. [47] conducted a study in which a total of 63 male Sprague–Dawley rats were
fed restrictively for 10 days. Animals were then divided into seven groups (n = 9 per group) and
switched to ad libitum consumption. The diet contained 70% (w/w) carbohydrates, 9% protein,
and 12% fat. Results demonstrated that hydroxycitrate (3%) significantly suppressed food intake
and body weight regain and neither conjugated linolein acid (CLA) (1%) nor guar gum (3%)
increased the effect of hydroxycitrate on these parameters. Also, CLA and guar gum alone had no
effect on food intake and body weight regain. The liver fat content of the combined hydroxycitrate
+ CLA groups was significantly lower compared to that of the control group. This study confirms
the effectiveness of hydroxycitrate to reduce food intake and body weight regain after a period of
restrictive feeding.
Wielinga et al. [48] investigated whether HCA reduces the postprandial glucose response by
affecting gastric emptying or intestinal glucose absorption in rats [48]. They compared the effect
of regulator HCA (310 mg/kg) and vehicle (control) on the glucose response after an intragastric
or intraduodenal glucose load to investigate the role of altered gastric emptying. Hydroxycitrate
treatment delays the intestinal absorption of enterally administered glucose at the level of the small
intestinal mucosa in rats. Hydroxycitrate strongly attenuated postprandial blood glucose levels after
both intragastric (p < 0.01) and intraduodenal (p < 0.001) glucose administration, excluding a major
effect of hydroxycitrate on gastric emptying. Hydroxycitrate delayed the systemic appearance of
exogenous glucose but did not affect the total fraction of glucose absorbed over the study period
of 150 min. This study supports a possible role for hydroxycitrate as a food supplement for lowering
postprandial glucose profiles.
The most recent study by Ono et al. [49] shows that the calcium salt of hydroxycitric acid does
not induce chromosomal aberration. Chromosomal aberration and micronucleus tests were con-
ducted in cultured Chinese hamster lung cells and in mice. The extract did not increase the number
of cells with structural aberration or numerical aberrations, nor did it increase the frequency of
micronucleated polychromatic erythrocytes.
CLINICAL STUDIES
Numerous clinical trials have been performed to assess the weight management potential of various
(–)-hydroxycitric acid preparations. Following are summaries of the human clinical studies con-
ducted with different forms of HCA and formulations.
A randomized, placebo-controlled, double-blind study was conducted in 54 male and female
subjects (ages, 21 to 55 years; degree of obesity, 15 to 45% overweight) [50]. This 8-week study
consisted of group A (n = 30) given Lipodex-2™ (500 mg rind of Garcinia indica and 100 µg
elemental chromium as chromium nicotinate) 3 times a day, and group B (n = 24), who received
placebo. All subjects were given the same dietary instructions, consisting of a low-fat, low-sugar,
low-sodium, and high-fiber diet plan (1200 kcal diet/day), and were encouraged to drink 64 oz of
water each day. Twenty-two subjects in group A and 17 subjects in group B completed the study.
The average weight loss per subject (n = 23) in group A was 5.06 kg (11.14 lb); under the identical
clinical conditions, group B subjects (n = 17) had an average weight loss of 1.91 kg (4.2 lb). One
subject in group A who had multiple allergies and experienced itching around the mouth was
advised to discontinue the study.
Ramos et al. [51] conducted a randomized, double-blind, placebo-controlled trial on 35 healthy
subjects for 8 weeks. Of the 40 subjects who started the program, 35 completed the study. Three
subjects dropped out due to influenza, and two subjects in the placebo group dropped out due to
a lack of positive results. The subjects were randomly divided into a placebo group (n = 17, 4
males and 13 females; ages, 38.7 ± 12.3 years; percent overweight, 52.4 ± 20.5%; BMI, 33.2 ±
4.4 kg/m2) and a Garcinia cambogia extract group (n = 18, 5 males, 13 females; ages, 35.3 ± 11.8
years; percent overweight, 50.7 ± 20.8%; BMI, 32.6 ± 4.3 kg/m2). The placebo group received 500
mg capsule of placebo before each meal, and the second group received 500 mg lyophilized extract
of Garcinia cambogia (GCE) in a similar form daily for 8 weeks. At the beginning of study and
every two weeks throughout the study, all subjects underwent a physical examination and blood
chemistry analysis. Both groups were placed on recommended diets providing 1000, 1200, or 1500
kcal depending on their theoretical ideal weight (TIW). At the end of the study, total cholesterol
significantly decreased by 18%, and triglyceride levels significantly decreased by 26% in the GCE
group as compared to the control group. Average weight loss after 8 weeks was 1.3 ± 0.9 kg in
the placebo group and 4.1 ± 1.8 kg (p < 0.001) in the GCE group. The GCE group also experienced
reduced appetite starting from the first day of administration. Two subjects treated with GCE stated
that they experienced slight headaches and nausea, and one subject in the control group experienced
similar symptoms. No other adverse reactions were observed.
A randomized, placebo-controlled, double-blind study was conducted in 60 obese subjects (44
females and 16 males) [52]. All subjects were on a low-fat diet of 1200 kcal/day and were instructed
to exercise 3 times a week for 8 weeks. Subjects were given either placebo (n = 30) or HCA (n =
30) t.i.d. (30 minutes before meals). The dose of hydroxycitrate was 1320 mg/day. The HCA group
significantly lost an average body weight of 6.4 kg (p < 0.001), and the placebo group lost an
average body weight of 3.8 kg. The difference in weight reduction is highly significant. The
composition of the weight loss, determined with a near-infrared (NIR) technique, showed that 87%
of the weight loss in the HCA group was due to fat loss compared to 80% in the placebo group.
Blood pressure, total cholesterol, and hip and waist circumferences were significantly reduced in
both groups. A statistically significant difference between the groups in favor of the HCA group
was seen in all of these parameters (p < 0.001). Appetite scores during the study, using visual
analog scales, were significantly reduced in the HCA group but not in the placebo group (p <
0.001). The tolerability of the treatments was excellent. Two subjects stopped the treatment due to
stomach pain, one in the HCA group and one in the placebo group.
Girola et al. [53] conducted a randomized, double-blind, placebo-controlled trial in 150 obese
subjects for four weeks. Group 1 (n = 50) received a hypocaloric diet plus 1 capsule per day of
dietary integrator (capsules containing chitosan 240 mg, Garcinia cambogia extract 55 mg, and
chromium 19 µg); group 2 (n = 50) received a hypocaloric diet and 2 capsules per day; and group
3 (n = 50) received a hypocaloric diet and a placebo. Following completion of the study, group 1
demonstrated a weight loss of 7.9%, total cholesterol reduction of 19.8%, LDL cholesterol reduction
of 22.9%, triglyceride reduction of 18.3%, and HDL cholesterol augmentation of 9.0%. Group 2
exhibited a weight loss of 12.5%, total cholesterol reduction of 28.7%, LDL cholesterol reduction
of 35.1%, triglyceride reduction of 26.6%, and HDL cholesterol augmentation of 14.1%. In the
placebo group (group 3), weight reduction was 4.3%, total cholesterol reduction was 10.7%, LDL
cholesterol reduction was 15.2%, triglyceride reduction was 13.2%, and HDL cholesterol augmen-
tation was 6.3%. Adverse events were reported in 6.4% of subjects in the placebo group (nausea
and/or constipation), 6.1% of the subjects in group 1 (nausea), and 2.1% of the subjects in group
2 (headache), without any statistically significant difference between these three groups. No patho-
logic or clinically significant changes in blood chemistry or hematological assay were observed.
Rothacker and Waitman [54] evaluated the effectiveness of a combination of HCA and natural
caffeine in weight loss in a randomized, placebo-controlled, double-blind study for 6 weeks. Of
the 50 obese subjects (BMI, 27 to 33) enrolled in the study, 48 completed the study. Subjects were
randomized to treatment with a proprietary combination containing 400 mg Garcinia cambogia
extract (50% HCA), 25 mg natural caffeine (guarana and green tea), and 20 µg elemental chromium
as chromium polynicotinate or an identical-appearing placebo caplet. Subjects (mostly females)
were instructed to take 2 caplets three times per day, 30 to 60 minutes before meals. All subjects
were instructed to follow the same 1200 kcal high-fiber diet. The herbal supplement group (n =
25) exhibited a mean weight change of –4.0 ± 3.5 kg, and the placebo group (n = 23) exhibited a
mean weight change of –3.0 ± 3.1 kg. The endpoint revealed directional differences between
treatment groups in favor of the HCA group (p = 0.30). No serious adverse events were reported.
Heymsfield et al. [55] conducted a randomized, placebo-controlled, double-blind study to
evaluate the antiobesity potential of a Garcinia cambogia extract (GCE). Of the 135 overweight
men and women (BMI, approximately 32 kg/m2) who enrolled in the study, 84 subjects completed
the study. Subjects were randomized to receive either GCE (n = 66; 1500 mg of HCA/day) or
placebo (n = 69), and both groups were prescribed a high-fiber, low-energy (1200 kcal) diet. The
treatment period was 12 weeks. Body weight was evaluated every other week and fat mass was
measured at week 0 and 12. Both the placebo and GCE groups lost weight; however, no significant
differences were observed. No significant adverse effects were reported. Unfortunately, the sources
or physicochemical characteristics of the HCA used in this study were not identified, which raises
questions about the proper dosing and bioavailability of the HCA in the test substance.
Kriketos et al. [56] conducted a double-blind, placebo-controlled, randomized, crossover study
involving 3 days of HCA (3.0 g/day) or placebo supplementation in sedentary adult male subjects
(n = 10; ages, 22 to 38 years; BMI, 22.4 to 37.6 kg/m2). The effect of HCA supplementation on
metabolic parameters with or without moderately intense exercise was studied over four laboratory
visits. Two of the four visits involved no exercise (Protocol A) with and without HCA treatment,
while the remaining two visits included a moderately intense exercise regimen (Protocol B; 30 min
at 40% maximal aerobic fitness [VO2max] and 15 min at 60% VO2max) with and without HCA
treatment. Energy expenditure (measured by indirect calorimetry) and respiratory quotient were
measured for 150 min following an overnight fast. Blood samples were collected for the determi-
nation of glucose, insulin, glucagon, lactate, and β-hydroxybutyrate concentrations. In a fasted state
and following 3 days of HCA treatment, the RQ was not significantly lowered during rest (Protocol
A) nor during exercise (Protocol B) compared with the placebo treatment. Treatment with HCA
did not affect EE, either during rest or during moderately intense exercise. Furthermore, the blood
substrates measured were not significantly different between treatment groups under the fasting
conditions of this study. These results do not support the hypothesis that HCA alters the short-term
rate of fat oxidation in the fasting state during rest or moderate exercise at doses likely to be
achieved in humans while subjects maintain a typical Western diet (approximately 30 to 35% total
calories as fat).
Mattes and Bormann [4] assessed the effects of HCA on appetitive variables in a randomized,
placebo-controlled, double-blind, parallel group study in 89 mildly overweight female subjects (18
to 65 years old). Forty-two subjects were given 400-mg caplets of Garcinia cambogia extract (GCE)
30 to 60 min before each meal, three times a day (total dose, 2.4 g/day; total dose of HCA, 1.2
g/day); 47 subjects were given placebo for 12 weeks. Weight and body composition were assessed
at baseline and every other week. Participants were counseled to adhere to a 1200-kcal exchange
diet that contained 30% of energy from fat. Although both groups lost body weight, the active group
(Garcinia cambogia group) achieved a significantly greater reduction (7.0 ± 3.1 vs. 2.4 ± 2.9 kg).
No adverse events were reported. No effects of the HCA were observed on appetitive variables.
In a study conducted by van Loon et al. [57], the effects of acute HCA supplementation on
substrate metabolism were assessed at rest and during exercise in a randomized controlled trial in
humans. Ten cyclists (ages, 24 ± 2 years; weight, 73 ± 2 kg; maximal oxygen uptake, 4.95 ± 0.11
L/min; maximal work output [W:max], 408 ± 8 W). Subjects were studied at rest and during 2 hr
of exercise at 50% W:max on 2 occasions. Both 45 and 15 min before exercise and 30 and 60 min
after the start of exercise, 3.1 mL/kg body weight of an HCA solution (19 g/L) or placebo was
ingested. Total fat and carbohydrate oxidation rates were assessed. Blood samples were collected at
15-min intervals at rest and every 30 min during exercise. Plasma HCA concentrations increased
after HCA ingestion up to 0.39 ± 0.02 mmol/L (82.0 ± 4.8 mg/L); however, no significant differences
in total fat and carbohydrate oxidation rates were observed between trials. Accordingly, plasma
glucose, glycerol, and fatty acid concentrations did not differ between trials. Plasma lactate concen-
trations were significantly lower in the HCA than in the placebo trial after 30 min of exercise, but
at the end of the exercise period they did not differ between trials. In conclusion, HCA, even when
provided in large quantities, does not increase total fat oxidation in vivo in endurance-trained humans.
Kovacs et al. [58] assessed the effects of 2-week ingestion of HCA combined with medium-
chain triglycerides (MCTs) on satiety and food intake in 21 normal to moderately obese subjects
(7 males and 14 females; ages, 43 ± 10 years; BMI, 27.6 ± 2.0 kg/m2). The study consisted of
three intervention periods of 2 weeks separated by wash-out periods of 2 or 6 weeks in a randomized,
crossover, placebo-controlled, double-blind study. Subjects consumed three self-selected meals and
four isoenergetic snacks daily with either no supplementation (placebo), with 500 mg HCA, or
with 500 mg HCA + 3 g MCT. Each intervention period ended with a test day consisting of a
standardized breakfast and ad libitum lunch and dinner. There was significant body weight loss
during the 2 weeks of intervention (placebo, –0.5 ± 0.3 kg, p < 0.05; HCA, –0.4 ± 0.2 kg, p <
0.05; HCA+MCT, –0.7 ± 0.2 kg, p < 0.01), but the reduction was not different between the
treatments. No adverse events were reported.
Hayamizu et al. [59] assessed the effects of long-term administration of Garcinia cambogia
extract on visceral fat accumulation in humans. A randomized, double-blind, placebo-controlled
trial was conducted in 40 subjects (BMI, 25 to 35 kg/m2) for 8 weeks. Subjects were randomized
to either a GCE group (n = 20, 1000 mg HCA per day) or a placebo group (n = 20). Each was
subjected to a computed tomography (CT) scan at the umbilical level before and after the treatment
period, and blood samples were taken to measure the clinical laboratory data every 4 weeks. As
for a higher visceral fat area (VFA) in the subjects (who had initial VFAs over 90 cm2), both the
VFA and the ratio of VFA to subcutaneous fat area (SFA) ratio were measured. In the GCE group,
both the VFA and VFA/SFA significantly decreased compared to the placebo group (p < 0.01 and
p < 0.05, respectively). Triacylglycerol was also reduced significantly in higher VFA subjects in
the GCE group, compared to the initial levels (p < 0.05), but no significant difference was found
between the groups with regard to the loss of body weight and waist-to-hip ratio. Thus, GCE is
useful in reducing body fat accumulation, especially visceral fat accumulation. No adverse effects
were noted.
Westerterp-Plantenga and Kovacs [60] evaluated the effect of HCA on energy intake and satiety
in a randomized, placebo-controlled, single-blind study in 24 overweight, healthy, dietary-unre-
strained subjects (12 males and 12 females; BMI, 27.5 ± 2.0 kg/m2; ages, 37 ± 10 years). In this
6-week trial, subjects consumed three times a day for 2 weeks 100 mL tomato juice (placebo) and,
separated by a 2-week wash-out period, 100 mL tomato juice with 300 mg HCA (HCA-SX). After
2 weeks, 24-hr energy intake, appetite profile, hedonics, mood, and possible change in dietary
restraint were assessed. Prevention of degradation and bioavailability were documented. The 24-hr
energy intake was decreased by 15 to 30% (p < 0.05) with HCA treatment compared to placebo.
No changes were observed in the appetite profile, dietary restraint, mood, taste perception, and
hedonics; body weight tended to decrease, and satiety was sustained.
Lim et al. [61] conducted a randomized, placebo-controlled study to determine whether short-
term HCA ingestion increases fat oxidation during exercise in athletic human volunteers. Subjects
were administered 250 mg of HCA or placebo for 5 days, after each time performing cycle ergometer
exercise at 60% VO2max for 60 min followed by 80% VO2max until exhaustion. Blood was collected
and expired gas samples were analyzed at rest and every 15 min. The respiratory exchange ratio
was significantly lower in the HCA trial than in the control trial (p < 0.05). Fat oxidation was
significantly increased by short-term administration of HCA, and carbohydrate oxidation was
significantly decreased (p < 0.05) during exercise, presumably resulting in an increase in the cycle
ergometer exercise time to exhaustion after 1 hr of 60% VO2max performance with increasing fat
oxidation, which spares glycogen utilization during moderate-intensity exercise in athletes.
In another randomized, double-blind, placebo-controlled study, Lim et al. [62] assessed whether
or not HCA ingestion increases fat utilization during exercise in six untrained female subjects.
Subjects ingested 250 mg HCA or placebo capsule for 5 days and then participated in a cycle
ergometer exercise. Subjects cycled at 40% VO2max for 1 hr, and then the exercise intensity was
increased to 60% VO2max until exhaustion on day 5 of each experiment. HCA decreased the
respiratory exchange ratio and carbohydrate oxidation during 1 hr of exercise. In addition, exercise
time to exhaustion was significantly enhanced (p < 0.05). These results suggest that HCA increases
fat metabolism, which may be associated with a decrease in glycogen utilization during the same
intensity exercise and enhanced exercise performance.
Preuss et al. [63] conducted a randomized, placebo-controlled, double-blind pilot study to
determine the efficacy of HCA-SX and a combination of HCA-SX, niacin-bound chromium, and
Gymnema sylvestre extract (GSE) in weight management in 30 obese subjects (ages, 21 to 50 years;
BMI, >26 kg/m2). Subjects were randomly divided into three groups (10 subjects per group): Group
A was given 4667 mg HCA-SX (60% Ca2+/K+ salt of HCA as HCA-SX). Group B was given a
combination of 4667 mg HCA-SX, 400 µg elemental chromium as niacin-bound chromium (NBC),
and 400 mg Gymnema sylvestre extract (GSE). Group C was given a placebo. Each group received
treatment daily in three equally divided doses 30 to 60 min before meals. In addition, subjects
received a 2000-kcal/day diet and underwent a 30-min/day supervised walking program 5 days a
week for 8 weeks. In group A, body weight and BMI decreased by 6.3%; food intake was reduced
by 4%; total cholesterol, LDL, and triglycerides levels were reduced by 6.3%, 12.3%, and 8.3%,
respectively; and HDL and serotonin levels increased by 10.7% and 40%, respectively. Serum leptin
levels were decreased by 36.6%, and the enhanced excretion of urinary fat metabolites, including
malondialdehyde (MDA), acetaldehyde (ACT), formaldehyde (FA), and acetone (ACON), increased
by 125 to 258%. Under identical conditions, group B reduced body weight and BMI by 7.8% and
7.9%, respectively; food intake was reduced by 14.1%; total cholesterol, LDL, and triglyceride
levels were reduced by 9.1%, 17.9%, and 18.1%, respectively; and HDL and serotonin levels
increased by 20.7% and 50%, respectively. Serum leptin levels decreased by 40.5% and enhanced
excretion of urinary fat metabolites increased by 146 to 281%. Group C (placebo) reduced body
weight and BMI by only 1.6% and 1.7%, respectively. No other significant changes were observed
in the placebo group.
In a subsequent randomized, placebo-controlled, double-blind study, Preuss et al. [64] evaluated
the effects of HCA-SX and a combination of HCA-SX plus NBC and GSE in 60 obese subjects
(ages, 21 to 50; BMI, >26 kg/m2). Subjects were randomly divided into three groups. Group A was
administered 4667 mg HCA-SX. Group B was administered a combination of 4667 mg HCA-SX,
400 µg elemental chromium as NBC, and 400 mg GSE. Group C was given a placebo. All three
groups received treatment daily in three equally divided doses 30 to 60 min before meals. All
subjects received a 2000-kcal/day diet and participated in a supervised walking program for 8
weeks. At the end of 8 weeks, body weight and BMI decreased by 5 to 6% in both treatment groups
A and B. Food intake, total cholesterol, LDL, triglyceride, and serum leptin levels were significantly
reduced in both groups, while HDL levels and excretion of urinary fat metabolites increased in
both groups. A marginal or nonsignificant effect was observed in all parameters in group C
(placebo). Results demonstrate that HCA-SX, and to a greater degree the combination of HCA-SX,
NBC, and GSE, are effective in reducing body weight and promoting healthy cholesterol levels.
No adverse effects were observed.
BENEFITS OF Ca2+ AND K+ IN HCA-SX

IN WEIGHT MANAGEMENT
Calcium (Ca2+) and potassium (K+) are important cations for regulating a number of metabolic
pathways influencing energy expenditure, leptin metabolism, and weight control. K+ is a major
mineral in the body, and the recommended daily intake is 3500 mg. Severe K+ deficiency causes
cardiac arrhythmias, muscle weakness, and glucose intolerance; a moderate deficiency leads to
increased blood pressure and salt sensitivity, an increased risk of kidney stones, and increased bone
turnover. Inadequate K+ intake may also increase the risk of cardiovascular disease, particularly
stroke, and may disturb intracellular pH homeostasis. K+ and Ca2+ flux may play important roles
in coupling intracellular energy production to leptin secretion [65,66]. Restriction of Na+ intake is
a common dietary recommendation in the treatment of syndrome X disorders; however, meta-
analyses indicate that increased Ca2+ and K+ intake should be the focus of dietary recommendations,
rather than restriction of Na+, in the management of such disorders as hypertension. Evidence
demonstrates that diets rich in Ca+ and K+ produce a potent antihypertensive effect [65]. Angelos
et al. [66] reported that rat hearts perfused with glucose, insulin, and K+ had significantly higher
adenosine triphosphate (ATP), creatine phosphate, and nicotinamide adenine dinucleotide phosphate
(NADP+) and lower adenosine monophosphate (AMP) and inosine levels compared to controls
after 30 min of reperfusion. Reperfusion improved post-ischemic recovery of contractile function
and the myocardial bioenergetic state.
Dietary Ca2+ also plays a crucial role in regulating energy metabolism. High Ca2+ diets have
been shown to inhibit fat synthesis and storage in adipocytes and reduce weight gain during
overconsumption of an energy-rich diet. High Ca2+ intake was shown to increase lipolysis and
preserve thermogenesis during caloric restriction, accelerating weight loss. In contrast, low Ca2+
diets have been shown to inhibit body fat loss [67,68]. Several clinical studies of Ca2+ intake were
found to be associated with reduced weight in all groups. The Ca2+-treated subjects in a controlled
trial exhibited significant weight loss across nearly 4 years of observation [69]. In addition, other
data from six observational studies and three controlled trials were evaluated to determine the
relationship between Ca2+ intake and body fat. Analysis reveals that higher intake of Ca2+ is
consistently associated with body weight loss and reduced weight gain. Heaney et al. [70] demon-
strated that a 300-mg increment of regular Ca2+ intake is associated with 1 kg less body fat loss in
children and 2.5 to 3.0 kg lower body weight in adults. Furthermore, Heaney et al. [70,71] estimated
that, although Ca2+ intake explains only a fraction of the variability in weight gains, increased Ca2+
intake could reduce the prevalence of overweight and obesity significantly. A related review by
Teegarden [72] reports that Ca2+ may play a key role in reducing the incidence of obesity and
prevalence of insulin resistance syndrome. The most obvious reason for adequate Ca2+ intake by
postmenopausal women during a weight-loss regimen is to reduce the risk of bone demineralization
disorders, such as osteoporosis [73]. This evidence supports the notion that adequate intake of
dietary K+ and Ca2+ enhances energy production, leptin, and insulin metabolism and satisfies
particular nutrient needs of important pathways required for healthy sustained weight loss and
maintenance.
In addition to 60% HCA, 4500 mg of HCA-SX supplies approximately 495 mg of Ca2+ (49.5%
of RDI) and 720 mg of K+ (15% of the Reference Daily Intake [RDI]) bound to HCA. The Ca2+
and K+ ions in this novel preparation contribute an important role in achieving significant improve-
ments in body composition and the weight distribution effects by multiple synergistic pathways.
MOLECULAR MECHANISMS OF SEROTONIN AND

NEUROPEPTIDE Y IN APPETITE SUPPRESSION
Earlier in vitro studies in our laboratories have demonstrated that HCA-SX can induce increased
serotonin (5-hydroxytryptamine, or 5-HT) release and serve as a mild serotonin receptor reuptake
inhibitor (SRRI) [25,74]. The effect of HCA on basal and potassium-chloride-depolarization-evoked
increases in radiolabeled serotonin ([3H]-5-HT) release from rat brain cortex slices in vitro was
investigated. Results demonstrated that HCA (10 µM to 1 mM) altered the baseline of spontaneous
tritium efflux, reaching a maximum at 300 µM, but had no significant effect on the potassium-
evoked release of [3H]-5-HT. HCA-SX can inhibit [3H]-5-HT uptake (and also increase 5-HT
availability) in isolated rat brain cortical slices in a manner similar to that of SRRIs and thus may
prove beneficial in controlling appetite, as well as treatment of depression, insomnia, migraine
headaches, and other serotonin-deficient conditions [81,82]. In subsequent in vivo studies, we found
elevated serotonin levels in the brain tissues of male and female rats (unpublished data). These
findings were further corroborated in the human clinical trials and the cDNA oligonucleotide
microarray studies conducted by Preuss et al. [56,57] and Roy et al. [45], respectively. Thus,
serotonin regulation may be a major mechanism of appetite suppression by HCA-SX. In a very
recent study, HCA-SX caused a significant reduction of basal neuropeptide Y (NPY) concentrations
in the hypothalamic tissues, further establishing a role for HCA-SX as an appetite suppressant
(unpublished data).
REGULATION OF GENES BY HCA-SX

Obesity is an energy-balance disorder in which certain genes that are programmed to resist loss
of body fat prevail [75,76]. This programmed genetic predisposition is responsible for downreg-
ulating the resting metabolic rate in response to dietary and caloric restriction, which is signif-
icantly disrupted following rapid-weight-loss regimens [77]. Overconsumption of food (excess
energy intake) is a normal consequence that contributes to weight gain and obesity. A resistance
to the hormone leptin also characterizes common obesity. Insulin has been shown to increase
leptin secretion by 25% [78]. Ample evidence demonstrates that insulin resistance is also a
primary contributor to obesity, suggesting that insulin-resistance-induced hyperinsulinemia can
provoke leptin-resistant hyperleptinemia with a consequential increase in fat synthesis and storage
in adipocytes, a characteristic sequel of syndrome X. Furthermore, adipocytes from fatter animals

secrete more leptin, and a correlation between intracellular ATP concentration and the rate of
leptin secretion appears to exist [78]. As such, the leptin concentration correlates positively with
percent body fat. A low resting metabolic rate for a given body size and composition, a low rate
of fat oxidation, and low levels of physical activity are risk factors for weight gain and common
traits of obese individuals [79].
The effects of low-dose oral HCA-SX were investigated on the body weight and abdominal
fat transcriptome in rats [45]. HCA-SX restricted body weight gain in rats and lowered abdominal
fat leptin expression. High-density microarray analysis of 9960 genes and expressed sequence tags
(ESTs) present in the fat tissue identified a specific set of genes sensitive to dietary HCA-SX [45].
Functional characterization of HCA-SX-sensitive genes revealed that upregulation of genes encod-
ing serotonin receptors represents a distinct effect of HCA-SX on appetite suppression [45].
HCA-SX upregulated a significant number of genes associated with serotonin receptor and neu-
ropeptide signaling, which demonstrate its appetite suppression ability [45]. Serotonin is believed
to be a mood-enhancing chemical in the brain. High levels of serotonin are important for emotional
well-being as serotonin provides a feeling of satiation and a calming effect. Serotonin also plays
a role in appetite suppression and reduces cravings for carbohydrates and foods with a high glycemic
index [78]. Appetite control involves an integration of the drive signals arising from energy stores
in the body with the satiety signals generated by periodic episodes of food consumption. Serotonin
(i.e., 5-HT1B and 5-HT2C postsynaptic receptors) has been implicated in the processes of within-
meal satiation and post-meal satiety, which are affected by the signals arising from the pattern of
food intake. Stimulation of serotonergic receptors reduces feeding and perhaps enhances the sati-
ating effect of food. Furthermore, regulation of the 5-HT2A gene plays an essential role in body
weight management through the regulation of cortisol secretion [79]. Also, polymorphism of the
5-HT2A genes causes abdominal obesity in humans [79]. These findings corroborate with our
previously conducted in vitro and in vivo studies demonstrating the ability of HCA-SX to enhance
serotonin release and availability in the brain vicinity and act as a mild serotonin receptor reuptake
inhibitor [25,56,57,74].
HCA-SX has also been shown to modulate a significant number of genes, including prostag-
landin D synthase (PGDS), aldolase B, lipocalin 2, fructose-1,6-biphosphatase 1, and low-density
lipoprotein (LDL) receptor-related protein 2, which play prominent roles in lipid metabolism,
carbohydrate metabolism, glycolysis, and cell communication [45]. It is worthwhile to mention
that PGDS serves as a ligand for the nuclear receptor peroxisome proliferator-activated receptor γ
(PPARγ), and PPARγ signaling causes metabolic changes that ultimately lead to obesity [80,81].
These findings agree with our clinical studies, which have demonstrated the influence of HCA-SX
on reductions in LDL, triglycerides, and total cholesterol; on the enhanced excretion of urinary fat
metabolites, including malondialdehyde, acetaldehyde, formaldehyde, and acetone; and on marginal
increases in HDL levels, in conjunction with body weight loss and BMI reduction [56,57]. The
mitochondrial/nuclear proteins necessary for fundamental support of the tissue were not affected
by HCA-SX, thus demonstrating the safety of HCA-SX [45]. These findings further emphasize
that HCA-SX is safe, efficacious, and capable of regulating a significant number of obesity regu-
latory genes.
CONCLUSION
Garcinia cambogia preparations are quite popular and have been used in India and Southeast Asia
for the last several centuries. In the practice of Ayurveda medicine, several G. cambogia preparations
are recommended for diverse therapeutic applications. In the Western world, a significant number
of scientists have conducted in vitro, in vivo, and mechanistic research on G. cambogia since the
late 1960s. A number of patents and manufacturing process have been developed, and several (–)-
hydroxycitric acid preparations are commercially available in the marketplace. Extensive safety,
mechanistic, and efficacy studies have been conducted on a novel calcium/potassium salt of HCA
(HCA-SX). Literature shows that the solubility, taste, and odor of HCA salts, as well as the structural
integrity, bioavailability, and stability of the HCA preparations, depend largely on the binding
cations and novel manufacturing technology.
It is worthwhile to mention that these physicochemical characteristics are very important to
demonstrating the safety and efficacy of HCA salts in weight management. A significant number
of studies have shown that HCA-SX is safe and efficacious in obesity management, as evidenced
by the lowering of body weight and BMI in clinical studies. HCA-SX also exhibits discrete
mechanisms for appetite suppression through serotonin and hypothalamic neuropeptide Y regula-
tion. HCA-SX has also been shown to promote fat oxidation, as demonstrated by enhanced excretion
of urinary fat metabolites, and to reduce serum leptin levels in human subjects. HCA-SX also was
found to promote healthy blood lipid profiles in a clinical study, and no significant adverse effects
were observed. Effective dose, bioavailability, balanced diet, and moderate exercise, coupled with
the synergistic influences of calcium and potassium, can significantly enhance the therapeutic
efficacy of HCA-SX in obesity regulation. These studies were further substantiated by an unbiased
cDNA oligonucleotide microarray study, which demonstrated the regulatory role of HCA-SX on
obesity genes, without compromising the levels of mitochondrial and nuclear proteins essential for
optimal biochemical and physiological functions in cellular system.
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28 AEfficacy
Review of the Safety and
of Citrus aurantium
in Weight Management
Sidney J. Stohs and Michael Shara
CONTENTS
Introduction ....................................................................................................................................371
Historical Perspective.....................................................................................................................372
Chemistry .......................................................................................................................................372
Review Articles ..............................................................................................................................373
Animal Studies...............................................................................................................................374
Clinical Studies ..............................................................................................................................375
Case Reports ..................................................................................................................................377
Other Safety Considerations ..........................................................................................................378
Summary and Conclusions ............................................................................................................380
References ......................................................................................................................................381
INTRODUCTION
Citrus aurantium extract and its primary alkaloidal constituent, synephrine, are widely used in
weight management products and as thermogenic agents. Citrus aurantium extract is also known
as bitter orange extract, a product that is derived from the unripe (green) fruits. In traditional
Chinese medicine, it is known as “Chih-shi” or “Zhi shi.” Synephrine is a phenylethylamine
derivative, also known as oxedrine or p-synephrine due to the hydroxy group in the para position
on the benzene ring. In recent years, bitter orange extract has been used in weight management
products due to its putative stimulant effects on metabolic processes, including increased lipolysis
and thermogenesis as well as its mild appetite suppressant effects.
Controversy exists regarding the safety and efficacy of bitter orange extract. This controversy
exists for a number of reasons. Little research is extant in which synephrine and extracts of bitter
orange have been studied without the addition of various other ingredients and herbal products.
The issues of safety and efficacy are clearly clouded by the structural similarity of synephrine to
ephedrine, notwithstanding that the pharmacokinetics of the two compounds and the receptor
binding specificities are vastly different due to significant structural differences. Risk-to-benefit
ratios have not been determined, and much of the information published that relates to risk has
been questionable.
Other issues have also clouded the picture with respect to the safety and efficacy of bitter
orange extract. Many of the extracts that are used are either nonstandardized or poorly standardized,
making it exceedingly difficult to establish reproducibility. Lack of knowledge of the chemical
composition of the extracts being used precludes meaningful comparisons. Products containing
bitter orange extract almost invariably contain a variety of other herbal extracts, many of which
371
contain caffeine. Issues exist regarding the appropriate use of products containing bitter orange
extract, and, in some cases, what might be considered high or excessive levels have been incorpo-
rated into some products. Warnings about not using products containing bitter orange extract or
bitter orange extract in combination with caffeine if one has a history of high blood pressure,
cardiovascular disease, diabetes, or thyroid disease are largely ignored by the consuming public.
A final serious issue that has added greatly to the overall confusion by the public and scientific
community has been the release of erroneous adverse events information by governmental agencies.
Statements implying that large numbers of adverse events and even deaths due to the use of products
containing bitter orange extract have been shown to be incorrect and misleading but are still widely
parroted by the popular press. Compounding the problem are pronouncements made by governmental
officials, lawmakers, and public figures based on information that is now known to be clearly in error.
The questions to be asked are “What information can be obtained from studies that have been
conducted on bitter orange extract?” and “Is bitter orange extract safe and effective for weight
management when used as directed in appropriate amounts?” This review will cover published data
associated with animal studies, human studies, and unpublished clinical studies, as well as case
reports.
HISTORICAL PERSPECTIVE
According to traditional Chinese medicine [8], Zhi shi (immature bitter orange) “is one of the best
herbs to treat gastrointestinal disorders characterized by stagnation and accumulation” and “is one
of the best herbs to relieve distention and hardness of the epigastric area caused by cholecystitis.”
Pharmacologically, this compendium reports that Zhi shi does not affect heart rate or respiration
and has minimal toxicity. Based on studies in mice, the estimated LD50 is approximately 175 mg/kg
for synephrine.
Youngken [31] described the collection and preparation of bitter orange peel USP and its uses
as an aromatic bitter and flavoring agent with an average dose of 1 g for the dried material and 4
mL for the bitter orange peel tincture USP. Trease and Evans [29] described the history of bitter
orange trees, noting that they were first brought to Europe about 1200 AD from Northern India via
Africa. At the time this book was published, the peel of the bitter orange was officially in the
British Pharmocopoeia. Bitter orange peel has been used in South America in folk medicine for
anxiety, insomnia, and epilepsy, and the oil from the peel has been shown to possess anxiolytic,
sedative, and anticonvulsant properties [7].
The current use of Citrus aurantium can be arguably traced to the work of Arch and Ainsworth
[3] which suggested that this product has the potential to augment thermogenesis and increase
calorie consumption while at the same time producing fewer cardiovascular perturbations than
ephedrine due to its lack of penetration of the central nervous system. As a result of the ban of
ephedrine in 2004, bitter orange extract rapidly replaced ephedra, although the use of bitter orange
extract had gradually increased as a thermogenic agent over the past 10 years.
CHEMISTRY
A number of studies have assessed the chemical components in bitter orange extract responsible
for the effects on weight management as well as other physiological effects. Hashimoto et al. [16]
developed a high-performance liquid chromatographic (HPLC) method for determining synephrine
content in Chinese medicinal drugs and concluded that synephrine was present at levels of 0.174
to 0.566% in these crude drug preparations. Pellati et al. [24] determined the alkaloidal content of
fresh fruit as well as two dried extracts and three herbal products. The synephrine content of fresh
fruit was approximately 0.02%, and it increased to about 0.35% in dried fruit. Two dried extracts
contained about 3% synephrine and three herbal products had yields of 0.25%, 0.66%, and 0.99%.
Dried extracts contained approximately 0.25% and 0.06% octopamine and tyramine, respectively.
A Review of the Safety and Efficacy of Citrus aurantium in Weight Management 373
The question regarding which synephrine alkaloids are present in Citrus aurantium has been
addressed by Allison et al. [1]. These investigators developed an isocratic reserve-phase liquid
chromatographic system coupled with mass spectroscopy, enabling them to separate and identify
the possible isomers of synephrine. They were able to differentiate p-synephrine (parahydroxy)
from m-synephrine (metahydroxy). The m-synephrine is also known as phenylephrine. Both isomers
are naturally present in small amounts in the body. The m-synephrine (phenylephrine) is available
as an over-the-counter nasal decongestant and as an ophthalmic product for mydriasis [30]. Allison
et al. [1] determined that both isomers were present in an over-the-counter weight-loss product
they had obtained. Confusion exists regarding whether both isomers are naturally present in bitter
orange extracts, whether environmental and extraction conditions influence the relative composition
of the two alkaloids, and whether some extracts may be adulterated with the m-isomer.
The question regarding which isomer is present is relevant to the effects and side effects of any
given product. Both meta and para isomers of synephrine are phenylethanolamine derivatives; however,
the p-isomer is believed to be primarily a β3-adrenergic receptor agonist that may be responsible for
inducing a thermogenic response [2,10]. m-Synephrine (phenylephrine) is believed to exert more
α-receptor activity as well as some β1 and β2 receptor activity, resulting in pressor as well as cardiac
effects. Chemically, although ephedrine is structurally related to p-synephrine, it differs in that it is a
phenylpropanolamine derivative rather than a phenylethanolamine, and ephedrine does not contain a
parasubstituted hydroxy group. These chemical differences can greatly alter pharmacokinetic properties,
particularly transport across the blood–brain barrier. The parahydroxy group of synephrine can pre-
dictably decrease lipophilicity and therefore transport into the central nervous system [19].
In addition to synephrine, Citrus aurantium contains a family of related phenylethylamines
including N-methyltyramine, tyramine, hordenine, and octopamine. For example, a product used
in a clinical trial by Gougeon et al. [13] was reported to contain an extract of C. aurantium such
that each capsule contained 26 mg synephrine, 4 mg octopamine, 3.5 mg N-methyltyramine, and
hordenine. Unfortunately, the entire alkaloidal profile of extracts is usually not determined
[16,24,25]. The net result is that as long as the chemical composition of any given dietary supple-
ment containing a bitter orange extract is not known, one cannot make informed comparisons
between different research studies nor can one make generalized statements regarding the safety
and efficacy of products containing a bitter orange extract.
REVIEW ARTICLES
Preuss et al. [26] reviewed the effects of Citrus aurantium as a thermogenic, weight reduction
replacement for ephedra. Based on the literature available at that time, these authors concluded
that C. aurantium might be a possible thermogenic substitute for ephedra. They also concluded
that more studies and widespread use of this natural product would reveal the efficacy and relative
safety of C. aurantium compared to ephedra.
A review of Citrus aurantium as an ingredient in dietary supplements marketed for weight loss
was published by Fugh-Berman and Myers [12]. This study is frequently cited as evidence for the
lack of safety of C. aurantium extracts and their use in dietary supplements associated with weight
management. Much of the evidence cited for the lack of safety related to increased blood pressure
due to synephrine. Unfortunately, essentially all of the data supporting the ability of synephrine to
increase blood pressure are related to studies involving the intravenous administration thereof, not
the oral consumption of extracts containing synephrine. These authors concluded that, although no
adverse events have been reported in conjunction with ingestion of C. aurantium products orally
to date, products containing synephrine have the potential to increase cardiovascular events in
humans, disregarding the route of administration. These investigators further concluded that little
evidence supports the use of products containing C. aurantium as effective aids to weight loss and
weight management [12]. It must be concluded that the warning about safety is hypothetical and
not based on scientific evidence or actual data involving oral product use.
The safety and efficacy of Citrus aurantium for weight loss were also reviewed by Bent et al.
[4]. These authors identified 157 titles of articles referring to C. aurantium, of which 7 were
randomized controlled trials; 6 studies were excluded because the products also contained ephe-
drine. Only one study satisfied all of the inclusion criteria and was a 6-week, randomized, placebo-
controlled trial reported by Colker et al. [9]. This study is described in greater detail under the
Clinical Studies section. Although a small but significant weight loss was reported by Colker et
al., Bent et al. [4] concluded that a systematic review failed to produce evidence that C. aurantium
was effective for weight loss. These authors also concluded that safety information is extremely
limited, but, because C. aurantium contains synephrine, use of the herb may pose risks of adverse
cardiovascular events, although no evidence to support this contention was presented.
ANIMAL STUDIES
Relatively few studies have been conducted concerning the efficacy and safety of Citrus aurantium
extracts in animals. One of the most widely cited studies is the work of Calapai et al. [6], who
examined the effects of repeatedly administering orally 2.5 to 20 mg/kg of two C. aurantium fruit
extracts that had been standardized to 4 and 6% synephrine. These investigators examined the
effects of these extracts on food intake, body weight gain, arterial blood pressure, electrocardiogram
(ECG), and mortality in male rats. Animals were treated for 7 consecutive days, and the various
measurements were recorded for 15 consecutive days. Significant dose-dependent decreases in food
intake as well as body weight were observed. No significant changes were observed in blood
pressure, but ECG alterations were significant after 10 days of treatment. Some deaths were noted
in the treated animals, although the difference was not statistically significant.
Several questions exist with respect to the study of Calapai et al. [6]. Parra et al. [23] have
examined the LD50 of various plant extracts including Citrus aurantium in mice. Of interest was
the observation that their calculated LD50 for a C. aurantium extract was approximately 477 mg/kg
in mice as compared to a maximum of 140 mg/kg in rats in the study of Calapai et al. [6]. The
reason for the large disparity in the apparent toxicity is unclear. Differences in the methods of
preparing the respective extracts may have contributed to the discrepancies. The concentration of
synephrine was not reported by Parra et al. [23]. One would not expect to see large differences in
response between mice and rats with respect to this extract.
In an earlier study, Huang et al. [18] investigated the effects of a Citrus aurantium extract on portal
hypertensive rats. In vitro contractile studies as well as hemodynamic effects were performed after
partial portal vein ligation. The C. aurantium extract was infused into the femoral vein. Synephrine at
up to 0.38 mg/kg/min was similarly infused. The results demonstrated a dose-dependent decrease in
portal venous pressure and heart rate with a dose-dependent increase in mean arterial pressure. Most
notable is the fact that the extract and synephrine were administered intravenously as opposed to orally.
As a consequence, it is difficult to meaningfully extrapolate the data obtained to the typical situation
where C. aurantium extract is used orally in dietary supplements for appetite control and weight
management. The concentrations of synephrine and related alkaloids used in dietary supplements would
not be expected to achieve the blood levels produced following intravenous administration.
Several other studies have examined the properties of preparations from Citrus aurantium. Car-
valho-Freitas and Costa [7] demonstrated a sedative effect of an essential oil product from peel and
a hydroethanolic (70% w/v) extract from leaves. No toxicological studies were conducted, and the
product was not known to contain phenylethylamine alkaloids. Hosseinimehr et al. [17] demonstrated
that a hydroethanolic extract of the dried peels of ripe fruit provided a radioprotective effect against
gamma radiation in mice. The citrus extract was given by intraperitoneal injection at doses up to 1000
mg/kg body weight. No toxicological studies were reported, and the studies were not repeated
following oral administration. The authors concluded that flavonoids were responsible for the radio-
protective effects. In general, few well-defined and definitive studies have been conducted in animals
on the safety of C. aurantium extracts as related to weight management and thermogenesis.
CLINICAL STUDIES
As is the case with animal studies, relatively few well-designed, controlled studies have been
conducted with Citrus aurantium extracts to assess their efficacy and safety. Most studies have
been conducted using products that contain not only an extract of C. aurantium but also other
ingredients, including caffeine, ephedrine, ginkgo, ginseng, and St. John’s wort. The fact that C.
aurantium extract is almost invariably incorporated into products containing other potentially active
ingredients makes comparative analyses exceedingly difficult, if not impossible. It is also difficult
to gather information on the safety and efficacy of C. aurantium extract alone.
Because Citrus aurantium extract is generally incorporated with other ingredients, it is appro-
priate to conduct studies on these combinations to assess not only their efficacy but also the safety
of these diverse preparations. One of the earliest studies to be conducted on the effects of C.
aurantium extract on body fat loss, lipid levels, and mood in overweight adult subjects was
conducted by Colker et al. [9]. The product used in this study contained 975 mg C. aurantium
extract (6% synephrine alkaloids), 528 mg caffeine, and 900 mg St. John’s wort on a daily basis.
Twenty subjects completed the study. The subjects followed an 1800-kcal/day American Heart
Association Step One diet and performed a circuit-training exercise program 3 days a week. The
study reported that, after 6 weeks of the study, the treated group lost a small but significant amount
of body weight (1.4 kg) and a significant amount of body fat (2.9%). No significant changes in
blood pressure, heart rate, electrocardiographic findings, serum chemistry, or urinalysis were noted,
and no significant changes were noted in the results of the Profile of Mood States Questionnaire
for fatigue or vigor. The treated group also experienced a significant increase in basal metabolic
rate as compared to the placebo rate, which experienced a significant decrease in this indicator [9].
Several observations can be made regarding this study. St. John’s wort (Hypericum perforatum)
is an antidepressant, and depression is associated with overeating and obesity; however, no change
in mood was noted in the study. The amount of caffeine consumed daily in conjunction with the
product (528 mg) is equivalent to approximately 4 cups of coffee, which is a well-known ther-
mogenic agent [11]. Whether the weight loss and increase in basal metabolic rate were due to the
caffeine, the Citrus aurantium extract, or a combination thereof is not clear; however, the net result
is that a small but significant loss in body weight as well as body fat was observed. The authors
concluded that the combination of C. aurantium extract, caffeine, and St. John’s wort was effective
and safe when used in combination with exercise and mild caloric restriction for promoting fat and
body weight loss in healthy, overweight adults. It should be noted that the total daily intake of
phenylethylamine-related alkaloids was approximately 58.5 mg.
Kalman et al. [20] reported the results of a 14-day clinical trial using a commercial weight-
loss product (Xenadrine EFX™) and involving 16 overweight or obese healthy subjects in combi-
nation with exercise. The product contained a proprietary blend of extracts from Citrus aurantium,
yerba maté, grapeseed, green tea, and ginger root in conjunction with several vitamins and amino
acids. The amount of phenylethylamine alkaloids from various sources was not reported nor was
the amount of caffeine and other methylxanthines. Over the 14 days of the study, no significant
effects of the product were noted as compared to the placebo group with respect to blood pressure,
heart rate, electrocardiographic data, fasting blood glucose, renal function, hepatic function, or
complete blood count with differentials. Sleep quality was negatively impacted in the treated group,
but this same group experienced a significant reduction in fatigue levels. The treated group expe-
rienced a reduction in diastolic blood pressure as compared to the placebo group (–8.0 vs. ±4.2
mmHg). No serious adverse events were reported. Minor effects including headache, sleep distur-
bance, dry mouth, and “spotting” were reported among participants of the treated group, while
headache, nervousness, and increased sweating were reported by participants of the placebo group.
The authors concluded that the product was safe over the course of the study. It should be noted
that no weight loss was observed. The study suffers from its short duration and small number of
subjects. Furthermore, the fact that no weight loss was observed over the 14 days of the study may
be surprising to some individuals but an expected outcome among others [20]. Furthermore, based
on the proprietary nature of the product, it is not possible to make meaningful comparisons with
other studies and other products.
Zenk et al. [32] conducted a randomized double-blind study to evaluate the effect of a propri-
etary weight management product (Lean Source™) on body composition of overweight men and
women. Of the 65 adults enrolled, 54 completed the 8-week study. In addition to Citrus aurantium,
the product contained extracts of guarana and green tea in conjunction with 7-oxo-dehydroandros-
tenedione (DHEA), conjugated linoleic acid, and chromium picolinate. The daily consumption of
C. aurantium extract was 200 mg. At the completion of the study, the treated group lost an average
of 2.9 kg body weight compared to a 1.5-kg body weight loss by the placebo group. The weight
loss experienced by the treated group was not large considering the time frame involved and the
fact that the subjects were overweight. No significant differences were noted between the treatment
group and the placebo group with respect to systolic and diastolic blood pressures, heart rate, or
temperature. Furthermore, no significant differences were observed in chemistry profiles and com-
plete blood counts between the two groups. There was also no difference in the reported incidence
of adverse events between the two groups, and no serious adverse events were reported. Constipation
and back pain were the most prominent adverse events reported among the treated group, and
nausea, headache, and peripheral neuropathy were reported by individuals on the placebo [32].
Several conclusions can be drawn. The complex product appeared to be safe when taken as directed.
Weight loss was minimal on the product. As with other studies involving complex products, it is
impossible to determine the contribution of C. aurantium to the weight loss that was reported, and
the net effect may well be due to the combination of ingredients.
A study by Zenk et al. [33] involved the use of another commercial weight-loss product (Lean
System 7™) and assessed various parameters. The study was a randomized, double-blind placebo-
controlled study involving 47 healthy, overweight adults. A total of 35 subjects completed the
8-week study. Each adult received three capsules of the weight-loss product twice daily or an
identical placebo in conjunction with a calorie-restricted diet and an exercise program. The com-
mercial product contained 6 mg synephrine per capsule (36 mg/day). The product also contained
3-acetyl-7-oxo-dehydroepiandrosterone (17 mg), Coleus forskohlli extract (50 mg extract, 10 mg
forskolin), yerba maté (167 mg), guarana extract (233 mg extract, 51 mg caffeine), piperine (1.67
mg from Piper nigrum), and dandelion leaf and root powder (83 mg). The most significant finding
of the study was a 7.2% increase in resting metabolic rate in the treated subjects; however, no
significant differences were noted between the treated and the placebo-controlled groups with
respect to body weight, body fat, or lean tissue [33]. No changes in heart rate or blood pressure
were observed, and no serious adverse events were reported. In general, the product was well
tolerated over the 8 weeks of the study, but no weight was lost.
Seifert et al. [27] conducted a study on the effects of a product containing Citrus aurantium
that evaluated the effects of an herbal blend on energy expenditure in mildly obese subjects. The
study involved 14 females and 9 males in a placebo-controlled, crossover design. Subjects ingested
three treatment capsules on day one, and one more capsule on the morning of the second day. Data
were collected 60 min after the last administration of the product. The results demonstrated that
from pre-test on day one to post-test on day two, caloric expenditure increased by 8% following
ingestion of the product. Oxygen uptake increased from 230 to 250 mL/min following treatment.
No differences were observed following treatment with regard to heart rate or blood pressure. The
study suffers from a lack of adequate information regarding the amount of phenylethylamine
alkaloids ingested, as well as the kinds and amounts of other herbal products present in the product.
Furthermore, the study was an acute study and did not provide information on long-term usage, as
is characteristic of weight-loss and weight-management products.
The thermic effects of food in conjunction with the phenylethylamine alkaloids extracted from
Citrus aurantium were investigated in healthy, weight-stable male and female subjects [13]. The
thermic effect of food from a 1.7-MJ, 30-g protein meal was determined intermittently for 300 min
by indirect calorimetry. The C. aurantium extract was provided in capsule form. Five capsules
provided 26 mg synephrine and 4 mg or less each of octopamine, N-methyltyramine, tyramine,
and hordenine. The thermic effect of food was determined on an initial 30 subjects. A subset of
11 men and 11 women was studied a second time after ingestion of the C. aurantium extract in
conjunction with the protein meal, and a subset of 12 women and 8 men was studied a third time
following ingestion of capsules containing C. aurantium alone. The study clearly demonstrated
that the thermic effect of food was 20% lower in women than men following a meal. When the C.
aurantium extract was used in conjunction with the protein meal, an increase in the thermic effect
on food was seen only in women, increasing by 29%. In men, the addition of the C. aurantium
extract did not significantly affect the thermic effect of food, and under these conditions the values
did not differ between men and women. A significant increase in the respiratory quotient occurred
in both sexes in response to the C. aurantium extract alone. Following exposure to the C. aurantium
extract, no significant changes occurred in pulse rates or systolic and diastolic blood pressures
when compared with baseline values. The results of this acute study do not provide information
regarding long-term usage as related to safety or efficacy in terms of weight loss; however, the
study does indicate a thermogenic effect of a C. aurantium extract in women. The study also
demonstrates an increase in resting energy expenditure in both sexes. The significance of an increase
in urinary epinephrine excretion remains to be determined.
CASE REPORTS
Several case reports have been presented in the literature regarding the possible involvement of
Citrus aurantium-containing weight-management products with cardiovascular incidents. From
these reports, it is difficult to determine whether the occurrence of the event was coincidental with
the use of a C. aurantium-containing product or whether there was a causal relationship. The finger
is pointed at C. aurantium in these reports, when in fact all of the products involved were
multicomponent, and it is difficult if not impossible to determine the cause of the cardiovascular
incident. Furthermore, in most cases, many other compounding factors were involved; therefore,
although these case reports should raise the level of consciousness and awareness with regard to
the use of complex weight-management products containing extracts of C. aurantium, it is not
possible to extrapolate the cause of these cardiovascular effects to the synephrine that may have
been present in the products. These case reports are presented below.
Nykamp et al. [22] reported what they believed to be a possible incidence of myocardial infarction
associated with the use of a Citrus aurantium-containing dietary supplement in a patient with
undetected coronary vascular disease. The product in question contained 200 mg of a C. aurantium
extract (alkaloidal content unknown), an herbal diuretic complex, extracts of guarana and green tea,
250 mg carnitine, 400 µg chromium, and 300 mg of an extract containing hydroxycitric acid.
The authors concluded that the use of Citrus aurantium-containing supplements may pose a
risk for cardiovascular toxicity and concluded that the C. aurantium “is probably associated with
this cardiovascular event.” It is truly difficult to determine how this conclusion could be reached
in light of the numerous confounding factors present, including preexisting heart disease (undetec-
ted), a 37-year history of smoking one and a half packs of cigarettes per day, overweight, probable
monosodium glutamate ingestion before the onset of symptoms, and high caffeine intake. Further-
more, the product in question contained a relatively low amount of C. aurantium extract (200 mg),
and, if one assumes the synephrine content was as high as 6%, then the daily ingestion of this
alkaloid would amount to only 12 mg/day. Up to 5 times this amount of total alkaloids daily have
been shown to be without adverse events in healthy adults over a 6-week period of time [9]. It
should be noted that the combination of all the confounding factors, including the use of this
weight-management product, may have led to the myocardial infarction; however, it is not scien-
tifically or physiologically plausible to assume that the single initiating ingredient or factor was
the C. aurantium extract.
A case of ischemic stroke associated with the use of a dietary supplement containing synephrine
has been reported by Bouchard et al. [5]. According to the manufacturer, each capsule contained
6 mg synephrine and 200 mg caffeine alkaloids (kola nut extract). The patient reported having
taken one or two capsules per day of the product for one week. The individual presented to the
emergency room with recent onset of unsteady gate, dizziness, memory loss, and difficulty in
concentrating. He had no family history of arterosclerotic disease. The subject was mildly obese
with a moderate history of cigarette smoking. The authors concluded that the diagnosis could be
consistent with stroke of vascular origin based primarily on the patient’s symptoms and the
coincident ingestion of the synephrine and caffeine-containing weight loss product; however, this
conclusion was not supported by laboratory analyses. A magnetic resonance angiography of cervical
arteries showed normal course and caliber of all vessels. Transthoracic and transesophageal echocar-
diography and carotid artery Doppler ultrasonography demonstrated no abnormalities. Furthermore,
erythrocyte sedimentation rate, hemoglobin A1c levels, serum lipid profiles, serum homocysteine,
thrombin time and fibrinogen, protein C, protein S, factor II, factor VIII, and factor V were all
normal. In addition, no commonly abused drugs were detected in the urine [5]. As a consequence,
it is difficult to conclude that the symptoms were related to the synephrine ingestion at a level of
not more than 12 mg/day. The authors did not consider the possibility that the symptoms might
have been related to the ingestion of the kola nut extract or a combination of ingredients. Further-
more, the subject may have been taking a much higher dose of the product than reported.
A case report involving Xenadrine EFX™ was presented by Nasir et al. [21]. Exercise-induced
syncope occurred in a healthy 22-year-old woman an hour after taking a dose of the weight-
management product. Electrocardiography indicated a prolongation of the QT interval, which
resolved within 24 hours. Results of an exercise stress test and an echocardiography were normal,
and a 9-month follow-up revealed no arrhythmias. The syncope was most probably due to multiple
factors. The individual had not run for over a month prior to the incident. She also had not used
the product regularly for the past month; she had taken one dose the previous evening and had
taken one tablet approximately 45 minutes before running three miles. She had not eaten that day
prior to the run. As a consequence, the combination of consuming a product with neuroactive
ingredients, the failure to have eaten prior to running, the lack of regular exercise, the distance run,
and the consumption of the weight-management product a short time before running may have all
contributed to the observed outcome. The discussion by the authors is confusing in that they point
to C. aurantium as the hemodynamically most active component; however, the product was reported
to contain only 3 mg of synephrine in addition to caffeine and other ingredients. The authors
presumed that the synephrine present was the metahydroxy isomer, when, in reality, the parahydroxy
isomer was present, which has little cardiovascular activity. Other ingredients in the product,
including L-tyrosine, caffeine, tyramine, and other methylxanthines, may have been contributing
factors. This case report should not be used as support for removing a product containing C.
aurantium extract from the market, but rather should be a case study in how multiple factors can
influence a physiological response and the inappropriate use of a product.
OTHER SAFETY CONSIDERATIONS

The cardiovascular effects of Seville (sour) orange juice in normotensive adults was determined
by Penzak et al. [25]. The study was conducted because extracts of this orange (Citrus aurantium)
contain phenylethylamines. Synephrine concentrations were approximately 57 µg/mL, and octo-
pamine was not detected. Twelve subjects consumed 8 ounces of orange juice and water in a
crossover design followed by repeat ingestion 8 hours later. Hemodynamic parameters, including
heart rate and blood pressure, did not significantly differ between control and treated groups. The
authors, however, concluded that individuals with tachyarrhythmias, severe hypertension, and
narrow-angle glaucoma, as well as monoamine oxidase inhibitor receptors, should avoid Seville
orange juice.
Haller et al. [15] examined the cardiovascular changes associated with a single oral dose of a
Citrus aurantium-containing extract (46.9 mg synephrine) as compared to a multiple-component
dietary supplement (Xenadrine EFX™), which contained 5.5 mg synephrine, caffeine, and other
ingredients. The protocol consisted of a randomized, double-blind, placebo-controlled crossover study
with a one-week wash-out between treatments. The results demonstrated that the dietary supplement
but not the synephrine-containing C. aurantium extract increased both systolic and diastolic blood
pressures at 2 hr post-treatment. Heart rate increased at 6 hr by 16.7 beats/minute for the dietary
supplement and by 11.4 beats/minute for the C. aurantium extract. The authors concluded that the
pressure effects were not likely caused by the C. aurantium alone, as no blood pressure effect was
observed with an 8-fold higher dose of synephrine. The authors also concluded that the increase in
blood pressure may be attributable to caffeine and other stimulants in the dietary supplement. Several
other possible explanations exist. The pressor effects could be due to a combination of multiple
ingredients exerting an adrenergic effect. Furthermore, based on the study of Allison et al. [1],
differences in isomers of synephrine between the two products might at least in part account for the
differences in effects on blood pressure. According to a personal communication from the manufac-
turer of the C. aurantium extract containing 46.9 mg synephrine (Advantra Z™; Nutratech, Wayne,
NJ), the synephrine present in the product is the para isomer, which is believed to exert its primary
effects on β3-adrenergic receptors, which are predominantly responsible for lipolysis and the removal
and oxidation of fat from adipose tissues. The C. aurantium extract associated with the dietary
supplement might contain the meta isomer of synephrine (phenylephrine, neosynephrine), which is
known to act on β1 and β2 receptors and therefore exert cardiovascular effects. Whether the amount
of synephrine (5.5 mg) in this product is sufficient to exert a cardiovascular effect by itself is not
clear, but it may contribute in combination with caffeine and other stimulants in the product.
The historical and traditional use of extracts of Citrus aurantium in Chinese medicine as well
as the fact that literally millions of doses of products containing C. aurantium have been admin-
istered in this country during the past several years without the widespread report of serious
incidence must be taken into consideration and should aid in putting the safety issue into context.
Several minor side effects including nausea, headache, jitters, and dizziness have been reported;
however, none of these events is considered serious, and these are common complaints and obser-
vations associated with numerous and common over-the-counter drugs as well as with placebos.
A major contributor to the concerns regarding the safety of Citrus aurantium extracts has been
the federal government. The Food and Drug Administration (FDA) anonymously supplied infor-
mation to a leading newspaper indicating that 85 adverse reactions and 7 deaths had been associated
with C. aurantium. Subsequently, the purported number of adverse events increased to 169 [28].
A dissection of the FDA information on which the reports were based clearly indicated that no
credible adverse events could be attributed directly to C. aurantium extracts. Unfortunately, this
reality has not prevented scientifically inastute and politically misguided individuals and newspapers
from parroting information clearly known to be untrue and from making statements regarding C.
aurantium that are clearly not based on the facts at hand.
Are there issues with Citrus aurantium extracts? The answer is clearly yes. Standardization is
most assuredly an issue. Furthermore, clear and decisive data regarding the efficacy of Citrus
aurantium extracts with respect to weight management and weight loss are currently insufficient
and clearly needed. Finally, as with anything we ingest, C. aurantium can be used inappropriately
and misused, and its use may be contraindicated for some individuals due to existing sensitivities
or physiological conditions.
Comparing the current evidence regarding adverse events for Citrus aurantium with widely
and commonly used over-the-counter drugs as well as prescription drugs and many food substances,
C. aurantium appears to be amazingly safe. We tend to forget the high incidence of adverse events
and deaths associated with such common household products as ibuprofen, acetaminophen, aspirin,
and other nonsteroidal anti-inflammatory agents, not to mention the anti-inflammatory agents that
have been removed from the market for causing presumably thousands of deaths.
We also tend to ignore the very high incidence of adverse events among the prescription drugs
used for weight management; for example, the drug orlistat (XENICAL®; Roche, Basel, Germany),
which is used for weight reduction, has a very high incidence of adverse events. Among users of
this drug, one fifth report abdominal pain and/or flatus with discharge, and as many as 15% of
patients report nausea and fecal incontinence (Physicians Desk Reference, 2005). One can spend
much time arguing risk–benefit ratios and risk management; however, to date, with literally millions
of consumers having used Citrus aurantium products and large numbers of anecdotal reports of
successful weight management without adverse events, the science does not support the politics
regarding C. aurantium.
The widespread advice by federal agents, politicians, newspapers, and some experts to avoid
Citrus aurantium-containing weight-loss products does not appear to be based on sound science.
The assumption that these products may have adverse effects on hemodynamic systems and may
cause interactions with many drugs has not been supported by current evidence and usage. For
example, the study of Gurley et al. [14] concluded that supplements containing C. aurantium
extracts did not appear to significantly modulate cytochrome P450 enzyme activities in human
subjects, and therefore posed minimal risk for cytochrome P450-mediated herb–drug interactions.

It is clear that additional research is necessary in terms of both the safety and efficacy of Citrus
aurantium extract. Studies involving the use of standardized products with and without other
commonly added ingredients such as caffeine need to be conducted in both animal and human
studies based on oral administration. Current confusion regarding the safety and efficacy is clouded
by multiple issues, including the lack of standardization of C. aurantium extract with respect to
alkaloidal constituents, the isomeric forms of synephrine present, political agendas, and the use of
complex mixtures of ingredients, including C. aurantium extract. Furthermore, many of the pro-
jected warnings regarding cardiovascular risks are extrapolated from studies involving intravenously
administered extracts and synephrine.
Based on the current data presented above, what conclusions can be drawn regarding syneph-
rine-containing extracts of Citrus aurantium? It is difficult to predict the number of doses of products
containing C. aurantium extract that have been consumed over the past few years. It is equally
difficult to estimate the number of individuals who have consumed these products; however, it is
clear that many millions of doses of C. aurantium-containing extract have been used, and the
number of individuals consuming these products may also be in the millions. In spite of this large
amount of consumption of these products, Fugh-Berman and Myers [12] acknowledged that no
adverse events have been reported in conjunction with ingestion of C. aurantium-containing prod-
ucts orally to date.
Since their review, several case studies have been reported involving cardiovascular incidents
in which Citrus aurantium was present as a component of complex products. Interestingly, in each
of these cases, the amount of synephrine ingested was very low relative to amounts used in clinical
trials involving healthy but obese subjects. In each of these case reports, a variety of other con-
founding factors were involved, in addition to the fact that the products in question contained
multiple ingredients and relatively low amounts of synephrine. The high levels of caffeine and
other neuroactive ingredients in these products in combination with synephrine must be taken into
consideration, and the mild adverse effects that have been infrequently reported are most probably
due to a combination of ingredients.
With respect to efficacy in terms of weight loss, the clinical studies that have been conducted
to date involve products with multiple ingredients, invariably containing caffeine from various
sources in addition to Citrus aurantium extract. The study of Gougeon et al. [13] has demonstrated
that an extract of C. aurantium can increase the resting energy expenditure in both sexes and, when
used in conjunction with a protein meal, can increase the thermogenic effect of food in women. In
contrast, however, the vast majority of studies involving products with C. aurantium extract in
conjunction with other ingredients have demonstrated, at best, very modest weight loss after 6 to
8 weeks of product usage. Because caffeine is known to have a thermogenic effect, and most studies
have involved products containing caffeine in addition to C. aurantium extract, any weight loss
cannot be clearly assigned directly and specifically to the C. aurantium.
In summary, based on currently published information, the dire consequences of using bitter
orange extract predicted by some have not materialized, and, based on wide product usage, the
extract appears to be exceedingly safe when used as directed and in reasonable amounts. Conversely,
the efficacy of Citrus aurantium-containing products has also not lived up to the expectations of
many with respect to weight loss and weight management. Weight loss from C. aurantium-
containing products has been modest at best based on a number of controlled studies. As is invariably
the case, additional studies in both animals and human subjects are necessary to bring greater clarity
to issues concerning both safety and efficacy. Longer term studies than those reported to date are
essential. Finally, the facts should be allowed to speak for themselves.
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29 Conjugated Linoleic Acid

and Weight Control:
From the Biomedical
Immune Viewpoint
Zwe-Ling Kong
CONTENTS
Introduction ....................................................................................................................................383
Chemical Properties, Sources, Pharmacology, and Safety............................................................384
Chemical Properties, Origin, and Production ........................................................................384
Pharmacology and Dosage .....................................................................................................385
Dietary Safety and Adverse Effects .......................................................................................385
Weight Control and Body Composition in Cultured Cell, Animal, and Human Studies ............386
Diseases Related to Obesity: The Role of Inflammation and Adipokines ............................386
Metabolic Syndrome, Adipogenesis, and Neurotrophins.......................................................386
Cell–Cell Interactions, Integrin, and Matrix Metalloproteinase ............................................387
Cell, Animal, and Human Lipid Metabolism Studies............................................................387
Mechanism of CLA Effects: Differentiation, Organelles, Gene Expression,
Putative Receptors, and Immune Response...................................................................................388
Adipocyte and Preadipocyte Differentiation and Activation .................................................388
Organelle Functions: Mitochondria and Endoplasmic Reticulum.........................................389
Gene Expression, PPARs, Signal Transduction, and Adipokines..........................................389
Estrogen and Retinoic Acid Receptors...................................................................................390
Inflammation and Oxidative Stress ........................................................................................391
Conclusion......................................................................................................................................393
References ......................................................................................................................................393
INTRODUCTION
Obesity is an important medical problem worldwide. It is associated with a number of acute and
chronic medical complications, including cardiovascular disease, diabetes, arthritis, depression, and
respiratory and gastrointestinal problems. Traditional weight-loss treatments, usually involving a reduc-
tion of fat intake, have generally had very limited success. In this chapter, we report on recent study
results and review updated knowledge on adipocytes with regard to conjugated linoleic acid (CLA)
effects, focusing on gene expression, cytokines, and adipokines in various models, including cultured
cell, rodent, and human studies. In 1987, Ha et al. [1] found that CLA present in fried ground beef
reduced tumor incidence in mice. CLA has attracted much attention over the past several years for
the role it might play in the obesity issue. Earlier research has indicated that the intake of CLA might
383
Dietary lipids (mainly triglycerides)
Hydrolysis
Glycerol Free fatty acids
Propionic acid Saturated fatty acid Unsaturated fatty acids

cis-9C18:0 C18:3 C18:2
C18:0
Rumen Isomerization Isomerization
cis-9,trans-11,cis-15 CLA
Hydrogenation cis-9,trans-11 CLA
trans-11,cis-15 CLA n
Hydrogenation tio
Hydrogenation a
en
og
dr
trans-11C18:1 Hy
1
2
C18:0 trans-11C18:1 cis-9,trans-11 CLA
Intestine
Desaturation
C18:0 trans-11C18:1 cis-9,trans-11 CLA
Tissues
∆9-desaturase
Milk and meat
FIGURE 29.1 Biosynthesis of CLA during its incorporation in meat and milk ruminants. (Adapted from
Tanaka, K., Anim. Sci. J., 76, 291–303, 2005. With permission.)
reduce adiposity, providing antioxidant protection for the treatment of diabetes and cardiovascular
disease in humans, among other potentially important beneficial effects. CLA-enriched diets have
been found to result in a rapid and marked decrease in fat stores in several species, including pig,
rat, hamster, chicken, and mouse [2–6], suggesting that CLA might be useful as a weight-loss agent.
Unfortunately, however, data regarding the use of CLA supplementation in human subjects have
shown marked variations in reports on the health-related outcomes. Additionally, adverse side effects
have been recently reported in mice fed a commercial CLA mixture. Thus, the relationship between
CLA taken as supplements and the treatment of obesity could be more complex than initially thought.
CHEMICAL PROPERTIES, SOURCES,

PHARMACOLOGY, AND SAFETY
CHEMICAL PROPERTIES, ORIGIN, AND PRODUCTION
The CLA family consists of several different conjugated forms, and many have been identified [7–9].
Natural forms of CLA can be found predominantly in ruminant products [10,11]. The most common
type, cis-9/trans-11 (c9t11)-CLA (also known as rumenic acid [15–19]), is present in milk fat, and
CLA isomers can also be found in hydrogenated vegetable oils (see Figure 29.1). Because the CLA
content of dairy products is related to the fat content, CLA levels are greater in higher fat than in lower
fat products. The two predominant isomers found in foods and commercial preparations are c9t11-
CLA and t10c12-CLA. Commercial dietary supplements contain the c9t11-CLA and t10c12-CLA
isomers in approximately equal amounts. Measurements of c9t11-CLA in human adipose tissue have
found that its presence is highly correlated with milk fat intake [20–24]. Anaerobic ruminant bacteria,
such as Butyrivibrio fibrisolvens [25], produce predominantly c9t11-CLA through biohydrogenation
Conjugated Linoleic Acid and Weight Control: From the Biomedical Immune Viewpoint 385
of linoleic acid (LA) and α-linoleic acid obtained from plant material, and pathway of linoleic acid
by cis-9,trans-11-octadecadienoate reductase [26]. CLAs found in fried ground beef are heat-altered
derivatives of linoleic acid [1]. In the formation of CLA, a hypothetical mechanism is that oxygen-
derived free radicals might induce a double bond of linoleic acid to shift [27].
In addition to dietary sources, some CLA can be produced endogenously by humans [28].
Several methods are currently available to chemically synthesize CLA [29,30], which is either
absorbed or further metabolized to vaccenic acid (trans-11-octadecenoic acid), a predominant trans-
fatty acid in milk fat that can be converted to c9t11-CLA by the enzyme ∆9 stearoyl-CoA desaturase,
an alternative route in mammals, including humans [31,32]. Blood levels of CLA in humans may
reflect both dietary intake of CLA and endogenous synthesis from trans-vaccenic acid. Interestingly,
in diabetes, the glycation and subsequent glycoxidation reactions are enhanced by elevated glucose
concentrations. Ratios of CLA to linoleic acid are significantly increased in diabetic erythrocytes
compared with control erythrocytes. This indicates that glycation via chronic hyperglycemia links
lipid peroxidation in the erythrocytes of both diabetic and healthy subjects [27]. The conjugated
trienoic fatty acids produced from α- and γ-linolenic acid were further saturated by Lactobacillus
plantarum to trans-10,cis-15-18:2 and cis-6,trans-10-18:2 [35]. Recently, purified CLA isomers
have become commercially available and are expected to facilitate clarification of the dietary
function paradox and the physiological activity of each isomer.
PHARMACOLOGY AND DOSAGE

In vitro and experimental animal studies found a number of potential health benefits for CLA. CLA
inhibits the proliferation of some cancer cells such as mammary, colorectal, prostate, and forestomach
cancers [36]. Most studies have used synthetic mixtures of CLA at doses from 10 to 25 µM. In
human serum, CLA has been reported to be around 7.1 µM. One report indicates that a potent
cytotoxic effect on cancer cell line can be exerted at physiological concentration [37,38]. In a study
of body composition, the intake of CLA reduced body fat and increased lean body mass in several
species of growing animals [39], and it improved glucose utilization and reversed symptoms of
diabetes in laboratory animals. CLA may lower total and low-density lipoprotein (LDL) cholesterol,
as well as triglyceride levels, and it has been shown to reduce the severity of atherosclerosis in
experimental animals [40]. Recent reports also suggest that each CLA isomer has different functions;
for example, t10c12-CLA has significant anticarcinogenic, anti-obese, and antidiabetic effects,
whereas c9t11-CLA seem to exert an anticancer effect. In addition, CLA enhances select immune
responses in experimental animals and increases the rate of bone formation by influencing factors
that regulate bone metabolism. Physiological difference between free and triglyceride-type CLA on
the immune function of C57BL/6N mice has also been investigated [41]. The typical dosage of CLA
ranges from 3 to 5 g daily as a dietary supplement. CLA was found to induce leptinemia and
adiponectinemia, followed by hyperinsulinemia, in C57BL/6J female mice fed a 1% isomeric mixture
of CLA for various periods of time ranging from 2 to 28 days. Only a few reports have been published
and evidence is weak with regard to the anticancer and anti-obese effects of CLA in humans study;
therefore, more detailed evaluations (especially double-blind, placebo-controlled studies using pure
CLA isomers) of the physiological bioactivities of CLA and how they affect lifestyle- and age-
related diseases in humans and animals would be of great interest in future studies.
DIETARY SAFETY AND ADVERSE EFFECTS

The t10c12-CLA isomer has an anti-obese effect that is especially dramatic in the mouse; however,
it is noteworthy that a significant impairment of insulin sensitivity has been reported in overweight
subjects receiving the purified t10c12-CLA isomer, among whom the isomer is associated with
severe hyperinsulinemia, insulin resistance, and massive liver steatosis (referred to as the CLA-
mediated lipoatrophic syndrome) [42,43]. This finding questions the safety of dietary supplements
containing CLA. In general, the usual doses of CLA used in animal studies greatly exceed those
used in human studies, which explains why animal studies produce better results than human studies
and may also explain the adverse effects of CLA in rats. Collectively, evidence for a putative
beneficial effect of CLA supplementation in humans is still inconclusive; perhaps the safety of
dietary supplements containing CLA requires more consideration, and additional isomer-specific
clinical trials are clearly necessary.
WEIGHT CONTROL AND BODY COMPOSITION IN

CULTURED CELL, ANIMAL, AND HUMAN STUDIES
DISEASES RELATED TO OBESITY: THE ROLE OF INFLAMMATION AND ADIPOKINES
Despite the enormous medical implications of obesity, effective prevention and treatment strategies
are still lacking. It is important to distinguish the term obesity, used to describe excess body fat,
from other forms of overweight. Obesity results from the hypertrophy and hyperplasia of adipocytes
within the organism and is generally thought to be the result of both genetic and environmental
influences. Being overweight or obese has become highly prevalent in Western countries, and the
obese population is growing rapidly in the developing world [44]. Obesity-related disorders, such
as insulin resistance, hypertension, and diabetes, are also dramatically increasing. Obesity is asso-
ciated with endothelial dysfunction and arterial stiffness from as early as the first decade of life
[45]; this is probably mediated in part by low-grade inflammation associated with cytokine-like
molecules called adipokines. White adipose tissue is a major endocrine/secretory organ that releases
a wide range of adipokines. A number of adipokines (e.g., IL-1β, IL-6, MCP-1, MIF, TNFα, leptin,
adiponectin, NGF, VEGF, PAI-1) are somehow linked to the inflammatory response. Recent research
indicates that adipose-tissue-derived factors influence metabolic and cardiovascular disease. Leptin
is now considered to play a key role in obese, hypertensive patients, and decreased secretion of
adiponectin appears to be an important predictor of diabetes [46,47]. A high leptin concentration,
in particular, is found in obese individuals and is strongly associated with vascular changes related
to early atherosclerosis [48,49].
METABOLIC SYNDROME, ADIPOGENESIS, AND NEUROTROPHINS

Obese adipose tissue originates from a long-term process of adipogenesis; it is characterized by
inflammation and the progressive infiltration by macrophages as obesity develops [50], both of
which point to a link between metabolic and signaling pathways and metabolic disease and immune
response that result in diabetes [51]. The elevated production of inflammation-related adipokines
is considered to be important in the development of diseases linked to obesity, particularly the
metabolic syndrome. [52]. Metabolic syndrome, which encompasses diabetes, hypertension, dys-
lipidemia, coronary artery disease, and obesity, is also known as syndrome X or the insulin resistance
syndrome [53–56]. The global epidemic of obesity and diabetes has led to a marked increase in
the number of persons with metabolic syndrome. Type 2 diabetes and metabolic syndrome share
common features and patients. An increasing number of researchers of the metabolic syndrome
assume that many mechanisms are involved in the complex pathophysiology of neurotrophins, such
as disorders of the hypothalamic–pituitary–adrenal axis, increased sympathetic activity, chronic
subclinical infections, the presence of proinflammatory cytokines, the actions of adipocytokines,
and psycho-emotional stress [57]. Research in this field confirms the role of the neurotrophins and
mastocytes in the pathogenesis of inflammatory and immune diseases [58]. Ciliary neurotrophic
factor, another neurocytokine expressed by glial cells in the nervous system, is generally recognized
for its function in survival of non-neuronal and neuronal cell types. It was recently acknowledged
for its potential role in the control of obesity [59].
c9t11-CLA
Triglyceride concentration (mmol/L)

t10c12-CLA
a
2 a a ab a
ab
c
c
0
p M 10 15 20 25 RA TZD
Sample (µg/L)
FIGURE 29.2 Effects of c9t11- and t10c12-CLA on triglyceride accumulation in differentiated 3T3-L1 cells.
Abbreviations: p, preadipocyte; M, MDI; RA, retinoic acid (5 µM); TZD, thiazolidine (10 µM).
CELL–CELL INTERACTIONS, INTEGRIN, AND MATRIX METALLOPROTEINASE

In obesity, changes in fat pad size lead to physical changes in the surrounding area and modifications
of the paracrine function of the adipocyte; for example, adipocytes begin to secrete tumor necrosis
factor α (TNFα), which will stimulate preadipocytes to produce monocyte chemoattractant [60–64]
and contribute to progressive inflammation. The processes of adipogenesis include the migration,
adhesion, proliferation, and differentiation of preadipocytes into mature adipocytes. Many of these
biological functions are related to cell integrins, such as the triglyceride content and gene expression
of peroxisome proliferator-activated receptor γ (PPARγ). Leptin levels have been shown to decrease
in response to treatment with disintegrin [65], and an in vivo model found that partial inhibition
of gelatinolytic activity is associated with moderate effects on adipose tissue development. Matrix
metalloproteinase (MMP) inhibitor decreases adipose conversion of 3T3-L1, and enhancement of
MMP expression counteracts the inhibitor in adipose tissue [66]. These findings suggest a role for
the MMP system in the control of proteolytic processes and adipogenesis during obesity-mediated
fat mass development [67].
CELL, ANIMAL, AND HUMAN LIPID METABOLISM STUDIES

Potential anti-obesity mechanisms of CLA include decreased preadipocyte proliferation and dif-
ferentiation into mature adipocytes, reduced fatty acid and triglyceride accumulation, and increased
energy expenditure, lipolysis, and fatty acid oxidation. CLA intake has consistently been demon-
strated to decrease body fat accumulation and increase lean body mass in several experimental
animals, including mice, rats, hamsters, and pigs; however, the effect of CLA on overall body
weight appears to be variable [68,69]. CLA was shown to accumulate in the white adipose tissue
much more than in the serum or liver, and levels of triglycerides in the white adipose tissue and
serum nonesterified fatty acid were reduced in a CLA dose-dependent manner [70]. In animal
studies, the most dramatic and desirable effects of CLA on body composition are ascribed to the
t10c12 isomer rather than the c9t11 isomer. Recent findings in mice and hamsters indicate that the
t10c12-CLA isomer is largely responsible for the effect of CLA on body composition and adipocyte
morphology, as well as for many of the effects of CLA seen in diabetes and obesity [71,72]. As
shown in Figure 29.2, we confirmed these earlier findings and found that t10c12-CLA prevents
triglyceride accumulation. The t10c12-CLA isomer has been reported to inhibit heparin-releasable
lipoprotein lipase activity and leptin secretion from 3T3-L1 adipocytes and to suppress delta 9-
desaturase activity [73]. Although many mechanisms are presumably involved, how CLA alters
body composition is still unclear and remains to be determined.
Little direct evidence is available with regard to the effect of CLA on body composition in
humans. Recent reports surprisingly suggest that supplementation with the t10c12-CLA isomer or
with c9t11-isomer-enriched foods may not contribute to the expected beneficial changes in the risk
variables associated with the metabolic syndrome. Because the effects of CLA on adiposity and
lipid metabolism are dependent on its isomer specificity, data on CLA supplementation in humans
are conflicting because these studies have used different mixtures and dosages of CLA isomers and
diverse subject populations [74]. Many published studies in human subjects have reported that CLA
does not affect body weight, body composition, or adipose tissue mass [75]; for example, a
randomized crossover study on plasma lipoproteins and body composition in men found that CLA-
enriched butter induced no significant change in the cardiovascular disease risk profile and had no
effect on the distribution of body fat [76].
From a fundamental viewpoint, extrapolation of CLA animal data to humans seems unrealistic,
as CLA apparently has only a limited effect on the immune functions in humans; however, dietary
CLA can be incorporated and metabolized as linoleic acid. In this way, it can influence linoleic acid
desaturation and elongation and is beta oxidized in peroxisomes, which, via activation of PPARs,
increase free retinol levels, which are linked to gene expression regulation [77]. In a study of 60
abdominally obese men with the metabolic syndrome, the subjects were randomly assigned to
supplements containing either 3.4 g/day of a CLA isomer mixture or the purified t10c12- isomer.
After 12 weeks of supplementation, the t10c12-isomer induced statistically significant reductions in
insulin resistance, in glycemia, and in plasma high-density lipoprotein (HDL) cholesterol concentra-
tions compared with placebo [76]. CLA supplementation with purified t10c12-CLA isomer decreases
fat mass and causes a significant reduction in insulin sensitivity in overweight humans [78].
MECHANISM OF CLA EFFECTS:

DIFFERENTIATION, ORGANELLES, GENE EXPRESSION,
PUTATIVE RECEPTORS, AND IMMUNE RESPONSE
ADIPOCYTE AND PREADIPOCYTE DIFFERENTIATION AND ACTIVATION
Adopogenesis is a multistage process originating in mesenchymal cells capable of forming muscle,
bone, or adipose tissue. Adipose tissue plays a key role in the pathogenesis of the obesity-related
metabolic syndrome. Adipocyte serves as an important source of proinflammatory molecules,
including leptin, TNFα, and interleukin 6 (IL-6), as well as antiinflammatory molecules, such as
adiponectin [79]. Most of these functions are carried out via adipocytokines capable of acting
locally or at distant sites [80]. A recent study demonstrated that calcineurin is a critical effector of
a calcium-dependent signaling pathway that acts to inhibit adipocyte differentiation [81]. Moreover,
a constitutively active nuclear factor of activated T (NFAT) mutant preadipocyte inhibits their
differentiation into mature adipocytes. Cells expressing NFAT lose contact-mediated growth inhi-
bition and are protected from apoptosis following growth factor deprivation. The first, and best
characterized, model of adipogenesis in vitro is the 3T3-L1 mouse fibroblast cell line [82,83]. When
confluent/growth-arrested 3T3-L1 cells are subjected to the adipogenic hormones — 3-isobutylm-
ethylxanthine, a phosphodiesterase inhibitor; dexamethasone; and insulin, (collectively known as
MDI) — they undergo a defined genetic program of terminal differentiation, giving rise to mature,
morphologically distinct adipocytes containing large cytoplasmic triglyceride depots [84]. This
process is dependent on the sequential activation of transcription factors, including CCAAT/
enhancer-binding protein (C/EBP), PPAR, and sterol regulatory element-binding protein (SREBP),
that results in changes in gene expression [85]. Another cell line, 3T3-F442A, requires only insulin
at a later stage to differentiate. Also, AP-18, a new non-embryo-derived preadipocyte cell line
established from an adult C3H/HeM mouse, provides a useful model for investigating adipocyte
differentiation and adipogenesis [86].
ORGANELLE FUNCTIONS: MITOCHONDRIA AND ENDOPLASMIC RETICULUM

Increasing evidence suggests that mitochondrial dysfunction in the prediabetic/insulin-resistant state
contributes to a variety of human disorders, including cardiac dysfunction, neurodegenerative
diseases, obesity, insulin sensitivity, and cancer, and that they play a key role during apoptosis
[87–89]. The induction of mitochondrial uncoupling proteins (UCPs) in mouse or human white
adipocytes promotes fatty acid oxidation and a resistance to obesity. UCP2 and UCP3 do not
mediate adaptive thermogenesis and do not seem to contribute to energy expenditure, but they may
be significantly thermogenic under specific pharmacological conditions. Both UCP2 and UCP3 are
considered to be potential targets for the treatment of aging, degenerative diseases, and perhaps
obesity [90,91]. PPARγ coactivator-1α (PGC-1α) plays a key role in regulating mitochondrial
biogenesis and fuel homeostasis, and overexpression favors a shift from incomplete to complete
beta-oxidation, thus enabling muscle mitochondria to better cope with a high lipid load [92]. These
findings suggest fundamental metabolic benefits of exercise training, and the upregulation of
PGC-1α may be an effective strategy for preventing or reversing insulin resistance and obesity
[93]. Obesity-induced endoplasmic reticulum stress has recently been demonstrated to underlie the
initiation of inflammatory responses and generation of peripheral insulin resistance [94]. It leads
to suppression of insulin receptor signaling through hyperactivation of c-Jun N-terminal kinase
(JNK) and subsequent serine phosphorylation of insulin receptor substrate-1 [95].
The beneficial effects exerted by low amounts of CLA raises questions about their mitochondrial
oxidizability. CLA appeared to be both poorly oxidizable and capable of interfering with the
oxidation of fatty acids near the beginning of the beta-oxidation cycle [96]. It was reported that
CLA is more effective than vitamin A in protecting mitochondria from the peroxidative damage
of 3T3-L1 cells [97]. Our research indicated that CLA induced apoptosis via the mitochondrial
pathway through PPARγ signaling, reduced mitochondria transmembrane potential, increased
mRNA expression of the apoptosis regulator Bax and Bcl-2, and enhanced cytochrome c release
to cytoplasm and activation of caspase-3 (reversed by pan-caspase inhibitor). CLA reduced mRNA
expression of cyclin D and increased mRNA expression of p53 and p21waf-1 but increased mRNA
expression of GADD45. In addition, research has found that CLA inhibits the elongation and
desaturation of 18:2n-6 into 20:4n-6. One might speculate that a diet enriched in CLA would be
useful in preventing carcinoma [98].
GENE EXPRESSION, PPARS, SIGNAL TRANSDUCTION, AND ADIPOKINES

Adipocytes act not only as fuel storage depots but also as critical endocrine organs that secrete a
variety of signaling molecules into the circulation. They play a central role in the maintenance of
energy homeostasis by regulating insulin secretion, glucose, and lipid metabolism. These secretory
factors include enzymes, growth factors, cytokines, and hormones involved in fatty acid and glucose
metabolism. The PPARs are ligand-activated transcription factors; the family of PPARs is comprised
of three closely related gene products — PPARα, PPARγ, and PPARδ/β — and is so named because
the activation of PPARγ elicits increases in the number and size of peroxisomes. Fatty acids,
eicosanoids, and some drugs are PPAR ligands. PPARα regulates fatty acid oxidation, primarily
in the liver, PPARγ serves as a key regulator of adipocyte differentiation and lipid storage, and
PPARδ is a positive factor for fat burning. PPARs function as important coregulators of energy
homeostasis. The PPARγ-1 and PPARγ-2 isoforms are generated by alternative splicing. The
PPARγ-1 isoform is expressed in liver and other tissues, and the PPARγ-2 isoform is expressed
exclusively in adipose tissue, where it regulates adipogenesis and lipogenesis. Also, oxidized LDL
regulates macrophage gene expression through ligand activation of PPARγ [99].
TABLE 29.1
Inhibitory Effect of c9t11- and t10c12-CLA in Differentiated 3T3-L1 Cells
Inhibitory Activity (%)
Concentration
Sample (ppm) SREBP-1 C/EBPα PPARγ
c9t11-CLA 10 4.14 ± 4.56 a 6.28 ± 1.53a 0.48 ± 4.28a
15 9.99 ± 2.42a 16.05 ± 2.42b 7.06 ± 2.09a
20 7.09 ± 3.09a 18.29 ± 1.94b 7.27 ± 5.67a
25 9.87 ± 1.39a 17.20 ± 1.38b 19.45 ± 2.99b
t10c12-CLA 10 2.02 ± 2.15a 12.46 ± 1.38a 5.82 ± 2.58a
15 1.69 ± 6.10a 23.79 ± 2.20b 9.29 ± 4.27a
20 13.86 ± 2.46a 34.09 ± 1.19c 32.46 ± 3.88c
25 35.8 ± 3.87b 56.06 ± 3.19d 61.39 ± 5.02d
Note: The values with different superscript letters (a–d) represent significant differences (p < 0.05).
When ICR and C57BL/6J mice were fed experimental diets containing CLA, the weights of
white adipose tissue and interscapular brown adipose tissue in the two strains were greatly reduced
[100]. It is apparent that dietary CLA brings about changes in the gene expression of proteins
regulating energy metabolism in white and brown adipose tissues and the skeletal muscle of mice.
The inhibition of lipid accumulation induced by t10c12-CLA treatment during adipocyte differen-
tiation is associated with a tight regulatory process between early (PPARγ and C/EBPα) and late
(LXRα, aP2, and CD36) adipogenic marker genes [101]. Furthermore, the authors have confirmed
the effects of c9t11 and t10c12 isomers of CLA on the expression of adipogenic genes (see Table
29.1). To study the effects of c9t11-CLA on C/EBPα mRNA expression in 3T3-L1 adipocytes,
2-day postconfluent 3T3-L1 was differentiated by MDI and treated with CLA. On day 8 after
induction of differentiation, total RNA was extracted from 3T3-L1 cells and subjected to reverse
transcription–polymerase chain reaction (RT-PCR) with primers specific for C/EBPα. The t10c12-
CLA isomer at concentration of 25 µg/L significantly decreased the mRNA expression of C/EBPα,
PPARγ, and SREBP-1 in a dose-dependent. manner; however, c9t11-CLA has no inhibitory function
on the expression of SREBP-1. The t10c12-CLA isomer has also been found to reduce the trig-
lyceride content of newly differentiated human adipocytes by inducing MEK/ERK signaling through
the autocrine/paracrine actions of IL-6 and IL-8 [102]. CLA may impart its effects by increasing
the expression of genes associated with apoptosis, fatty acid oxidation, lipolysis, and inflammation,
in addition to decreasing stromal vascular cell differentiation and lipogenesis [72].
Serum leptin is correlated to body fat level and acts in the hypothalamus to regulate satiety
[103]. Leptin, a cytokine, is the ob gene product from mature adipocytes; its expression is accel-
erated in the obesity state to inhibit food intake and accelerate energy expenditure. Dietary CLA
produced a significant reduction in serum leptin levels in Sprague–Dawley rats [104].
ESTROGEN AND RETINOIC ACID RECEPTORS

Estrogen receptor α (ER-α) plays an important role in mediating estrogen signaling and is involved
in both osteoporosis and obesity [105,106]. Interestingly, obesity is positively associated with
breast cancer for postmenopausal women [107]. Estradiol affects the metabolic action of insulin
in a concentration-dependent manner; high concentrations of estradiol inhibit insulin signaling by
modulating the phosphorylation of insulin receptor substrate 1 (IRS1) via a JNK-dependent pathway
[108]. In addition, estrogens and the phytoestrogen genistein were found to regulate adipogenesis
and lipogenesis in males and females [109]. CLA compounds possess potent anti-estrogenic prop-
erties that may partly account for their antitumor activity in breast cancer cells [110,111], where
they induce the dephosphorylation of ER-α through stimulation of protein phosphatase 2A activity
Cyclin D
beta-actin
120
a
100
a
80
% of control
b
60
40 c
c
20
0
Control RA LA c9t11 t11c12
CLA CLA
FIGURE 29.3 Effects of 10-µM retinoic acid, 200-µM linoleic acid, c9t11-CLA, and t10c12-CLA on cyclin
D mRNA expression. 3T3-L1 preadipocytes treated for 6 hr. Results are expressed as mean ± S.D. for n = 3
each group (p < 0.05).
[112]. At present, no direct evidence has been found in support of the anti-estrogenic pathway of
CLA contributing to its anti-obesity functions. Retinoids modulate various biological functions,
such as cell differentiation, proliferation, and embryonic development, through specific nuclear
receptors — retinoic acid receptor (RAR) and retinoid X receptor (RXR); their endogenous ligands
are all-trans-retinoic acid and 9-cis-retinoic acid, respectively [113–116]. It is possible that CLA
induces apoptosis of 3T3-L1 preadipocytes through reduced mRNA expression of cyclin D (see
Figure 29.3) and increased mRNA expression of p53, GADD45, and p21waf-1, but it does not activate
RAR in a reporter gene assay.
INFLAMMATION AND OXIDATIVE STRESS

Metabolic and immune responses are highly integrated and interdependent. Obesity and diabetes
are now firmly linked to inflammatory mediators. Peripheral blood mononuclear cells in obesity
are in a proinflammatory state with an increase in intranuclear nuclear factor kappa-B (NF-κB)
binding [117]. NF-κB plays a key role in inflammatory and immune responses [118]. TNFα and
adiponectin are antagonistic in stimulating NF-κB activation. In the 3T3-L1 adipocyte model, nerve
growth factor (NGF), a neurotrophin, is an important inflammatory response protein. NGF is
secreted in white adipose tissue, and its synthesis is influenced by TNFα [119]. In response to
proinflammatory cytokines such as TNFα, the IκB kinase is activated and further stimulates the
formation of additional inflammatory cytokines, along with adhesion molecules that promote endot-
helial dysfunction and downstream modulate the metabolic syndrome. TNFα induces oxidative
stress, which leads to oxidized LDL and dyslipidemia, insulin resistance, hypertension, endothelial
dysfunction, and atherogenesis [120].
Oxidative stress levels are elevated in obesity and correlate with fat accumulation in humans
and mice [121]. Reactive oxygen species (ROS) were found to be selectively increased; they
augmented expression of NADPH oxidase, decreased expression of antioxidative enzymes, and
dysregulated the production of adipocytokines, all of which are important pathogenic mechanisms
of the obesity-associated metabolic syndrome [122]. Serum concentrations of C-reactive protein
(CRP), TNFα, and IL-6 correlate significantly with weight, body mass index (BMI), and visceral
adipose tissue [48,49,123,124]. Leptin expression is accelerated in the obesity state; similar to other
c9t11-CLA
t10c12-CLA
TNFα (ng/106 cells)

2
0
Concentration (µg/L)
FIGURE 29.4 Production of TNFα by human monocytic THP-1 cells treated with CLA. The concentration
of TNFα in the cell supernatant was measured by ELISA.
proinflammatory cytokines, it promotes Th1 cell differentiation and cytokine production [125].
Leukocyte populations within adipose tissue may be involved in the development of the inflamma-
tion that is characteristic of obesity [126].
Both the innate and acquired immune responses are affected by dietary CLA supplementation.
In vitro studies of the use of immune cells and animal models have demonstrated that CLA
modulates immune function and enhances IL-2 production and lymphocyte proliferation but
decreases TNFα and IL-6 production [127]. The authors have confirmed the effect of CLA isoforms
on TNFα production in a human monocyte assay, and c9t11-CLA seems to work most effectively
(Figure 29.4). A slight but significant difference was observed between the functionalities of
triglycerides and free dietary CLA on immunoglobulin modulation and the production of various
cytokines [41]. A double-blind, randomized, parallel, reference-controlled intervention study on
human immune function suggests that CLA may beneficially affect the initiation of a specific
response to hepatitis B vaccination [128].
Nitrolinoleic acid (LNO2), formed by nitric-oxide-dependent oxidative inflammatory reactions,
is a potent endogenous ligand for PPARγ. NO-mediated cell signaling reactions can be transduced
by fatty acid nitration products and PPAR-dependent gene expression [129]. The involvement of
CLA in endotoxin lipopolysaccharide (LPS)-activated inflammatory events in macrophages (e.g.,
TNFα production) negatively regulates the expression of inflammatory mediators [130] and
decreases prostaglandin E2 (PGE2) and NO synthesis by suppressing the transcription of cycloox-
ygenase-2 (COX-2) and inducible nitric oxide synthase (iNOS) [131]. CLA was found to signifi-
cantly (p < 0.05) depress rat placental growth factor (PGF) synthesis in the placenta, uterus, and
liver [132]. Evidence also suggests that t10c12-CLA supplementation can lead to a marked increase
in human plasma C-reactive protein (CRP), a marker of inflammation and oxidative stress, as
compared to placebo [76].
The adipokine resistin displays potent proinflammatory properties by strongly upregulating IL-6
and TNFα, which were diminished by the NF-κB inhibitor [133]. The t10c12-CLA isomer performs
as an antioxidant and promotes, at least in part, NF-κB activation and subsequent induction of IL-6,
both of which are partly responsible for the suppression of PPARγ target gene expression and insulin
sensitivity in mature human adipocytes [134]. In contrast, the c9t11-CLA isomer possesses weak
antioxidant activity; in fact, at higher concentrations (200 µM), it acts as a strong pro-oxidant [135].
Take together, it is likely that CLA modulates the accumulation of arachidonic acid in phospholipids,
resulting in a reduced arachidonic acid pool and reduced production of downstream PGE2 [34].
CONCLUSION
Aging and hypertrophy are associated with increased body fat and insulin resistance, and with a
higher risk for cardiovascular diseases. What happens in obese tissue? Here, we propose that obese
tissue may be activated via cell–cell interaction due to sustainable cell proliferation and size
enlargement, which trigger progressive inflammation. Adipokine (e.g., resistin) secretion from
adipocytes demonstrates potent proinflammatory properties and induces mitochondrial dysfunction
as well as metabolic syndrome. Those complicated mechanisms are involved in the immune
response, gene expression, and intracellular signal transduction, and CLA or its specific isoforms
might somehow offer beneficial biological activity in this regard. Having reviewed recent research
data from in vitro and in vivo investigations, as well as human clinic studies, that have studied the
functions, mechanisms, and safety of dietary CLA, we must conclude that the data are still
insufficient and ambiguous. Despite conflicting results, likely due to the large variability in protocols
used, the use of CLA for weight management in humans should still be considered, under medical
control. Meanwhile, the question of the safety of high-dosage dietary CLA supplements must be
addressed. A commercially available functional food (CLA in soft gelatin capsules) is perhaps not
the best way to accommodate consumer tastes and does not offer the best bioavailability of the
active form. A better approach to this problem may be the low glycemic index diet, which considers
the effect of food on blood sugar and insulin level after a meal. It may be a practical and safe
approach to the prevention and treatment of obesity and its related complications.
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30 The Role of Tea in

Weight Management
Chithan Kandaswami
CONTENTS
Introduction ....................................................................................................................................401
The Composition of Tea ................................................................................................................402
Animal Studies...............................................................................................................................403
Human Studies ...............................................................................................................................405
Conclusion......................................................................................................................................409
References ......................................................................................................................................409
INTRODUCTION
Bioactive ingredients of dietary origin show a propensity to stimulate energy expenditure by
influencing subtle cellular and metabolic processes linked with energy dissipation. There is immense
interest in these naturally occurring substances in view of their potential application in body weight
reduction. Natural ingredients have received particular attention as alternatives to conventional
weight management strategies with limited long-term effectiveness. One such natural-product-
derived ingredient is tea, deemed to possess biological activities relevant to the treatment of obesity.
The potential body-fat-suppressive effects of tea have recently drawn attention, and the perceived
benefits of tea intake have received increased scientific scrutiny. Dietary adjuncts, as exemplified
by caffeine and tea-associated constituents, exert a facile effect on metabolic rate and substrate
oxidation [1,14–16,20,29,34].
Tea components exhibit thermogenic properties [15,16,63] ascribed to their interactions with
the sympathoadrenal system [15,16]. The activity of the sympathetic nervous system is pivotal in
driving energy metabolism and thermogenesis [5,7,13,36]. Integral to the process of diet-induced
thermogenesis is the activation of the sympathetic nervous system by dietary components and the
resultant metabolic and cellular processes linked with energy dissipation [7,8,36]. Energy metab-
olism encompasses a complex network of hormonal and neural mechanisms. The sympathoadrenal
system plays a marked role in the intricate regulation of thermogenesis and fat oxidation through
circulating epinephrine and sympathetically released norepinephrine [7,8,13,36]. The stimulation
of the sympathetic nervous system results in increased plasma norepinephrine levels accompanied
by postprandial elevation of lipid oxidation [54]. Tea components appear to have the potential to
elevate endogenous levels of catecholamines [15]. This action could have a pronounced effect on
energy expenditure (EE) and fat oxidation.
Tea is brewed from the dried leaves and buds of the tea plant (Camellia sinensis var. sinensis
and Camellia sinensis var. assamica), an evergreen shrub of the family Theaceae. The three principal
types of manufactured tea are green (unfermented), oolong (partially fermented), and black (fully
fermented) [3,18,38,44]. The manufacture of black tea entails oxidation due to the activation of
polyphenol oxidases, which oxidize susceptible tea leaf polyphenol moieties, culminating in the
401
formation of brown pigments. It is this process that develops the color and aroma of the liquor
[38,39,45,46]. The term fermentation refers to the oxidative transformations undergone by tea
phenolics that involve natural browning reactions induced by oxidizing enzymes (polyphenol
oxidases) within the plant cell. The production of green tea involves the rolling and steaming of
tender tea leaves, a process that minimizes the activation of these enzymes and consequently
oxidation. Oolong tea is a partially fermented product having components common to both green
and black teas.
Tea has been touted as a healthful and medicinal beverage for centuries and is considered a
highly desirable drink. Next to water, tea is the most popular beverage in the world; it is consumed
by over two thirds of the world’s population [3,18,44] and is an integral part of the diet in many
countries. A Chinese legend places the introduction of tea at about 2737 B.C. [38]. Chinese history
indicates that emperor Sin-Non declared more than 3000 years ago that the daily consumption of
a cup of tea could dissolve many poisons in the body [37]. Traditionally, tea consumption was
undertaken to improve blood flow, to eliminate toxins, and to increase resistance to diseases [3].
Tea has been a conventional drink in China used to combat obesity [54], and traditional medicine
has frequently attributed the putative anti-obesity effects of herbal medicinal preparations to the
inherent properties of tea.
Comprehending the salutary effects of tea requires a steadily expanding area of scientific
endeavor. Efforts to elucidate and evaluate the therapeutic potential of tea have been very intense
during the past ten years or so, resulting in a spate of information. Key epidemiological studies
have highlighted the possible association of tea intake with attenuation of the incidence of chronic
disease; laboratory investigations have discerned the ability of tea to impact cellular metabolism
and have provided evidence to support the beneficial effects of tea [12,60]. Tea constituents exert
profound effects at the cellular and subcellular levels and may subtly influence metabolic processes
linked with energy dissipation. The distinctly different and diverse array of components character-
istically constituting tea seems to endow it with a multitude of biological properties. Although the
popularity of tea may be mainly due to its alkaloid content, the potential health-promoting effects
of tea have been ascribed to the phenolic substances present in tea. Accruing evidence indicates
that the pharmacological actions evoked by tea might originate from the intrinsic activities of the
phenolic and methylxanthine constituents present in tea. This chapter discusses the role of tea in
weight management with regard to thermogenesis and substrate oxidation. It also reviews data
garnered from animal studies and clinical investigations.
THE COMPOSITION OF TEA

Fresh tea leaves contain on average (related to dry substance mass): 36% polyphenolic compounds,
25% carbohydrates, 15% proteins, 6.5% lignin, 5% ash, 4% amino acids, 2% lipids, 1.5% organic
acids, and 0.5% chlorophyll, as well as carotenoids and volatile substances constituting less than
0.1% [3,18,38,39]. Tea leaves contain unusually high concentrations of the polyphenols belonging
to the flavanol group denoted as catechins, which may constitute 17 to 30% of the dry leaf weight.
The flavanols belong to the broad category of flavans and proanthocyanidins, a distinct class within
the immensely diverse group of plant flavonoids [21,26]. A flavanol is a 15-carbon (C6–C3–C6;
6-carbon ring, 3-carbon ring, 6-carbon ring) membered substituted phenylchroman.
Fresh tea leaf contains caffeine at an average level of 3% along with smaller amounts of other
common methylxanthines: theobromine and theophylline. Tea leaf also contains characteristic
catechins such as (–)-epigallocatechin-3-gallate (EGCg), (–)-epigallocatechin (EGC), (–)-epicat-
echin-3-gallate (ECG), and (–)-epicatechin (EC), as well as (+)-catechin and (–)-gallocatechin (GC)
[3,18,38,44–46]. EGCg is the most abundant catechin in tea leaves. Other green tea polyphenols
include flavonols (present as glycosides), depsides such as chlorogenic acid, coumarylquinic acid,
and a phenolic acid unique to tea, theogallin (3-galloylquinic acid).
The Role of Tea in Weight Management 403
During the manufacture of black tea, a major proportion of monomeric free catechins in the
fresh green tea leaf undergoes oxidative changes culminating in the generation of a series of
compounds, including bisflavanols, theaflavins, epitheaflavic acids, and thearubigins, which
impart the characteristic taste and color properties of black tea [18,28,38,45,46,48]. Unchanged
flavanols constitute 3 to 10% of the dry weight in black tea [3,38]. Green tea leaf and commercial
oolong tea preparations also contain dimeric proanthocyanidins, free and as gallate esters
[23–25,65]. More significantly, Nonaka et al. [65] detected two novel and distinct dimeric flavan-
3-ol gallate esters, theasinensins A and B, in green tea leaf, and Hashimoto et al. [23] detected
theasinensins D-G and oolongtheanin in oolong tea. Hashimoto et al. [25] isolated 8- C-ascorbyl-
(–)-epigallocatechin-3-O-gallate and novel dimeric flavan-3-ols, oolonghomobisflavans A and B,
from oolong tea.
Tea leaf contains a unique amino acid, 5-N-ethyl-L-glutamine (L-theanine), detected by Sakato
[47], which is the γ-ethylamide of L-glutamic acid (γ-glutamylethylamide). L-Theanine is a precursor
of the nonpeptide antigen ethylamine, an alkylamine [31]. Ethylamine is present in brewed tea as
an intact molecule and in its precursor form, L-theanine [9,47]. In addition to catechins, gallic acid,
and caffeine, L-theanine (1 to 2%, w/w) also contributes to the quality of green and black teas [2].
L-Theanine is the predominant amino acid component in tea, constituting between 1 and 2% of the
dry weight of the tea leaf. It is as prevalent in tea as all other free amino acids combined. The
L-theanine content of black tea varietals is similar to or higher than that of green teas [17]. It is
present in very high concentrations in certain varietals of black tea [51].
Green and black teas principally differ in terms of their catechin and oxidized catechin (con-
densation) contents. Because oolong tea is partially oxidized, it contains both native and oxidized
catechins; its composition reflects an intermediate range between that of green and black teas. In
particular, catechins such as EGCg, EGC, ECG, and EC, which are characteristic of green tea, are
present in oolong tea, along with catechin oligomers, oligomeric proanthocyanidins, and polymeric
polyphenolics, which are typically constituents of black tea.
ANIMAL STUDIES
Some studies have investigated the anti-obese effects of green tea powder and tea extracts by
examining their effects in the reduction of body weight gain. Studies indicate that green tea and
EGCg, the major polyphenol of green tea, reduce body weight in experimental animals [32,50], a
finding that might be attributed to increased EE. Oral administration (3g/100 g of body weight) of
a black tea extract for 15 days resulted in a decrease in body and liver weight gain and food intake
in rats [52]. The administration (1%, w/v) of a black tea extract as a drink for 25 days attenuated
plasma triacylglycerol levels and induced a 29% reduction in weight gain in sucrose-fed rats [61].
A 27% decrease in fat pads was accompanied by a diminution in food intake. A water extract of
oolong tea prevented the obesity and fatty liver normally induced by a high-fat diet in mice [19].
Further, this extract of oolong tea, in concert with caffeine, accentuated norepinephrine-induced
lipolysis in isolated fat cells.
Interestingly, Pu-Erh black tea (product of Yunnan district, China) consumption caused a
reduction in plasma triacylglycerol levels in rats ingesting this tea extract (10g/500 mL for 8 to 16
weeks) [49]. A significant decrease in the weight of the abdominal tissue was observed. The weight
ratio of adipose tissue to whole body was also lower. Lipoprotein lipase activity in the abdominal
tissue was low, and the activity of epinephrine-induced lipolysis was significantly high in rats fed
this tea for 8 or 16 weeks. These observations suggest that the successive administration of this
tea could stimulate lipolysis in the adipose tissue and decrease its weight. Sayama et al. [50] studied
the anti-obesity effects of tea in female ICR mice by feeding diets containing 1, 2, and 4% green
tea powder for 16 weeks. The administration of diets containing 2 and 4% green tea powder resulted
in body weight reduction.
Kao et al. [32] documented a direct effect of EGCg on body weight decrease, independent of
caffeine, by employing a very high dose of this catechin in acute studies. Parenteral administration
of EGCg (70 to 92 mg/kg) resulted in a significant body decrease in both male and female
Sprague–Dawley rats. Male rats treated daily with 85 mg EGCg per kg body weight lost 15 to
21% of their body weight relative to their initial weight and 30 to 41% relative to the control weight
after 7 days of treatment. The administration of 12.5 mg EGCg (approximately 92 mg/kg body
weight) to female Sprague–Dawley rats resulted in a loss of 10% of their body weight relative to
their initial weight and 29% relative to the control weight after 7 days of treatment. EGCg treatment
significantly reduced or prevented an increase in body weight in lean and obese male and female
Zucker rats. EGCg administration strikingly reduced food (energy) intake in both Sprague–Dawley
and Zucker rats and might have contributed to body weight reduction. The loss in body weight
was reversible; the animals regained the lost body weight upon withdrawal of the EGCg treatment.
Structurally related catechins other than EGCg were not effective at the same dose in depressing
body weight or diminishing food intake. The reduction in food intake and body weight observed
in both lean (leptin-receptor-intact) and obese (leptin-receptor-defective) Zucker rats suggested that
the effect of EGCg was independent of an intact leptin receptor. The loss of appetite might involve
neuropeptides other than leptin. Kao et al. [32] proposed that EGCg might interact specifically with
a component of a leptin-independent appetite control pathway.
Zheng et al. [62] examined the anti-obesity effects of three components of green tea — catechins,
caffeine, and theanine — in female ICR mice fed on diets containing 2% green tea powder (GTP)
and diets containing 0.3% catechins, 0.05% caffeine, and 0.03% theanine, which correspond, respec-
tively, to their concentrations in a 2% GTP diet singly and in combination for 16 weeks. There was
a significant decrease in the weight of intraperitoneal adipose tissues and in body weight increase
for diets containing green tea, caffeine, theanine, caffeine + catechins, caffeine + theanine, and
caffeine + catechins + theanine. In particular, the adipose tissue weight decreased by 76.8% in the
caffeine + catechins group compared to that of the control group. Green tea, catechins, and theanine
resulted in a diminution of serum concentrations of nonesterified fatty acids (NEFAs). These results
indicated that caffeine and theanine were possibly responsible for the effect of GTP in suppressing
the weight of adipose tissues and body weight gain. The authors consider that catechins and caffeine
interact synergistically in manifesting anti-obesity effects.
Very few investigations have evaluated the specific effects of tea on energy expenditure and
the respiratory quotient (RQ) with regard to reduction of body weight and the treatment of obesity
in experimental animals. Systematic investigations on body composition and regression of obesity
in animals are lacking. Dulloo et al. [16] reported that, in rats, a green tea extract stimulates brown
adipose tissue thermogenesis to a much greater extent than can be attributed to its caffeine content
per se. They suggested that the thermogenic properties of green tea are due to an interaction between
catechin polyphenols and caffeine, constituents of green tea, with sympathetically released cate-
cholamine and norepinephrine that invoked the following mechanisms. By inhibiting catechol-O-
methyl transferase (COMT), catechins would protect noradrenaline (NA) against inactivation by
O-methylation and thereby would sustain the actions of this catecholamine. Tea phenolics compet-
itively inhibit this enzyme [6]. The inhibitory action of caffeine on the enzyme cyclic adenosine
3′,5′-monophosphate (cAMP)-dependent phosphodiesterase, which degrades cAMP, would result
in the intracellular accumulation of cAMP, a critical signaling molecule involved in the direct
activation of β-adrenergic receptors [5,8]. The unimpeded cellular availability of cAMP would
endow this intracellular messenger with increased capacity to elicit its intracellular actions on
catecholamines in prolonging thermogenesis. At this juncture, mention should be made of the fact
that tea contains the methylxanthines caffeine and theophylline and that the latter is more potent
than caffeine in its inhibition of cAMP phosphodiesterase activity [43].
The autonomic nervous system typically modulates carbohydrate and fat metabolism through
direct neural stimulation as well as through hormonal effects. Catecholamine hormones such as
norepinephrine and epinephrine can increase thermogenesis and lipolysis, leading to increased EE
and decreased fat stores. Tappy et al. [53] reported that the stimulation of the sympathetic nervous
system increased plasma norepinephrine levels by 27% and lipid oxidation by 72%, whereas it
reduced glucose oxidation by 14% in the postprandial state. Beta-adrenergic receptors of the
adipocytes mediate the responses to the catecholamines [5]. The potential of tea components to
positively impact the pools of endogenous catecholamines [15] could, therefore, have a pronounced
effect on EE and substrate oxidation. Alterations of neurotransmission can markedly change the
relative contribution of the catecholamine outflow to the pancreas, liver, adrenal medulla, and
adipose tissues, leading to modulation of carbohydrate and fat metabolism [64].
Klaus et al. [33] examined the acute effects of very high concentrations of orally administered
EGCg (500 mg/kg) on body temperature, activity, and EE in male New Zealand black mice by
indirect calorimetry. The authors reported no significant changes in any of these parameters;
however, a decrease in the respiratory quotient was observed at night (activity phase), supportive
of increased fat oxidation. The authors suggest that EGCg attenuates diet-induced obesity in mice
by decreasing energy absorption and increasing fat oxidation. In a separate study [58], the authors
studied the regression of diet-induced obesity by dietary supplementation with EGCg (in a pure
form) in Sprague–Dawley rats. Supplemental EGCg reversed established obesity in these rats. In
vitro studies support the ability of EGCg to enhance adipocyte lipolysis. The incubation of fully
differentiated 3T3-L1 cells with EGCg for 4 hours strongly stimulated lipolysis [41]. Treatment of
mature adipocytes (3T3-L1 cells) with GTP in cell culture resulted in enhanced lipolysis [22].
HUMAN STUDIES
In an epidemiological study, Wu et al. [59] found an inverse association between the number of
cups of tea consumed and body fat content. Tsuchida et al. [56] reported a reduction of body fat
in humans following long-term administration of tea catechins. Consecutive intake of tea catechins
(588 mg/day) reduced body fat, especially abdominal, fat in humans [55]. Dulloo et al. [15]
examined whether an extract of green tea, by virtue of its high content of both caffeine and catechin
polyphenols, could effectively promote thermogenesis in human subjects. They assessed the effect
of multiple administrations of capsules containing a green tea extract (standardized for catechins
and caffeine) and caffeine on 24-hour EE, RQ, and the urinary excretion of nitrogen and catechola-
mines in 10 healthy men (mean body mass index [BMI], 25.1 kg/m2) in a respiratory chamber.
Inclusion criteria included body fatness ranging from lean to mildly obese (8 to 30% body fat). Fat
contributed 35 to 40% of dietary energy intake in these subjects, who habitually consumed a typical
Western diet, and their estimated intake of methylxanthines (primarily as caffeine-containing bev-
erages) ranged from 100 to 200 mg/day. On three separate occasions, the authors randomly assigned
the study subjects among three treatment groups receiving green tea extract (50 mg caffeine and
90 mg EGCg), caffeine (50 mg), or placebo, which they ingested at breakfast, lunch, and dinner.
The ingestion of capsules containing the green tea extract provided total daily intake of 150 mg
caffeine and 375 mg catechins, of which 270 mg was EGCg. The amounts of catechin polyphenols
consumed with each meal were comparable with the amounts commonly ingested by tea drinkers.
Compared to placebo, treatment with the green tea extract resulted in a significant increase in
24-hour EE (4%) and a significant decrease in 24-hour RQ (from 0.88 to 0.85) without any change
in urinary nitrogen [15]. None of the subjects experienced any significant differences in heart rates
across treatments during the first 8 hours that the subjects were assessed in the respiratory chamber.
The results indicated that the lower RQ during treatment with the green tea extract was due to a
shift in substrate utilization in favor of fat oxidation. Also, 24-hour urinary norepinephrine excretion
was higher during treatment with the green tea extract than with the placebo (40%). Treatment
with caffeine in amounts equivalent to those found in the green tea extract had no effect on EE,
RQ, urinary nitrogen, or catecholamines. Dulloo et al. [15] concluded that green tea has thermogenic
properties and promotes fat oxidation beyond that explained by its caffeine content alone. The
authors believe that caffeine in the dosage (50 mg each treatment, 150 mg total intake per day)
employed, although ineffective by itself, might have enabled a synergistic interaction with other
bioactive ingredients in the green tea extract to promote catecholamine-induced thermogenesis and
fat oxidation. They perceived that green tea extract might play a role in the control of body
composition via sympathetic activation of thermogenesis, fat oxidation, or both. Dulloo et al. [15]
suggested that the interaction between green tea (catechin polyphenols) and caffeine that stimulates
and prolongs thermogenesis could be of value in the management of obesity.
In an open study, Chantre and Lairon [10] evaluated the effects of a standardized green tea
extract in 70 (63 female, 7 male) moderately obese patients (BMI, 25 to 32 kg/m2). Each subject
received a daily green tea extract ingestion of 4 capsules (2 capsules in the morning and 2 capsules
at midday), which provided a daily total of 375 mg catechins, of which 270 mg was EGCg. After
3 months, body weight and waist circumference decreased by 4.6% and 4.48%, respectively. The
authors did not observe any significant differences in blood pressure during the 3 months of
treatment. Martinet et al. [40] reported that commercial preparations of green tea and 11 other plant
preparations had no discernible effect on EE or RQ. In view of the thermogenic activity of defined
green tea extracts in humans [15] and animals [16] and oolong tea in human subjects [11,34,64],
the constitution and standardization of the composition of the tea extract and the dose ranges
selected for administration could be critical in evaluating the efficacy of the extract in elevating
metabolic rate and fat oxidation.
Chen et al. [11] evaluated the clinical efficacy of oolong tea in Chinese women. They reported
that 102 subjects who consumed four cups of oolong tea per day (the brew from four 2-g tea bags)
lost over a kilogram of body weight during a 6-week period. The subjects received approximately
125 mg of caffeine per day from the consumption of oolong tea. The data suggested that oolong
tea might promote weight loss by increasing EE by 10 to 20%.
Rumpler et al. [63] evaluated under controlled conditions whether consumption of oolong tea
increases EE or modulates substrate oxidation in comparison to control beverages. Employing a
randomized, crossover design, they compared the 24-hour EE of 12 men consuming one of four
treatments: (1) water, (2) full-strength tea (daily allotment brewed from 15 g of tea), (3) half-strength
tea (brewed from 7.5 g tea), or (4) water containing 270 mg caffeine, equivalent to the concentration
in the full-strength tea treatment. Each treatment consisted of consuming a beverage five times daily
that contained one of the four test beverages, over a period of 6 hours (8:30 a.m. to 2:30 p.m.).
The total caffeine consumption for subjects consuming five servings of the caffeinated water, full-
strength tea, or half-strength tea treatments was 270, 270, and 135 mg/day, respectively. The
consumption of the full-strength tea and half-strength tea provided a daily total intake of 244 mg
of EGCg (662 mg of catechins, 952 mg of polyphenols) and 122 mg of EGCg, (331 mg of catechins,
476 mg of polyphenols), respectively. The subjects refrained from consuming caffeine or flavonoids
for 4 days prior to the study. They received each treatment for 3 days; on the third day, EE was
determined by indirect calorimetry in a room calorimeter. The increases in EE for the full-strength
tea and caffeinated water treatments in comparison to that for the water treatment were 2.9 and
3.4%, respectively, and were significant [63]. When subjects consumed the full-strength tea beverage
rather than water, the 24-hour fat oxidation was significantly higher (12%). Elevations in fat
oxidation were 12% and 8% for the full-strength tea and the caffeinated water, respectively.
These studies indicate that the consumption of oolong tea may promote weight loss by stim-
ulating EE and fat oxidation. The elevation of metabolic rate and fat oxidation by the consumption
of tea confirms the results obtained by Duloo et al. [15]. It is not clear whether one could ascribe
the above responses resulting from oolong tea intake exclusively to caffeine.
The intake of EGCg from the full-strength (containing 270 mg of caffeine) oolong tea in the
Rumpler et al. [63] study was similar to that for the green tea extract employed by Dulloo et al.
[15], even though caffeine levels were nearly twice as high; however, the increases in 24-hour EE
reported in both investigations were very similar. The administration of oolong tea was as a drink
in the Rumpler et al. study, whereas Dullo et al. [15] supplied the green tea extract in capsule form.
The elevation in EE associated with the consumption of caffeine (caffeinated water containing 270
mg caffeine) alone was not significantly different from that obtained with the full-strength tea.
Rumpler et al. [63] reasoned that the consumption of the full-strength tea would have elicited a
much higher thermic effect if there had been some synergistic interaction of caffeine with bioactive
components in tea, as suggested by Dulloo et al. [15]. The studies by Rumpler et al. [63] revealed
a significant effect of tea on 24-hour fat oxidation, which was not evident with caffeinated beverages
alone. The observed impact of tea on fat oxidation may reflect the synergistic effect of caffeine and
tea catechins, as proposed by Dulloo et al. [15]; however, in the absence of data discriminating the
independent effect of non-caffeine components of tea in stimulating fat oxidation, it remains to be
determined whether caffeine from tea and extracts is essential to produce this effect.
Komatsu et al. [34] evaluated the effect of oolong tea on EE in comparison with that of green
tea. Randomly divided, 11 healthy Japanese females consumed one of the following three treatments
in a crossover design: (1) water, (2) oolong tea, or (3) green tea. The composition of the oolong
tea consumed was as follows: caffeine, 77 mg; total catechins, 206 mg (EGCg, 78 mg); and
polymerized polyphenols, 68 mg. The green tea beverage provided the following components:
caffeine, 161 mg; total catechins, 293 mg (EGCg, 94 mg); and polymerized polyphenols, 17 mg.
Resting energy expenditure (REE) and EE after consumption of the test beverage for 120 min were
determined using an indirect calorimeter. The cumulative increases of EE for 120 min were 10%
and 4% after the consumption of oolong tea and green tea, respectively, and were significant. EEs
at 60 and 90 min were significantly higher after the consumption of oolong tea than that of water.
Oolong tea consumed by the subjects contained approximately half the caffeine and EGCg in
comparison with the amounts in green tea but the amount of polymerized polyphenols was double.
The efficacy of oolong tea was much higher than that of green tea, and the authors suggested that
the polymerized polyphenols present in oolong tea promote EE.
Bérubé-Parent et al. [4] evaluated the effect of ingestion of four mixtures of green tea (catechins)
and guarana (a plant containing caffeine) extracts (containing a fixed dose of caffeine and different
amounts of EGCg) on 24-hour EE and fat oxidation in men. Fourteen subjects (mean BMI, 25.7
kg/m2) participated in this randomized, placebo-controlled, double-blind, crossover study. The
subjects consumed a capsule of placebo or capsules containing 200 mg caffeine and a variable
dose of EGCg (90, 200, 300, or 400 mg) three times daily, 30 min before standardized meals,
between 8.00 a.m. and 6:00 p.m. Ingestion of the EGCg–caffeine mixtures significantly increased
24-hour EE (by 8%) compared to that for the placebo. Increasing the dose of EGCg in the mixtures
induced a mild increase in 24-hour EE, but these differences were not significant even between the
lowest (270 mg/day; 3 × 90 mg) and the highest (1200 mg/day; 3 × 400 mg) doses. EGCg did not
evoke a dose-related effect on 24-hour EE. The intake of EGCg–caffeine mixtures had no effect
on RQ, fat oxidation, or catecholamine excretion. It is surprising that the authors did not find any
effect of EGCg–caffeine mixtures on fat oxidation. Their findings are at variance with those of
Dulloo et al. [15] and Rumpler et al. [63], who demonstrated the elevation of fat oxidation by the
ingestion of EGCg-containing green and black teas.
Harada et al. [20] investigated the effect of long-term ingestion of tea catechins on postprandial
EE and dietary fat oxidation. Twelve healthy male subjects consumed 350 mL of a test beverage
daily that contained either a high dose of catechin (592.9 mg) or a low dose of catechin (77.7 mg)
for a period of 12 weeks. The authors conducted respiratory analyses before and at 4, 8, and 12
weeks during the test period; they included oxygen consumption and the excretion of (CO2)–13C
over 8 hours after a single ingestion of a test meal containing 13C-labeled triglyceride. A significant
increase was observed in the excretion of (CO2)–13C in the high-dose catechin group (the HC group)
at 4 and 12 weeks of the test period compared to the low-dose catechin group (the LC group); this
elevation ranged from 8.9% at week 0 to 12.9% at week 12. Diet-induced thermogenesis (DIT),
defined as an increase in energy expenditure from the fasting baseline for 8 hours after the single
ingestion of a test meal, was significantly higher in the HC group at 8 and 12 weeks compared to
that in the LC group. The results indicate that enhanced dietary fat oxidation and an increased DIT
may play an important role in the anti-obesity effect of tea catechins.
Kajimoto et al. [30] assessed the effect of consumption of a catechin-containing drink on body
fat levels in healthy adults. The beverage (250 mL/bottle) contained 215.3 mg of tea catechins,
mostly possessing a galloyl moiety, which included EGCg (74.6 mg), ECG (34.1 mg), (–)-gallo-
catechin gallate (77.8 mg), and (–)-gallocatechin (24.5 mg). This double-blind study had three
parallel groups. The subjects (98 men and 97 women) received 3 bottles of placebo drink (control
group), 2 bottles of catechin-containing drink and 1 bottle of placebo drink (low-dose group), or
3 bottles of catechin-containing drink (high-dose group) each day at mealtimes for 12 weeks (the
daily consumption of catechins was 41.1, 444.3, and 665.9 mg, respectively). Body weight and
BMI were significantly lower in both of the catechin groups than in the control group from 4 to
12 weeks. The authors reported a significant reduction of total fat and visceral fat areas in both
catechin groups compared with the control group at 12 weeks.
Nagao et al. [42] performed a 12-week double-blind study to elucidate the effect of catechins
on body fat reduction and the relationship between oxidized low-density lipoprotein (LDL) and
body fat variables. After a 2-week diet run-in period, healthy Japanese males divided into two
groups with similar BMI and waist circumference distributions ingested 1 bottle of oolong tea daily
that contained 690 mg catechins (tea extract group; n = 17) or 1 bottle of oolong tea daily that
contained 22 mg catechins (control group; n = 18). The authors observed that body weight, BMI,
waist circumference, body fat mass, and subcutaneous fat area were significantly lower in the tea
extract group than in the control group. The results showed a positive association of changes in
the concentration of malondialdehyde-modified LDL with changes in body fat mass and total fat
area in the green tea extract group.
Kovacs et al. [35] conducted a randomized, parallel, placebo-controlled study to explore whether
green tea may improve weight maintenance by preventing or limiting weight regain after a weight
loss of 5 to 10% in overweight and moderately obese subjects. The participants included a total of
104 overweight and moderately obese male and female subjects (BMI, 25 to 35 kg/m2). The majority
of subjects were women. The treatment study consisted of a very-low-energy diet intervention of
4 week followed by a weight maintenance period of 13 weeks during which the subjects consumed
green tea or a placebo. The green tea capsules used in the study contained caffeine (104 mg/day)
and catechins (573 mg/day, of which 323 mg was EGCg). The subjects were in a free-living
condition and continued their habitual caffeine intake, varying approximately from 0 to 100 mg/day.
The results suggested that that green tea was not effective in weight maintenance after a weight
loss of 7.5% in originally overweight and moderately obese subjects; however, weight maintenance
was stronger with green tea among the low caffeine users compared with the high caffeine con-
sumers.
Kovacs et al. [35] indicated that the magnitude of habitual caffeine intake might impair the
effectiveness of green tea administration. The plasma leptin concentration at baseline was lower in
high caffeine consumers than in low caffeine consumers, indicating that the habitual use of caffeine
may reduce leptin levels. The authors indicate the possibility that supplementation with green tea
is only effective under conditions of low habitual caffeine intake and that a much higher dose of
green tea is required when habitual caffeine intake is high.
The investigations of Westerterp-Plantenga et al. [57] further corroborated that the magnitude
of habitual intake of caffeine was a critical determinant of the effectiveness of green tea in
maintaining body weight. In a randomized, placebo-controlled, double-blind parallel trial study,
these authors evaluated the effect of a green tea–caffeine mixture on weight maintenance after body
weight loss in 76 overweight and moderately obese subjects (BMI, 27.5 ± 2.7 kg/m2) matched for
sex, age, BMI, height, body mass, and habitual caffeine intake. The treatment included a very-low-
energy diet intervention of 4 weeks followed by a weight maintenance period of 13 weeks, during
which the subjects consumed a green tea–caffeine mixture (270 mg EGCg + 150 mg caffeine per
day) or placebo. During the weight maintenance period, green tea reduced body weight, waist
circumference, RQ, and body fat in the low caffeine consumers, but resting EE increased compared
with restoration of these variables in the placebo group. The consumption of the green tea–caffeine
mixture did not have any effect on weight management in the high caffeine consumers, whereas it
significantly improved weight management in habitual low caffeine consumers, supported by the
relatively higher thermogenesis and fat oxidation. The authors furnished evidence to suggest that
overweight subjects who lose 5 to 6 kg weight in 4 weeks and who rarely consume coffee or tea
or other caffeine-containing products may benefit from a regular intake of green tea–caffeine
mixture containing 270 mg of EGCg and 150 mg of caffeine per day.
Tea polyphenolics and methylxanthines are known to exhibit strong binding activities. In view
of this, the intake of large amounts of tea may be a cause for concern because of the potential
consequences of tea drinking on nutrition and other problems. The consumption of tea, however,
is remarkably safe, and no solid evidence points to the harmful effects of tea consumption.
CONCLUSION
Tea has gained prominence as a functional food and as a repository of pharmacologically active
ingredients. Bioactive entities associated with this dietary adjunct could have a propensity to
augment EE by influencing subtle cellular and metabolic processes linked with energy dissipation.
Conceivably, some of these ingredients may positively influence intracellular energy transduction
systems in the mitochondrion or promote the mobilization of fat and the catabolic breakdown of
triacylglycerol into free fatty acids. Certain animal and human studies have demonstrated the
thermogenic properties of tea. The limited information garnered illustrates that the administration
of tea as a beverage or as an extract promotes EE and fat oxidation in human subjects.
Twenty-four hour EE determinations clearly document that both green and oolong teas con-
taining variable amounts of EGCg (and other catechin components) and caffeine promote thermo-
genesis and fat oxidation, but no specific information exists regarding the specific contributory role
of the various tea components in these processes. Green tea provides native catechins (polyphenol
monomers), but oolong tea furnishes oxidized catechins and oligomers and polymers derived from
catechins, in addition to native catechins. Further studies are necessary to discriminate the exclusive
effects of caffeine and non-caffeine components of tea on metabolic rate and fat oxidation in human
subjects. Recently gathered evidence indicates that overweight individuals who have experienced
a loss in body weight could substantially benefit from a regular intake of a caffeine and green tea
mixture to sustain that weight loss. These investigations suggest a promising application of green
tea components to the maintenance of body weight.
A few encouraging studies have recently emerged illustrating the primary anti-obesity effect
of a mixture of EGCg and other tea-derived catechins. These studies document that prolonged (12-
week) ingestion of a mixture of tea catechins intensifies postprandial EE and fat oxidation in healthy
male subjects. Long-term (12-week) administration of a combination of tea-derived catechins
significantly diminished body weight, body fat mass, and BMI in a large sample of male and female
subjects. The intake of tea catechin mixtures resulted in a significant reduction of total and visceral
fat areas. The outcome of these investigations adds a promising new dimension to evaluating the
anti-obesity effect of tea and tea products. Such investigations provide an impetus for the devel-
opment of “designer” supplements containing tea components and other thermogenic agents to
target obesity. The utility of tea as a weight management aid clearly requires further long-term,
systematic, and in-depth investigations.
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31 Laboratory and Clinical

Studies of Chitosan
Harry G. Preuss, Debasis Bagchi,
and Gilbert R. Kaats
CONTENTS
Introduction ....................................................................................................................................413
Proposed Mechanisms of Action Behind Use of Chitosan for Body Weight Loss......................414
Toxicology of Chitosan..................................................................................................................414
Effect of Fiber in General on Fecal Fat Excretion and Body Weight Loss .................................414
Influence of Chitosan on Gastrointestinal Absorption of Fats......................................................415
In Vitro Studies Examining Fat Trapping...............................................................................415
Animal Studies Examining Lipid Binding.............................................................................415
Clinical Studies Examining Lipid Absorption ..............................................................................415
Clinical Studies on the Role of Chitosan in Body Fat Loss.........................................................417
Conclusion: Chitosan As a Weight Management Option..............................................................419
References ......................................................................................................................................419
INTRODUCTION
Because public attention has largely been focused on avoiding dietary saturated fats with the hope
of preventing or ameliorating atherosclerosis, less emphasis has been placed on limiting overall
caloric intake. This fact may account, at least in part, for the so-called “obesity epidemic” [1]. It
is difficult to understand how this diversion became so prolonged, because it has long been held
that overweight and obesity are responsible for thousands of deaths each year via heart disease,
stroke, and diabetes. To add to the problem, it is common knowledge that most individuals who
work so hard to lose fat weight subsequently regain it. Americans are not alone. The World Health
Organization (WHO) has acknowledged the global spread of overweight and obesity [2]. Accord-
ingly, strategies to prevent the further widening of America and the world are necessary. Oral intake
of chitosan, a soluble fiber with reputed special properties that prevent gastrointestinal fat absorp-
tion, offers a possible partial solution to the problem [3,4]. What do we know about chitosan?
Pulverized powders from the exoskeleton of crustaceans were originally noted for their ability to
soak up oils after environmental spills [3,4]. Based on this ability, it was hypothesized that chitosan
powder might also soak up fats in the human gastrointestinal tract, thus limiting the consumption
of calories from them. Indeed, animal studies demonstrate that chitosan does bind neutral fats under
a variety of conditions.
413
PROPOSED MECHANISMS OF ACTION

BEHIND USE OF CHITOSAN
FOR BODY WEIGHT LOSS
Chitin is a cellulose-like polymer found principally in exoskeletons of marine invertebrates and
arthropods such as shrimp, crabs, and lobsters [3,4]. Chitin is composed of long chains of
acetylated glucosamine, and chitosan results from the deacetylation of chitin. Theoretically,
weight loss associated with chitosan consumption could occur through a number of physiological
mechanisms that are not mutually exclusive; for example, the most popular concept is that
positively charged chitosan might bind to negatively charged fat molecules and prevent absorp-
tion of calorie-containing fat [3]. In a similar vein, the positive charges of chitosan appear to
bind bile acids and thus could indirectly increase fecal fat excretion [5,6]. Also, the ability of
other viscous fibers such as guar and psyllium to augment fecal fat loss suggests that chitosan
may work like many uncharged soluble fibers in general. What is the mechanism behind the
latter? In an acid stomach, chitosan is a soluble fiber, readily dispersed among the digestive
secretions and food particles [7–9]. Binding several times its weight in water, the chitosan fiber
begins to swell, entrapping and encapsulating dietary fats and oils [7–9]. As chitosan fiber
passes along into the small intestines, it encounters an environment that is no longer acidic. In
a non-acid environment, chitosan fiber becomes insoluble and forms a gel-like complex that
binds fats and bile acids. This insoluble complex passes undigested through the large intestine
and is naturally eliminated. Another possibility to explain weight loss is that the bulk of chitosan
could act to suppress appetite.
TOXICOLOGY OF CHITOSAN
Although chitosan appears quite safe based on data from animal and human studies [10–12],
theoretically it can be detrimental, like all substances taken improperly or in gross excess.
Although minerals and electrolytes could be depleted, evidence for such is rare [11]. Dietary
chitosan reportedly affects calcium metabolism in animals [13]. In a large clinical trial [14],
allergic reactions were seen in 2 to 3% of subjects, mainly in those with an allergy to seafood,
and constipation was reported in 20% of the subjects. For the most part, constipation passed
over time, especially when the intake of fluids was increased [14]. Problems encountered with
extremely high doses of chitosan are caused by gastric dehydration and impaction due to
expansion of the fiber [12,14].
EFFECT OF FIBER IN GENERAL ON FECAL FAT EXCRETION

AND BODY WEIGHT LOSS
Based on previous experiences with other fibers, a precedent exists for chitosan to augment
fecal fat loss and hasten body fat loss. Bran, resins, pectin, etc. have been used successfully in
the past for weight loss and cholesterol reduction [9]. Krotkiewski [15] examined the viscous
fiber guar and noted reduced hunger and positive effects on lipid and carbohydrate metabolism
in obese individuals. Pectin increased fecal fat excretion by 44% (p < .001), neutral steroids
by 17% (p < .001), and fecal bile acids by 33% ( p < .02) [16]. In African Green Monkeys,
psyllium husk was associated with increased volatile fatty acid output [17]. Ganji and Kies
[18], investigating the effects of psyllium fiber supplementation on fat digestibility and fecal
fatty acid excretion in healthy humans, reported increased fecal fat loss, decreased fat digest-
ibility, and increased fecal palmitic acid excretion with psyllium supplementation. They hypoth-
esized that these associations played a prominent role in the cholesterol-lowering action of
psyllium fiber.
Laboratory and Clinical Studies of Chitosan 415
INFLUENCE OF CHITOSAN ON
GASTROINTESTINAL ABSORPTION OF FATS
The original rationale for using chitosan in weight loss regimens is based on the belief that this
natural substance could trap calorie-loaded fat in the gastrointestinal tract — preventing absorption
of this densely rich macronutrient.
IN VITRO STUDIES EXAMINING FAT TRAPPING

Many in vitro studies have corroborated previous environmental studies showing that chitosan can
trap neutral fats [3,14].
ANIMAL STUDIES EXAMINING LIPID BINDING

Animal studies, usually performed on rats, have consistently demonstrated the ability of chitosan to
trap fat in the gastrointestinal tract [19]. In one study, a low-molecular-weight chitosan hydrolysate
inhibited cholesterol absorption in the intestine and increased fecal neutral steroid excretion similar
to highly viscous chitosan [20]. The mechanism for the inhibition of fat digestion by chitosan and
also a synergistic effect in the presence of ascorbate were examined extensively in animal models
[21]. Chitosan dissolves in the stomach and then changes to a gel in the intestines that entraps fat.
The mechanisms behind the synergistic effect of ascorbate are considered to be (1) viscosity reduction
in the stomach, (2) an increase in the oil-holding capacity of the chitosan gel, and (3) the chitosan–fat
gel being more flexible and less likely to leak entrapped fat in the intestinal tract.
One study examined 23 different fibers added at 5% w/w to a purified diet containing 20%
w/w corn oil [22]. After 2 weeks of this regimen, feces were collected from each animal during a
3-day period. Ten of the tested fibers significantly increased fecal lipid excretion compared with
the cellulose control. Chitosan reduced the fat digestion to one half of control and did not influence
protein digestibility. Because it was noted that the fatty acid composition of the fecal lipids closely
resembled that of dietary fat, these results strongly suggest that chitosan has the potential for
interfering with fat digestion and absorption in the intestinal tract.
In an excellent experimental design, rats had their lymphatics cannulated and were subsequently
gavaged with a test emulsion containing: (1) 25 mg of [14C] cholesterol; (2) 50 mg of guar gum,
cellulose, or chitosan; and (3) 200 mg of safflower, high-oleic safflower, or palm oil [23]. Both
the type of dietary fiber (p < 0.001) and the type of fat (p < 0.05) examined significantly influenced
cholesterol absorption; for example, chitosan effectively lowered cholesterol absorption more than
guar gum or cellulose. In addition, the effect of chitosan was more significant when given with
safflower or high-oleic safflower oil than with palm oil. Dietary fiber also significantly lowered
triglyceride absorption (p < 0.05). Absorption tended to be low with chitosan, high with cellulose,
and intermediate with guar gum. The results show that the type of dietary fat significantly influences
the effect that dietary fiber can exert on lipid absorption.
CLINICAL STUDIES EXAMINING LIPID ABSORPTION

The first reported clinical study on chitosan was performed in Norway [24], where the resultant
weight loss found in the test subjects was attributed to the fat-binding abilities of chitosan. In five
ensuing studies, all performed in Italy, many included the observation that stools in weight-losing
treatment subjects were larger and softer than placebo-receiving subjects [25–31]. Among 30
subjects in a study, Macchi reported that “fecal excretion of fats … was observed only in those
taking chitosan” [27]. Girola et al. [25] conducted a clinical study on 150 subjects of both sexes
and noted that the administration of the dietary integrator containing 240 mg chitosan per capsule
caused significant weight loss. The subjects were also evaluated for changes in circulating triglyc-
erides on the 28th day of study. The placebo group showed a 13.2% reduction, whereas the treatment
groups showed a greater decrease of 26.6%. The most likely explanation for the exaggerated
decrease in triglyceride concentrations in the presence of chitosan is decreased fat absorption. In
support of this assumption, Hoffman La Roche investigators found that the triglyceride levels in
their animals were lower after chitosan per os and believed the reduced blood triglycerides were
directly correlated with reduced fat availability via digestive processes [32]. While some observers
believe that the appearance of stools is a good indicator of the presence of fat, direct measurements
are still necessary for corroboration.
Many studies have measured fat in the feces directly to gauge absorption. These measurements,
mostly performed using a gravimetric procedure, have shown varying results. A group from the
University of California, Davis, performed direct measurements of fecal fat on healthy subjects in
three similar studies [33–35]. In these studies, subjects consumed extraordinary amounts of fat,
and no placebo controls were followed. Fecal fat excretion was increased under some circumstances
but not others; nevertheless, the investigators questioned the clinical significance of the small
differences [35]. In a different study, 12 healthy adult volunteers within 20% of ideal body weight
entered a 7-day run-in diet period before half of them were randomized to the drug orlistat (120
mg) and the other half to chitosan (890 mg) 3 times daily for 7 days [36]. Subjects were then
crossed over for the other treatment regimen. Fecal fat excretion increased markedly with orlistat,
but the 20% average increase with chitosan did not achieve statistical significance. It was concluded
that chitosan had no significant effect on fecal fat excretion.
Not all studies have been negative, however. Nesbitt et al. [37] examined a formula containing
chitosan. Nineteen female subjects received 2.0 g of formula containing chitosan (40% w/w),
psyllium (51% w/w), apple pectin (4% w/w), and glucomannan (4% w/w) twice a day preceding
lunch and dinner; 18 female subjects were simultaneously given a placebo under similar conditions.
After 30 days, the treatment group showed a statistically significantly greater increase in fecal fat
content; the supplement group experienced an average 2.48% increase in fecal fat content over
baseline, whereas the placebo group had an average decrease of 3.73% in fecal fat content (p =
0.0002). In another weight loss study examining chitosan, total fecal fat was analyzed at baseline
and week 8 in a small set of subjects, three in the placebo group and four in the treatment group
[38]. In this small population, a statistical trend for chitosan to increase fecal fat excretion was
observed. Total fecal fat excretion increased on an average +6.0 g ± 2.7 SEM over baseline in the
treatment group and decreased –2.3 g ± 2.4 SEM under baseline in the placebo group (p < .07).
Borosso-Arranda et al. [39] measured fecal fat directly after chitosan administration. Although the
increase in fecal fat was statistically significant, it could account for only 30 to 40 kcal/day savings
in calories. A paper from Japan discussed the use of chitosan to treat Crohn’s disease [40]. The
investigators found that a mixture of chitosan (1.05 g/d) and ascorbic acid significantly increased
fat concentrations in the feces during treatment (average 60 mg/day dry weight before vs. 79 mg/day
after 8 weeks; p < 0.035).
None of the above studies that made direct measurements of fecal fat reported the accuracy of
the methodology. This is particularly important, because the presence of chitosan could affect such
measurements; therefore, it is necessary to examine findings utilizing other methods to estimate
fecal fat excretion.
In a study by Maezake et al., levels of total fecal volatile fatty acid increased significantly from
14.3 ± 3.2 mg/g to 20.3 ± 2.4 mg/g on day 14 of chitosan intake (p < 0.01), with a significant
increase of acetic (p < 0.05) and propionic (p < 0.01) acids [41]. Utilizing a breath test involving
radioactive materials, Swedish investigators reported that subjects receiving chitosan showed
reduced fat uptake compared to placebo [14]. In the entire group, the reduction in animal fat uptake
with the chitosan compound was approximately 13% after 6 hours. The results were statistically
significant (p < 0.05) at the 5-hr mark. Four volunteers did not react at all, but the rest showed an
average reduced fat uptake of approximately 25%.
Blum [42] believed (as mentioned previously [32]) that the amount of fat absorbed from a fat-
containing meal is proportional to an incremental increase in plasma triglycerides; therefore, the
effects of chitosan after fat challenge were estimated by examining multiple triglyceride levels over
the time necessary for the triglyceride levels to return to baseline. One gram of chitosan was taken
5 to 10 minutes before a fatty meal purchased at a local restaurant. Out of 13 subjects, 9 (roughly
2/3) responded favorably. The investigators estimated that chitosan inhibited the absorption of
dietary fat in the range of 20 to 28 g of fat for every gram of chitosan in 5 of the subjects.
The overall weight of evidence favors the long-held assumption that chitosan fiber taken
properly under proper conditions increases fecal fat loss, but whether the trapped fecal fat could
account for significant weight loss remains open to question at this time.
CLINICAL STUDIES ON THE ROLE

OF CHITOSAN IN BODY FAT LOSS
Results may differ among studies, because conditions are rarely the same. To give examples: (1)
The quality of chitosan material often fluctuates [43,44]; (2) the quantity of material used (dosage)
frequently varies [44]; (3) the timing of the dosing may also be an important variable; (4) the diet
offered with chitosan (e.g., low or high fat, low or high caloric content) can influence outcome; (5)
the different methodologies used for assessing endpoints (e.g., weight loss rather than fat loss) may
affect interpretations; (6) the individual biological responses may be dissimilar; and, finally, (7) the
compliance of subjects may differ markedly. Accordingly, a broad and complete picture emanating
from many studies must be used to assess the effectiveness of chitosan as a weight loss agent.
The initial weight loss investigation using chitosan, performed over 10 years ago, was a double-
blind, placebo-controlled study on 18 subjects ingesting a low-caloric diet and consuming 1.92 g
of chitosan per day [24]. Weight loss in test subjects compared to controls was significant after 14
and 28 days. The next studies, performed in Italy, were very similar in format — randomized,
double-blind, and placebo-controlled [25–27,31]. In these particular studies, subjects consumed a
1000-kcal diet and received four tablets of chitosan or placebo per day for 28 days. Unfortunately,
the amount of chitosan in each tablet was never revealed. In addition, other ingredients, such as
guar and psyllium, were added to a formula, although the authors tended to attribute benefits
principally to chitosan.
Giustini and Ventura [28,29] reported that weight loss of the chitosan group significantly
exceeded the placebo group in 100 subjects. Sciutto and Columbo [30] wrote that the chitosan
weight loss significantly exceeded placebo in 90 subjects. Girola et al. [25], in 150 subjects, noted
that weight loss on an integrator containing chitosan significantly exceeded placebo. Veneroni et
al. [26] similarly showed that weight loss in the chitosan group significantly exceeded placebo in
80 subjects. When Colombo and Sciutto [31] studied 86 subjects, the weight loss in the chitosan
group significantly exceeded placebo. Macchi [27] found that weight loss in the chitosan group
also significantly exceeded placebo in 30 subjects.
The earliest studies were performed on subjects consuming very caloric restricted diets; there-
fore, the question was raised concerning the influences of chitosan on individuals consuming more
normal levels of calories. Wuolijoki et al. [45] showed an effect of chitosan on lipid lowering but
discovered no significant change in body weight; however, they raised the possibility of poor
compliance in their report. The authors hypothesized that reduced lipid absorption from the gas-
trointestinal tract decreased energy intake, stimulating hunger. Pittler et al. [46] in a double-blinded,
placebo-controlled study on 34 subjects, reported that weight loss in the chitosan group did not
exceed placebo. The subjects ate regular diets and were supposed to consume 1.2 g of chitosan per
day for 28 days. Unfortunately, the amount of chitosan given was lower than expected (i.e., 60%
of the designated amount); thus, the treatment group, eating regular amounts of fat, received a
relatively small dose. In an open-label study composed of 332 subjects [12], 221 of the subjects
responded to chitosan per os by losing a significant amount of weight (–4.1 kg). Nesbitt et al. [37]
provided 1.6 g of chitosan per day for 30 days in a formulation comprised mainly of chitosan to
37 mildly to moderately obese subjects and saw a significant decrease in body weight (placebo
gained +2.3 lb and treatment lost –3.6 lb). It must be noted that the average body weight of the
treatment group at the initiation of the study was 192 lb compared to 172 lb for the placebo group.
Obviously, this discrepancy makes interpretation more difficult, even though this weight loss was
accompanied by a corresponding significant increase in fecal fat content in the treatment group vs.
the placebo group. Likewise, total cholesterol and low-density lipoprotein (LDL) decreased, and
high-density lipoprotein (HDL) increased in the treatment group compared to the placebo group.
All differences were statistically significant.
Schiller et al. [38] performed a randomized, double-blind, placebo-controlled study in over-
weight and mildly obese individuals. Subjects took either three capsules of a rapidly soluble
chitosan (1.5 g, b.i.d.) or matched placebo twice daily for 8 weeks. Interestingly, the study
overlapped a holiday period when increased caloric intake might be expected, but the subjects
continued to consume their regular diet. To back this assumption, the placebo group showed a
mean weight gain of +1.5 kg over the holiday period, but the mean weight loss was –1.0 kg within
the treatment group over the 8-week period. Chi-square analysis for weight loss between the
groups indicated significantly more subjects lost weight within the treatment group than within
the placebo group (63% and 17%, respectively; p < 0.001). Krotkiewski et al. [47] reported that
their treatment subjects received a low-caloric diet (1000 kcal/day for 6 months) along with
chitosan in a randomized, placebo-controlled, double-blind study. The chitosan group received
1.5 g three times daily. Significantly greater body weight losses and decreased systolic blood
pressure were noted compared to the placebo group. Ho et al. [48] examined 68 subjects who
were overweight and hypercholesterolemic and found no significant changes in the measured
parameters and no severe side effects in chitosan-treated subjects; however, the investigators stated:
“We believe that subjects could have inadvertently increased their caloric intake under the false
belief that chitosan would bind all fat that was consumed.” Further, it was noted that the patients
took approximately 80% of the correct dose of chitosan. The authors postulated that this might
represent underdosing. A 24-week randomized, double-blind, placebo-controlled trial, conducted
at the University of Auckland, examined 250 participants (82% women) with a mean body mass
index (BMI) of 35.5 kg/m2 [49]. Participants in the treatment group, who were given advice on
diet and lifestyle, received 3 g of chitosan per day. In an intention-to-treat analysis with the last
observation carried forward, the chitosan group lost more body weight than the placebo group
(–0.4 ± 0.2 kg vs. +0.2 ± 0.2 kg; p = 0.03). The investigators did not deem these differences to
be clinically significant. Unfortunately, the report did not give information on a singled-out group
of compliant individuals. Similar small changes occurred in the circulating total and LDL cho-
lesterol and glucose (p < 0.01).
Kaats et al. [50] examined the effects of chitosan on fat loss using DEXA, the state-of-the-
art means to estimate body fat. Over an 8-week study period, 150 subjects were examined to
evaluate the effects of a novel chitosan formulation on body weight, body composition (lean-to-
fat ratios), bone density, and blood chemistries under real-life conditions. Subjects were randomly
assigned to one of three 50-subject groups: (1) a treatment group that was provided with a behavior-
modification program and consumed a dietary supplement containing principally chitosan, (2) a
placebo group that was provided with the same behavior-modification program but consumed a
placebo supplement, and (3) a control group that was asked to follow any program of their choosing
but who also completed the same beginning and ending tests as the treatment and placebo groups.
A total of 131 (87%) of the subjects completed the study. For those completing the study, highly
statistically significant differences were found between the treatment group compared to placebo
and control in body weight loss. The loss of body weight in the treatment group was –3.4 lb ±
5.9 SEM compared to placebo (–0.9 lb ± 4.2 SEM; p = 0.028) and control (+0.6 lb ± 4.4 SEM;
p = 0.001). In addition, there were highly significant differences between treatment and placebo
in reduced percent fat (–1.1% ± 2.0 SEM vs. 0.4% ± 1.7 SEM; p = 0.001) and fat mass (–3.2 lb
± 4.7 SEM vs. +0.5 lb ± 4.1 SEM; p = 0.001). Comparing treatment to control, the loss of fat
mass was significantly reduced (control = –0.1 lb ± 4.4 SEM; p = 0.002), but only trends in
lowering percent fat were observed. These data provide compelling evidence for the efficacy of
the novel chitosan product to facilitate the depletion of excess body weight, presumably fat
weight, under free-living conditions very similar to those in which these products are most likely
to be used.
CONCLUSION: CHITOSAN AS A
WEIGHT MANAGEMENT OPTION
After examining all data presented on chitosan as a weight-loss supplement, some could question
its importance for a number of reasons. First, only a limited number of human clinical trials have
been conducted on chitosan for the purposes of weight management, and, with few exception, these
dealt only with scale weight, not including fat mass. As a second point, the results among studies
are not as consistent as one would like, probably due to the multiple differences in protocols —
different types of chitosan, different doses, different timing of the doses, different diets, different
endpoints, and different populations. As a third point, so-called “weight-loss studies” in general,
even randomized, double-blinded, placebo-controlled ones, present problems. First, the odds are
stacked against showing significant weight loss in most clinical studies using the randomized,
double-blind, placebo-controlled protocol. We base this on the following realities. Regimens that
simultaneously increase muscle mass may mask any fat loss when only scale weight is assessed
[51]; in reality, fat loss rather than overall scale weight loss is important. As a final point, most
subjects invariably weigh themselves and subsequently believe they are on placebo whether that is
true or not. This leads to poor compliance. Noncompliance will adversely cloud the positive results
in the treatment group, especially when an intention-to-treat analysis is used. It is our opinion that
merely counting pills is not sufficient to judge compliance. It is our contention that, even in
randomized, placebo-controlled, double-blind studies on weight loss, the odds are stacked against
positive results. Accordingly, when such studies are positive, those consumers willing to comply
with directions may have even better success.
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32 Phaseolus vulgaris and

α-Amylase Inhibition
Dennis E. Meiss
CONTENTS
Introduction ....................................................................................................................................423
Natural Amylase Inhibitors: Occurrence and Chemical Characterization....................................425
Clinical Studies: Crude White Bean Extract .................................................................................425
Clinical Studies: Partially Purified White Bean Extract ...............................................................425
Clinical Studies: Phase 2® Standardized White Bean Extract ......................................................426
Safety Studies.................................................................................................................................429
Conclusions ....................................................................................................................................429
Disclosures .....................................................................................................................................429
References ......................................................................................................................................430
INTRODUCTION
Obesity and being overweight are serious health crises confronting the United States, with the
prevalence of obesity increasing nearly 65% over the past decade. Currently, it is estimated that
60% of adult Americans are either overweight, defined as having a body mass index (BMI) greater
than 25 kg/m2, or clinically obese (BMI greater than 30 kg/m2). This represents about 110 million
overweight adults and 39 million obese adults [1,2]. In addition, obesity is reaching epidemic
proportions in adolescents and teens; approximately 25% of American children are overweight and
about 10 to 15% are obese [3,4]. Overweight individuals have an increased risk of adult-onset
diabetes, coronary heart disease, hypertension, stroke, degenerative arthritis, obstructive apnea,
cancer, and perhaps asthma [5,6]. Mortality related to obesity is approximately 300,000 lives per
year in the United States. Annual medical costs for diabetes alone are at least $100 billion [2]. In
addition to the health risks, overweight individuals often experience a decreased quality of life,
including depression, impaired mobility, and poor self-esteem [7]. Fortunately, obesity and over-
weight are treatable and in many individuals respond favorably to dietary modification and moderate
exercise. Even a modest weight loss (5%) is associated with a significant reduction in the risk of
developing chronic diseases, particularly diabetes and heart disease [8]. Numerous pharmacological
treatments are available today for weight management. These include serotonergic agents (fluox-
etine), noradrenergic agents (sibutramine), and lipase inhibitors (orlistat). While these have been
shown to be effective as adjunctive agents to a sensible diet and exercise program, their utility is
limited by adverse side effects that include hypertension, seizures, irregular or rapid heartbeat,
decreased sexual drive, and fecal incontinence [8].
423
Natural-based products (vitamins, minerals, herbs, and other nutritional supplements) and meal-
replacement preparations are also promoted for weight loss. These include products that are reported
to restrict fat absorption (chitosan) and lipogenesis (Garcinia cambogia); products that are ther-
mogenic and increase metabolic rate (e.g., ephedrine, caffeine, cayenne, medium-chain triglycer-
ides, conjugated linoleic acid, Citrus aurantium); products that enhance insulin sensitivity (e.g.,
chromium and banaba leaf extract); products that act as diuretics (e.g., vitamin B6, dandelion root,
Uva ursi); and products that serve as bulking agents (soluble fibers, such as guar gum, glucomannan,
and pectin, and insoluble fibers, such as bran and psyllium). Unfortunately, few of these products
are backed by rigorous scientific research establishing their effectiveness and, in many cases, safety
in humans. Furthermore, many of them are not without adverse side effects that may include
increased blood pressure and heart rate, insomnia, anxiety, flatulence and gastrointestinal discom-
fort, and nutrient losses [9].
The general public is using several popular diets that promote weight loss through severe dietary
restriction (e.g., high protein, avoidance of carbohydrates, extreme low fat). Individuals often fail
to stick with these diets due, in large part, to the difficulty of changing eating preferences that have
developed from an early age. Many people who go on and off diets not only gain their original
weight back but also put on additional pounds as well. The result is a new and higher base-level
weight, one that is more difficult to lose the next time a diet is attempted. Further, avoidance diets
may not ensure that the individual’s diet contains an appropriate balance of macronutrients (protein,
carbohydrate, and fat) and micronutrients (vitamins, minerals, trace elements, amino acids, and
essential fatty acids) [10].
Obviously, in conjunction with regular physical exercise, an effective approach to weight
management is the restriction of calorie intake under conditions in which all of the essential nutrients
are maintained at optimal levels. Although simple in theory, calorie restriction is often impractical
because of the instinct to overeat and the difficulty in making long-term changes to dietary habits.
One promising mechanism is the limitation of calorie contribution from starches, as these contribute
nearly one half of the total calorie intake in the average American diet [11]. Starches (also referred
to as complex carbohydrates) are large polysaccharides present in plant foods and are provided in
the diet primarily from potatoes, bread, pasta, and rice.
When starches are eaten, the first step in their digestion takes place in the mouth, where salivary
α-amylase is secreted by the parotid glands. Starches are hydrolyzed primarily into the disaccharide
maltose. Because of the brief time that food is chewed, however, salivary digestion accounts for
only a small percentage (approximately 5%) of total starch digestion. The majority of starch
digestion takes place in the upper small intestine (duodenum and jejunum), where pancreatic cells
secrete a large quantity of another form of α-amylase that is nearly identical to the salivary enzyme
but is many times more powerful. In general, starches are almost completely converted to maltose
and other small glucose polymers at about the time the contents are passed farther into the intestine,
where other enzymes break the disaccharides into monosaccharides, primarily glucose. These sugar
molecules are absorbed by the brush border of the small intestine. Once absorbed, these sugars are
delivered to the liver via the portal vein and enter into intermediary metabolism, where they are
stored as glycogen and eventually burned by cells for energy. However, if caloric intake exceeds
energy output, the sugars are converted to and stored as fat. Inactivity leads to the progressive
accumulation of fat and increase in body weight.
Starches that escape digestion and absorption in the intestine pass into the colon, where they
are fermented into short-chain fatty acids, organic acids, carbon dioxide, and hydrogen by anaerobic
bacteria [12]. The extent of carbohydrate digestion can be measured by hydrogen exhalation [13]
or a combination of carbon dioxide and hydrogen exhalation [14]. It is estimated that approximately
10% of all starch consumed by humans passes through the GI tract undigested [15]. An increase
in the amount of undigested starch may have multiple health benefits, including weight loss, blood
lipid improvement, glycemic control, and antioxidant protection.
Phaseolus vulgaris and α-Amylase Inhibition 425
NATURAL AMYLASE INHIBITORS:

OCCURRENCE AND CHEMICAL CHARACTERIZATION
Common beans (Phaseolus vulgaris) and grains (wheat, barley, rye) are natural sources of α-amy-
lase inhibitors. Although the physiologic role of these inhibitors is not completely elucidated, they
are proposed to be a defense mechanism against insects or metabolic regulators [16]. Three different
glycoprotein isoforms (αAI-1, αAI-2, and αAI-3) have been isolated from P. vulgaris that differ
with respect to electrophoretic mobility, heat stability, and subunit composition [17–19]. αAI-1, a
43-kDA dimeric glycoprotein, inhibits porcine [19] and human [20] pancreatic amylase and is
thermostable. Kinetic data suggest that αAI-1 binds tightly to specific locations on the amylase
molecule and induces an irreversible conformational change, resulting in impairment of enzyme
activity [19,20].
CLINICAL STUDIES: CRUDE WHITE BEAN EXTRACT

In the 1970s, researchers reported the presence of a proteinaceous component of the white kidney
bean (Phaseolus vulgaris L.) that specifically inhibited α-amylase activity [21]. Several crude bean
extracts were subsequently marketed promising to reduce body weight by limiting starch digestion
in humans. Subsequent clinical studies, however, failed to show significant effectiveness in humans
[22–25], and the U.S. Food and Drug Administration halted further sales in 1983 [26]; however,
later studies conducted at the Mayo Clinic confirmed that the commercial preparations exerted anti-
amylase activity in test tube experiments but did not have sufficient activity to decrease starch
digestion when ingested by humans.
CLINICAL STUDIES: PARTIALLY PURIFIED WHITE BEAN EXTRACT

Subsequently, a partially purified extract was synthesized from the white kidney bean that had much
higher anti-α-amylase activity and was stable in gastric and intestinal solutions [27]. The extract
(purified six- to eightfold by total protein content), perfused into the duodenum of seven human subjects,
inactivated amylase in the intestinal lumen in a dose-dependent fashion as measured by continuous
aspiration of gastric and duodenal contents. At 2.0-, 3.5-, and 5.0-mg/mL perfusions, amylase inhibition
of 94%, 99%, and 99.9%, respectively, was observed. It was concluded that a partially purified amylase
inhibitor that is stable in gastric fluid may decrease intestinal digestion of starch in humans.
Four fasting subjects were intubated with an oroileal tube for measurement of duodenal, jejunal,
and ileal intraluminal amylase activity following ingestion of 50 g of rice starch given with placebo,
5 g of the white bean extract, or 10 g of extract [28]. The extract significantly (p < 0.05) reduced
amylase activity by more than 95% in as soon as 15 minutes and persisted for up to 2 hours. It
also increased postprandial delivery of carbohydrates to the bowel, increased breath hydrogen, and
shortened duodenoileal transit time. Additionally, decreases in insulin, C-peptide, gastric inhibitory
peptide, and postprandial glucose levels were observed. The extract did not affect trypsin secretion,
suggesting a specific action of the extract on amylase. Coingestion of the partially purified white
bean extract with 50 g of starch substantially reduced postprandial release of insulin and plasma
glucose concentrations both in normal and diabetic individuals [29]. The extract was thus proposed
to be possibly beneficial for the clinical management of individuals with diabetes mellitus.
A placebo, 2.0 g, or 2.9 g of the white bean extract was administered to 8 healthy subjects along
with a 650-calorie mixed meal containing protein, fat, and carbohydrate [30]. Compared to placebo
and 2.0 g of extract, individuals consuming 2.9 g of extract showed significant increase in breath
hydrogen excretion between 45 and 180 minutes after the meal. Postprandial glucose, C-peptide,
and gastric inhibitory peptide were also lowered. No diarrheic side effect was observed, indicating
that the extract may be a safe and effective adjunctive aid for use in obesity or diabetes mellitus.
Carbohydrate malabsorption was observed in 13 volunteers who ingested lactulose as a starch

substrate, spaghetti alone, and spaghetti with inhibitor [31]. Breath hydrogen excretion was
increased more than twofold with amylase inhibitor over an 8-hour test period compared to the
other two test conditions (p < 0.05). Calculation of the percentage of malabsorbed starch showed
significant reduction with spaghetti plus inhibitor (7.0 ± 1.4%) compared to spaghetti alone (4.7 ±
1.9%; p < 0.05).
Six non-insulin-dependent diabetics were given 4 to 6 g of the partially purified white bean
extract with each meal over a 3-week test period [32]. Significant reductions (p < 0.05) were seen
at days 7, 14, and 22 in postprandial plasma glucose, C-peptide, gastric inhibitory peptide concen-
trations, and total carbohydrate absorption (measured by breath hydrogen). Diarrhea occurred on
the first day of administration of the extract but decreased thereafter, presumably due to changes
in probiotic metabolism of undigested carbohydrate.
Eighteen healthy volunteers were intubated with an oroileal tube and administered a standard-
ized mixed meal over 10 minutes [33]. Simultaneously, test solutions of normal saline or carbohy-
drate were perfused over a 7-hour period. The perfusate administered to one half of the test subjects
contained white bean amylase inhibitor. Gastric emptying (measured by dual-headed camera) was
significantly slowed by amylase inhibitor compared to placebo or carbohydrate alone. Plasma
concentrations of hormones and the amount of carbohydrates passing the ileum were measured
every 10 minutes. Slowing of gastric emptying time was positively associated with decreased
concentrations of gastric inhibitory peptide and neurotensin and increased concentrations of peptide
YY. No association was seen between slowing of gastric emptying and plasma concentrations of
C-peptide, glucagons, motilin, gastrin, and human pancreatic peptide. Thus, the white bean amylase
inhibitor extract increases gastric emptying through mediation of gastrointestinal hormones.
Sixty-two overweight (BMI = 26 to 30 kg/m2) and obese (BMI > 30 kg/m2) subjects were
randomized to receive either 150 mg of Phaseolus vulgaris extract mixed with 25 mg of locust
bean extract or placebo [34]. Subjects were instructed to take two capsules three times daily at the
main meals and to avoid any changes in daily diet and exercise. After 3 months, serum cholesterol
levels were modestly reduced in the extract group but not in the placebo. No change was seen in
high-density cholesterol, low-density cholesterol, or triglyceride levels in either group; however,
after 9 months, low-density cholesterol and the ratio of low- to high-density cholesterol were
reduced in the active group without accompanying further change in total cholesterol. Placebo
group values remained unchanged. Neither the extract nor the placebo was associated with changes
in other nutritional parameters, including serum vitamin B12, folic acid, ferritin, and albumin.
Overall, long-term supplementation with white bean extract increased fecal fat excretion and
improved serum lipoprotein profiles.
These studies demonstrate that a partially concentrated extract of the white kidney bean
containing a natural amylase inhibitor demonstrates an ability to reduce carbohydrate absorption
in humans and the subsequent rise in blood sugar levels in healthy and diabetic individuals. This
suggests potential benefit for weight loss and management of glucose metabolism.
CLINICAL STUDIES: PHASE 2®

STANDARDIZED WHITE BEAN EXTRACT
Recently, a standardized extract from the white kidney bean (Phaseolus vulgaris) was developed
that appears to effectively reduce starch absorption in humans. The extract survives undiluted gastric
and intestinal solutions, retaining about 70 to 80% of its activity. It is also specific to α-amylase,
and no effect is seen on other digestive enzymes [35]. The following studies were all performed
using the Phase 2® proprietary white bean extract.
A double-blind, placebo-controlled pilot study on ten human subjects (male and female)
comparing Phase 2® to placebo in normoglycemic individuals measured pre- and postprandial
glucose levels as an index of starch digestion and absorption [36]. After an overnight fast, baseline
plasma glucose levels were obtained and participants were then randomized to receive a standard-
ized meal containing 60 g of starch (4 slices of white bread) and either a placebo or 1500 mg of
Phase 2®. Participants (laboratory personnel) went about their regular work activity. Plasma glucose
was measured every 30 minutes postprandial for 4 hours. After one week, the participants crossed
over and repeated the procedure with the other product. The plasma glucose levels of the Phase 2®
group showed consistently lower values and returned to baseline 20 minutes earlier than the placebo
group. In addition, the area under the curve (a measure of glucose absorption), averaged 57% less
in subjects taking Phase 2® compared to those taking a placebo. Statistical significance was not
reported. No adverse effects were reported by any of the test subjects following consumption of
the extract.
A second pilot study was identical in design to the first, with the exception that test subjects
were inactive during the course of the study, and plasma glucose measurements were taken every
15 minutes for the first hour and every 20 minutes for the second hour [37]. The same test meal
that was used in the previous study was given to the subjects, and the Phase 2® dosage remained
at 1500 mg. This study was undertaken to determine whether physical activity may have significantly
influenced the observed differences in the earlier pilot study. Although only 4 subjects completed
the study (2 withdrew unrelated to side effects and 4 because they were classified as nonresponders
due to negative areas under the curve), participants receiving Phase 2® averaged an 85% reduction
in plasma glucose response as determined by the area under the curve. Results did not reach
statistical significance due to the small sample size. Again, no adverse side effects were reported.
Seven subjects were fed two standardized mixed meals (630 calories; 64 g carbohydrate, 29 g
protein, 29 g fat) in random fashion with and without coadministration of one half (750 mg) the
dosage of Phase 2® used in the previous two pilot studies [38]. Plasma glucose levels were monitored
at 10-minute intervals for the first hour and at 20-minute intervals for the second hour. The area
under the curve was 28% lower when Phase 2® was consumed with the meal, and plasma levels
returned to baseline faster than control. If the contribution of simple sugars consumed in the dessert
portion of the meal is excluded, then the area under the curve was 42% lower for the Phase 2®
group. Compared to earlier studies described above, Phase 2® white bean extract appears to exert
a dose–response effect at 750 mg and 1500 mg per meal dosage.
The results of these pilot studies indicate that a proportion of the starch calories from the test
meal were undigested when coingested with Phase 2® white bean extract as indicated by reduced
postprandial glucose absorption and metabolism. Participants reported no adverse side effects in
any of these studies.
A 12-week randomized, double-blind, placebo-controlled study was conducted on 40 over-
weight and obese subjects of both sexes ages 18 years or older [39]. Subjects in the active group
consumed 400 mg of Phase 2® three times daily immediately before each meal. Subjects consuming
Phase 2® showed statistically significant body weight loss, BMI reduction, and body fat loss
compared to those consuming the placebo. Subjects in the active group lost an average of 3.5 kg
(7.7 lb) by the end of the study. Body fat analyses by two different methods (bioimpedance and
near-infrared) showed that the majority (>85%) of the weight loss was accounted for by body fat.
No significant differences in hip and waist circumferences in the active group were found. The
placebo group showed no significant changes in any of the test parameters. None of the subjects
in either group reported any adverse side effects. The results are somewhat complicated by the
inclusion of inulin (derived from chicory root) and Garcinia cambogia in the formula. Inulin is
particularly interesting, as it is approved by the German Commission E for use as an appetite
stimulant. Garcinia cambogia (and its active ingredient, (–)-hydroxycitrate) is purported to assist
weight loss by preventing the uptake of fat from the small intestine [40], although few studies have
been published to confirm this.
Twenty-seven (BMI > 30 kg/m2) individuals completing a randomized, double-blind, pla-
cebo-controlled study were instructed to take either 1500 mg of Phase 2® white bean extract or
placebo twice daily with lunch and dinner for a period of 8 weeks [41]. Participants taking the
active material lost an average of 3.8 lb at the end of the 8-week study period, whereas those
on placebo lost an average of 1.65 lb. Active participants thus lost 129% more than those on
placebo. Patients on the active material also lost an average of 1.47 in. around their waists
which was 36% more than those on placebo (average loss, 1.07 in.). While not statistically
significant due to the limited sample size, the results are consistent with other human weight-
loss studies using Phase 2®. Another favorable result of this study was the effect of the active
extract on serum triglycerides, which are directly associated with body fat storage. Test subjects
taking the white bean extract exhibited an average 26.3 mg/dL decrease in triglyceride levels,
whereas those on placebo averaged an 8 mg/dL decrease. Again, while not statistically significant
due to sample size, the difference in average values between the two groups was more than
300%. Additionally, subjects on the extract reported a 13% increase in energy as measured by
the Likert Scale compared to those on placebo who reported no improvement. Although this is
a subjective measure and not statistically significant, this is worth noting because amylase
inhibitors do not exert any stimulant action.
A more extensive study involved 60 healthy males and females ages 25 to 45 years [42].
Volunteers were selected for the double-blind, placebo-controlled study based on a stable body
weight ranging from 5 to 15 kg (12 to 33 lb) over optimal body weight for 30 days prior to
participation in the study. They were instructed to follow a recommended diet with daily
consumption of starchy foods during one of the principal meals. Study participants consuming
445 mg of white bean extract once daily before one of the principal meals lost an average of
6.45 lb (3.96% of body weight) by the end of the 30-day study, whereas those consuming a
placebo lost an average of 0.76 lb (0.47% body weight). In addition, those on Phase 2 ® lost
10.45% of fat body mass, 3.44% waist circumference, 1.44% thigh circumference, and 1.39%
hip circumference. These losses occurred without any change in lean muscle mass. Placebo
participants had losses of 1.30%, 0.53%, 0.39%, and 0.10%, respectively. The observed differ-
ences were statistically significant for all test parameters (p < 0.001, Student’s t-test). No
significant adverse effects were reported by any of the patients taking the extract, indicating
that it is safe and well tolerated.
A randomized, double-blind, placebo-controlled study (with crossover) was performed using
60 overweight and obese subjects [43]. Subjects received either 1000 mg of Phase 2® white bean
extract (combined with 500 mg of fennel seed powder) or placebo with lunch and dinner. Subjects
were randomly allocated into two groups. Group 1 received placebo for 12 weeks, then crossed
over to active for the next 12 weeks. Group 2 received the active treatment for the entire 24-week
study period. Subjects were instructed to include at least 100 to 200 g of carbohydrates in each
lunch and dinner meal. Preliminary data analysis failed to demonstrate a significant difference in
body weight, waist and hip circumference, or body fat composition between active and placebo.
This appears to reflect wide variation in patient values and differences in adherence to study
protocol. However, serum cholesterol levels decreased 10.7 mg/dL in the active group and increased
1.6 mg/dL in the placebo group (p = 0.07) and triglycerides showed a decrease of 10.22 mg/dL in
the active group compared to an increase of 1.5 mg/dL in the placebo group (p = 0.07). No
differences were seen in diastolic or systolic blood pressure. No adverse events were reported by
any of the subjects in either test group.
Ten subjects (five male, five female) with body fat > 25% and BMI of 25 to 30 kg/m 2 were
administered 750 mg of Phase 2® 30 minutes prior to lunch and dinner for 8 weeks [44]. The
test supplement also contained 100 mg clove powder and 10 mg each of L-lysine, L-arginine,
and L-alanine. The following results comparing baseline and end-of-study average values were
determined to be statistically significant at the 0.5 level. Body weight decreased 1.8 kg, body
fat ratio decreased 1.2%, body fat decreased 1.4 kg, BMI decreased 0.7, waist circumference
decreased 4.8 cm, and hip circumference decreased 3.1 cm. Favorable effects were observed
on cardiovascular parameters. Systolic pressures decreased an average of 9 mmHg, and diastolic
pressures decreased 11 mmHg. Triglycerides were lowered an average of 37 mg/dL. Lean muscle
mass was similar for all test subjects at the beginning and at the end of the 8-week study period.
No unfavorable effects were reported, and standard serum chemistry panel results showed no
changes that might indicate an adverse clinical effect.
SAFETY STUDIES
Acute toxicity studies of Phase 2® Phaseolus vulgaris extract showed that ingestion of amounts up
to 2.5 g/kg body weight produced no changes in hematological, biochemical, or histopathological
parameters after 7 days administration to rats [45]. Similarly, no adverse changes were seen after
90 days when Phase 2® was chronically administered at dosages as high as 3.0 g/kg body weight
[46]. The results of these studies indicate that Phase 2® Phaseolus vulgaris extract is safe and
support its use as a weight management adjunct.
High amounts of white bean amylase inhibitor may cause diarrhea and flatulence due to the
increased amount of fermentable fiber passing into the colon [30,32]. The effect was transient and
resolved quickly, leading to the suggestion that there was an inducible change in probiotic flora
that compensated for the increased fiber content; however, the majority of the human clinical studies
using Phaseolus vulgaris reported no adverse events. This is in contrast to prescription α-glucosi-
dase inhibitors (e.g., acarbose), which frequently induce flatulence, diarrhea, or abdominal discom-
fort [47]. No reported drug interactions with amylase inhibitors have been reported.
Given that the effective dosage seen in human clinical studies is between 500 and 1500 mg
and is without adverse effect or drug interactions, Phaseolus vulgaris amylase inhibitor extract
promises to be a safe and effective weight management adjunct.
CONCLUSIONS
Control of carbohydrate absorption through the inhibition of α-amylase activity offers promise
as an effective adjunct to a sensible weight management program. Amylase inhibitors can be
extracted from a number of plant sources, especially those in the legume family (Phaseolus
vulgaris) and wheat. The studies reported here suggest that ingestion of moderate (500 to 1500
mg) amounts of an extract of the white bean Phaseolus vulgaris containing a natural amylase
inhibitor with starch-rich meals shows promise as a safe and effective therapeutic adjunct for
reducing absorption of dietary starches, thus lessening the caloric load. In addition to the potential
benefits for weight management, a reduction in carbohydrate absorption through amylase inhibition
appears to help normalize blood cholesterol and triglyceride levels. The long-term benefit may be
a reduction in comorbidities associated with excess body weight and obesity including diabetes
and heart disease. Additional research is necessary to fully understand the potential benefits of
this mechanism for human use. More randomized, double-blind, placebo-controlled studies are
needed to confirm statistical differences in weight loss induced by limiting carbohydrate calories
through α-amylase inhibition. Such studies should be extended over several months to determine
if the effect of calorie neutralization is lasting. More information is required to establish the
optimal effective dose and time of administration. Through sound, rigorous scientific research on
natural weight-control products, we will ensure a healthier population, improved quality of life,
and reduced risk of chronic disease.
DISCLOSURES
The author discloses that he has provided consulting services to Pharmachem Laboratories, Kearney,
NJ, to assist in the development of Phase 2® extract derived from Phaseolus vulgaris. The author
has no financial interest in Pharmachem Laboratories. He is the President/CEO and founder of
ProThera®, Inc., which distributes a line of dietary supplements, including one containing Phase
2®, to the professional medical market.
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33 Glucomannan in
Weight Loss: A Review
of the Evidence
Barbara Swanson and Joyce K. Keithley
CONTENTS
Introduction ....................................................................................................................................433
Prevalence of Dietary Supplement Use for Weight Reduction..............................................434
Dietary Fiber and Weight Reduction......................................................................................434
Glucomannan .................................................................................................................................435
Structure ..................................................................................................................................435
Proposed Mechanisms of Action............................................................................................435
Dilution of Energy Density .............................................................................................435
Promotion of Satiety........................................................................................................435
Fecal Energy Loss ...........................................................................................................436
Pharmacokinetics ....................................................................................................................436
Safety ......................................................................................................................................436
Drug Interactions ....................................................................................................................437
Dosage.....................................................................................................................................437
Glucomannan and Weight Loss: Review of Controlled Trials .....................................................437
Clinical Implications ......................................................................................................................438
Case Study......................................................................................................................................438
Past Medical History ..............................................................................................................439
Conclusions and Future Directions ...............................................................................................440
References ......................................................................................................................................440
INTRODUCTION
Treatment of overweight and obesity is exceedingly difficult. Conventional management consists
of low-calorie diets, physical activity, behavioral interventions, and pharmacological agents; how-
ever, long-term adherence to these approaches is problematic, and most individuals regain the
majority of lost weight within one or two years [1]. It has been suggested that the addition of novel
approaches to conventional treatments may produce sustainable weight loss. One approach is fiber
supplements. Glucomannan, a water-soluble dietary fiber supplement, has been associated with
reductions in body weight in a few small studies [2–9] and may be an effective adjunct for
overweight and obese individuals.
433
PREVALENCE OF DIETARY SUPPLEMENT

USE FOR WEIGHT REDUCTION
In 2001, retail sales of weight-loss supplements in the United States totaled $1.3 billion [10],
likely reflecting the aggressive marketing of these products by their manufacturers. A multistate
survey (N = 14,679) found that, within the previous two years, 14.3% of persons who were
currently trying to lose weight and 11.3% of obese persons had used nonprescription weight-
loss supplements. Among obese women, usage rates rose to 28.4%. Interestingly, 5.1% of
normal-weight persons reported use of nonprescription supplements, potentially exposing them-
selves to supplement-specific risks that are not offset by the benefits of weight reduction [11].
Among the many categories of dietary supplements used for weight loss are those containing
dietary fiber.
DIETARY FIBER AND WEIGHT REDUCTION

Dietary fiber refers to indigestible plant and nonplant dietary substances. Dietary fiber and fiber
supplements are postulated to promote weight loss by modulating energy intake and loss.
Because of their low energy density, coupled with their bulking and viscosity-producing prop-
erties, fiber and fiber supplements can supplant energy-dense nutrients, decrease hunger and
appetite, and reduce protein, carbohydrate, and fat absorption [12,13]. Studies examining the
association between dietary fiber and weight loss date back to the late 1950s. Epidemiologic
studies have generally found that fiber intake is inversely associated with body weight and body
mass index (BMI) in individuals consuming self-selected diets [14–17].
With few exceptions, the majority of clinical studies have found that high-fiber diets are
associated with reduced energy intake, reduced hunger and increased satiety, and increased
weight loss. In a recent systematic review [13], beneficial effects were seen with both high-
fiber diets and fiber supplements. Almost all studies reported decreases in energy intake,
increases in satiety or decreases in hunger, and increases in weight loss. Greater reductions in
energy intake (82% vs. 94% of baseline intake) and weight (2.4 kg vs. 0.8 kg) were noted in
overweight and obese individuals compared to normal-weight individuals. In the majority of
studies, fiber supplements yielded better results than high-fiber diets, suggesting greater benefits
from fiber supplements, as well as easier use and adherence, compared to fiber-rich foods. Fiber
supplement dosages ranged from 5 to 40 g/day (mean, 7 to 10 g/day), and the effects of soluble-
fiber vs. insoluble-fiber vs. mixed-fiber supplements were comparable. Other comprehensive
reviews provide additional evidence that increased fiber consumption is associated with increases
in satiety and reductions in hunger, energy intake, and body weight [18,19].
The most widely used fiber supplements for achieving weight loss include guar gum,
plantago psyllium, and glucomannan. The safety and efficacy of guar gum, a water-soluble
fiber, for reducing body weight were evaluated in a meta-analysis [20]. Statistically pooled
data from 11 double-blind prospective randomized clinical trials indicated that guar gum was
ineffective for promoting weight loss and was associated with numerous adverse events,
including diarrhea, flatulence, and other gastrointestinal complaints. Plantago psyllium, another
water-soluble fiber, has been evaluated in one prospective randomized clinical trial [21]. No
significant changes in weight were reported, although glucose and lipid parameters were
significantly improved.
Although fiber is hypothesized to promote weight maintenance following weight loss, few
long-term trials have been conducted. Two small studies have shown that mildly obese partic-
ipants who were given fiber supplements were better able to sustain weight loss over 6 months
to 1 year than those given a placebo [22,23]. Limited evidence indicates that glucomannan may
be a promising fiber supplement for weight loss.
Glucomannan in Weight Loss: A Review of the Evidence 435
6
CH2OH CH2OCOCH3 CH2OH CH2OH
5
O O O O
H H H H
H H H H
O 4 1 O O O
OH H OH H OH HO OH HO
H H H H
3 2
H OH H OH H OH H H
Glucose Glucose with Mannose Mannose
acetate group
on carbon 6
FIGURE 33.1 Structure of a segment of glucomannan with repeating glucose and mannose units.
GLUCOMANNAN
STRUCTURE
Glucomannan is a water-soluble, fermentable dietary fiber extracted from the tuber or root of the
elephant yam, also known as konjac (Amorphophallus konjac or Amorphophallus rivieri). Gluco-
mannan consists of a polysaccharide chain of β-D-glucose and β-D-mannose with attached acetyl
groups in a molar ratio of 1:1.6 with β-1,4 linkages (Figure 33.1) [24–26]. Human amylase cannot
split β-1,4 linkages, thus glucomannan passes relatively unchanged into the colon, where it is highly
fermented by colonic bacteria. It has a high molecular weight (average, 1,000,000 Daltons) and
can absorb up to 50 times its weight in water, making it one of the most viscous dietary fibers
known [25]; therefore, much smaller doses of glucomannan are needed compared to other types
of fiber supplements.
PROPOSED MECHANISMS OF ACTION

See Table 33.1.
Dilution of Energy Density

Fiber has a low calorie content and can lower the energy-to-weight ratio of consumed food [13].
Because studies suggest that eating patterns are driven by the weight of food consumed, rather than
caloric intake [27,28], fiber can displace the energy of other nutrients for a given weight of food
and still induce satiety [29].
Promotion of Satiety
Glucomannan may promote satiety via several mechanisms. Eating fiber requires increased masti-
cation effort that may induce cephalic- and gastric-phase signals that promote satiety [13]. Gluco-
mannan increases the viscosity of the gastrointestinal contents, thus slowing gastric emptying and
TABLE 33.1
Mechanisms by Which Glucomannan May Induce Weight Loss
Stomach Small Bowel Colon Feces
Absorption of water → Mechanical barrier to Fermentation → short-chain fatty Excretion of most short-
↑ intraluminal viscosity, enzymatic digestion acids → ↓glucose production, chain fatty acids
↓ energy intake, ↑ satiety, ↑insulin sensitivity, ↓insulin and some undigested
↓ gastric emptying, secretion glucomannan
↓ insulin secretion
TABLE 33.2
Physiochemical Characteristics of Glucomannan
Characteristic Property
Molecular weight Average, 1 million Daltons
Molar ratio 1 glucose:1.6 mannose
Solubility Highly water soluble; expands up to 50 times its weight in digestive tract
Digestibility Small intestine, resistant to hydrolysis by digestive enzymes
Large intestine, fermented by colonic bacteria
Absorption Minimal from large intestine
inducing satiety. Moreover, evidence suggests that the short-chain fatty acid byproducts of gluco-
mannan fermentation in the gut regulate satiety [18]. Additionally, glucomannan can attenuate
postprandial insulin surges by reducing absorption, accelerating the delivery of food to the terminal
ileum where satiety signals are transmitted, and elevating plasma cholecystokinin levels, a hormone
postulated to mediate fat-induced satiety [12,13,30–32].
Fecal Energy Loss
Soluble fibers have been shown to reduce fat and protein absorption [33], possibly by reducing
their physical contact with intestinal villi; however, it remains unclear whether this mechanism
leads to weight loss. Evidence suggests that this energy loss is offset by the energy produced
through the fermentation of soluble fibers and trapped nutrients in the colon [13]. Considerable
evidence indicates that soluble fiber inhibits carbohydrate absorption [34] and improves glycemic
parameters [35,36].
PHARMACOKINETICS
The bioavailability of glucomannan is very low; only small amounts are absorbed and reach the
plasma (Table 33.2). To date, no validated methods exist to measure plasma concentrations of
glucomannan or its metabolites in humans following therapeutic doses, thus limiting investigation
of its pharmacokinetic properties. Glucomannan is resistant to hydrolysis by digestive enzymes, so
it is only minimally digested in the small intestine. Substantial fermentation by colonic bacteria
occurs in the large intestine, producing short-chain fatty acids and several byproducts (e.g., formic
acid, acetic acid, butyric acid, propionic acid, glucose, mannose). Although small amounts of some
of these products may be absorbed from the large intestine, most are excreted in the feces, along
with some undigested glucomannan [37].
SAFETY
The konjac tuber is widely used in Asia as an ingredient in the manufacture of jelly candies, tofu,
and noodles. Konjac flour has been used as a food stabilizer and gelling agent and has been approved
by the U.S. Department of Agriculture as a binder for meat products. Because of its water-absorptive
properties, konjac jelly candies have been implicated in several choking deaths around the world,
leading to its ban in the United States, Europe, and Australia [38]. Glucomannan is available in
capsule form or as a drink mix. It is no longer available in tablet form, as contact with water can
cause the tablets to swell before they reach the stomach. Nine cases of esophageal obstruction
caused by ingestion of glucomannan tablets have been reported [39]. No reports of esophageal
obstruction associated with ingestion of glucomannan capsules have been reported, presumably
because the outer casing shields the fiber from water prior to reaching the stomach [40]. There
TABLE 33.3
Clinical Studies of Glucomannan and Weight Loss
Study Sample Design Intervention Duration Weight Results
Walsh et al. [9] 20 F, OB Parallel 1 g 3×/day 8 weeks –5.5 lb, p ≤ 0.005
Reffo et al. [5] 31 NW hypertensives Parallel 1 g 3×/day 4 weeks –1.4 kg, p < 0.001;
–2.4 kg, p < 0.01
with calorie restriction
Reffo et al. [6] 28 NW post-MI Parallel 1.5 g 2×/day 8 weeks –2.2 kg., p < 0.001
Livieri et al. [4] 53 OB children Parallel 2–3 g/day 4 months Significant reductionsa
Vita et al. [8] 50 OB Parallel 4 g/day 3 months Significant reductionsa
Vido et al. [7] 60 OB children Parallel 2 g/day 8 weeks Significant reductionsa
Cairella et al. [3] 30 OW/OB children Parallel Not specifieda 8 weeks Substantial reductionsa
Birketvedt [2] 176 OW Parallel 1.24 g/day 5 weeks –3.8 kg, p < 0.01
a From English abstract of Italian manuscript.
Abbreviations: F, females; OB, obese; OW, overweight; NW, normal weight; MI, myocardial infarction
have been few adverse events associated with the use of glucomannan capsules. Most events have
involved minor gastrointestinal complaints, such as bloating, gas, and mild diarrhea; in clinical
studies of glucomannan, the overall rate of adverse effects is less than 0.05% [41,42]. One case
report in Spain indicated a possible association between acute hepatitis of cholestatic type and the
use of glucomannan in a patient with a previous history of drug use and recent use of several other
herbal supplements [43].
DRUG INTERACTIONS
Glucomannan has been shown to lower blood glucose levels and should not be taken in association
with medications or other dietary supplements that have hypoglycemic effects [35,36,44]. Gluco-
mannan reduces the absorption of sulfonylurea medications [45] and may reduce the bioavailability
of other oral medications taken concomitantly. Glucomannan also may reduce the absorption of
fat-soluble vitamins in supplements or in foods. For these reasons, oral medications should be taken
1 hour before or 4 hours after ingesting glucomannan capsules [42].
DOSAGE
The recommended dosage for weight loss is 1 g three times a day, 1 hour before meals. For
managing type 2 diabetes or insulin resistance, 3.6 to 13 g/day have been administered [41].
GLUCOMANNAN AND WEIGHT LOSS:

REVIEW OF CONTROLLED TRIALS
A few small studies suggest that glucomannan may be well tolerated, promote moderate weight
loss in overweight and obese individuals, and have beneficial effects on lipid and glucose param-
eters. Seven studies with weight loss as the primary outcome measure found that daily supplemen-
tation with glucomannan (dosage range, 2 to 4 g; treatment duration, 4 to 16 weeks; mean sample
size, 39) produced significant or nonsignificant decreases (–3.08 to –5.5 lb) in body weight in
healthy overweight and obese individuals (Table 33.3) [3–9]. Similar effects were seen whether
the participants consumed self-selected, normocaloric, or hypocaloric diets. Other beneficial effects
were increased satiety, improved lipid profile, improved diet adherence, and improved glycemic
status. Adverse events were minimal and included a few reports of mild bloating/flatulence, which
caused two participants to drop out of one study [6]. These findings are consistent with those of a
recent short-term study in which glucomannan supplements in conjunction with a 1200-kcal diet
resulted in a weight loss of approximately 8.8 lb over a 5-week period in healthy overweight
individuals [2]; the addition of guar gum and alginate to glucomannan did not confer additional
weight loss effects. Limitations of these studies include the use of sample sizes not supported by
power analysis, the use of heterogeneous samples of overweight and obese individuals with lack
of appropriate controls for comorbidities and confounders, and the use of mostly Caucasian par-
ticipants. It is also noteworthy that most of the studies were conducted 10 or more years ago, and
four of the studies were published in Italian, limiting the depth and amount of information
abstracted.
A series of studies have examined the safety and efficacy of glucomannan for modulating
lipoprotein and glucose parameters in patients with type 2 diabetes and/or hypercholesterolemia
with body weight loss as a secondary outcome measure [35,36,44,46,47]. The lipid profiles (total
cholesterol, LDL-C, and TC/HDL-C) were significantly improved in three of the studies [36,44,47].
Other findings included significant reductions in systolic blood pressure [35], serum fructosamine
[35,36], and apolipoprotein B [36,44], as well as greater excretion of fecal neutral sterol and bile
acids [44,47]. Similar to the weight-loss studies, either no adverse events or only a few transient
gastrointestinal symptoms (flatulence, soft stools) were reported. These findings suggest that glu-
comannan favorably modulates metabolic parameters independent of weight loss.
Interestingly, all of the studies that measured weight loss as a secondary endpoint showed no
reductions in body weight, when presumably many of the participants were overweight. One
explanation might be that the duration of these studies (3 to 4 weeks) was inadequate to observe
a statistically significant weight loss. Additionally, these studies generally had small sample sizes
and may have been underpowered to detect statistically significant weight changes.
CLINICAL IMPLICATIONS
Clinicians should encourage patients to use glucomannan supplements from manufacturers that
are state certified as compliant with good manufacturing practices. Additionally, when possible,
they should select products whose composition and purity have been tested by an independent
laboratory. Such products may contain quality labels, such as USP ®, ConsumerLab®, or TruLa-
bel®. Unless purity data are available, supplements imported from foreign countries should be
avoided, as manufacturing practices may fall short of U.S. standards. Some glucomannan products
contain multiple pharmacologically active ingredients. For example, Glucomannan+® (Swanson
Health Products; Fargo, ND) contains glucomannan, as well as chromium, chitosan, guar gum,
gymnema, psyllium, and L-carnitine. Chromium and gymnema both have hypoglycemic proper-
ties, thus the risk of hypoglycemia, as well as pharmacodynamic interactions with oral hypogly-
cemics or insulin, may be increased. This underscores the need for clinicians to consider the
safety profile and potential drug interactions of each ingredient when reviewing multi-ingredient
supplements with their patients. The following case study illustrates other clinical implications
of glucomannan.
CASE STUDY
BF, a 42-year-old female, presents to the clinic for consultation on weight loss. She mentions that
she began taking glucomannan a week ago and has lost 2 pounds. You have seen BF routinely for
several months, and she wonders what you think of glucomannan. She has tried a number of fad
diets — Slim·Fast®, the grapefruit diet, Sugar Busters!® — all without success. You are concerned
about her weight (192 lb prior to starting glucomannan), particularly because at her last visit she
had an elevated fasting blood glucose (180 mg/dL) and was hypertensive (180/95).
PAST MEDICAL HISTORY

BF is overweight with history of multiple fad diets and cycles of weight gain and loss.
• Lifestyle history — BF denies use of wine, hard liquor, and beer and denies current use
of tobacco products. She has no structured activity or exercise patterns.
• Social history — BF is married with four children (ages 3 to 14); a homemaker; college-
educated with a degree in English.
• Family history — Her family has a tendency to be overweight. Her mother has a history
of diabetes, and her father is hypertensive with coronary artery disease.
• Medications — Hydrochlorothiazide (HCTZ), 12.5 mg/day; Mavik® (ACE inhibitor), 4
mg/day.
• Over-the-counter — Glucomannan, but does not remember type or amount; she reports
no other use of dietary supplements or herbal therapies.
• Physical assessment — Height, 61 inches; weight, 190 lb; pulse, 90; BP, 145/90; waist
circumference, 35.5 inches (90 cm); BMI, 35.9.
Comment: This case highlights the growing use of dietary supplements, such as glucomannan, for
weight loss. It also highlights the importance of assessing for complementary and alternative
medicine (CAM) use and advising patients about dietary supplements for weight loss. Long-term
weight loss and maintenance through lifestyle changes are difficult to attain, and adjunctive therapies
have become increasingly popular weight loss options.
Question: How would you ascertain more about the type and amount of glucomannan that BF is taking?
Comment: It is laudable that BF mentions that she is taking glucomannan and wants your opinion.
An estimated 70% of individuals who use CAM therapies do not report it to their healthcare
providers, because: (1) healthcare providers either neglect to ask or are uncomfortable asking about
CAM therapies, and (2) patients are fearful or embarrassed or do not see the importance of reporting
CAM use. To elicit more specific information about the glucomannan product that BF is using,
questions might include: (1) Where did you learn about glucomannan? (2) What encouraged you
to try glucomannan? (3) How often and when do you take it? (4) What form is it in? and (5) Where
did you obtain the glucomannan? Additionally, arrange to have BF call or e-mail the product brand
and ingredients to you.
Question: How would you advise BF with regard to the safety and efficacy of glucomannan?
Comment: Results from a few, limited studies suggest that glucomannan in doses of 2 to 4 g/day
may be safe and effective in promoting weight loss. Potential advantages of glucomannan are its
tolerability and low rate of side effects; however, additional studies of standardized glucomannan
products are needed before they are recommended as a weight-loss adjunct. One concern is that
many over-the-counter preparations of glucomannan contain a combination of products that may
have dangerous side effects. Some examples to review with BF are bitter orange, country mallow,
and caffeine from natural or disguised sources, such as extracts of guarana or tea. A second concern
is that glucomannan may reduce the absorption of fat-soluble vitamins and oral medications;
therefore, BF should be advised to take other oral medications 1 hour before or 4 hours after taking
glucomannan capsules [42]. Another concern is the high solubility of glucomannan capsules; thus,
discuss the importance of taking capsules with 8 oz. of water and notifying the healthcare provider
if any side effects occur (e.g., difficulty swallowing, abdominal distention). Some reliable sources
of information about dietary supplements are the National Center for Complementary and Alter-
native Medicine (http://nccam.nih.gov), the Natural Medicines Comprehensive Database (available
through many library databases), and the Office of Dietary Supplements (http://dietary-supple-
ments.info.nih.gov/). Additionally, clinicians can keep abreast of new safety information about
dietary supplements through the FDA MedWatch program (http://www.fda.gov/medwatch/).
CONCLUSIONS AND FUTURE DIRECTIONS

Studies have shown that dietary fiber is a safe and effective adjunct to weight-reducing diets. Fiber
has been shown to promote and prolong satiety [48–50], to increase long-term adherence to low-
calorie diets [51,52], and to be inversely associated with weight gain [53]. However, commonly
used dietary fiber supplements, such as guar gum and psyllium, have not been consistently shown
to promote weight loss [54,55]. In contrast to other fiber supplements, glucomannan appears to
possess properties that promote weight loss when used in conjunction with either a normocaloric
or a hypocaloric diet. The findings of controlled trials suggest that doses of 2 to 4 g/day will
significantly reduce body weight in overweight and obese persons. Moreover, glucomannan is well
tolerated and inexpensive and has relatively few side effects. Limited data show it improves risk
factors for cardiovascular disease and diabetes, so it may be an acceptable alternative for overweight
individuals who are unable or unwilling to increase their fiber intake through food sources. Yet,
before glucomannan can be safely recommended, additional trials of standardized preparations are
necessary to further describe its safety, efficacy, and weight-reducing mechanisms of action.
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34 inRoleWeight
of Caralluma fimbriata
Management
Ramasamy V. Venkatesh and Ramaswamy Rajendran
CONTENTS
Introduction ....................................................................................................................................443
History of Use................................................................................................................................443
Active Ingredient, Preparation of Extracts, and Mode of Action of Caralluma fimbriata ..........444
Safety Evaluation of Caralluma fimbriata ....................................................................................445
Conclusion......................................................................................................................................448
References ......................................................................................................................................449
INTRODUCTION
Caralluma fimbriata, a succulent belonging to the family Asclepiadaceae, is a large group of tender
succulents found growing wild in India, Pakistan, the Canary Islands, Arabia, southern Europe,
Ceylon, and Afghanistan. The plants of this group (Figure 34.1 and Figure 34.2) vary from thin,
recumbent stems 1/2 to 1-1/2 inches thick to erect-growing clumps up to 8 inches tall. The spines
that cover the angled stems are actually leaves. The star-shaped, fleshy flowers of these plants are
some of the worst smelling of the succulent plants. Ordinarily borne in late summer, the foul-
smelling blossoms are usually colored purple, black, yellow, tan, maroon, red, or dark brown. They
are from 1/2 to 2 inches or more across and are borne at the base of the plant. In the wild, these
blossoms are pollinated by flies, which are greatly attracted to the plant. The succulent is also
referred to as Caralluma adscendens and Caralluma attenuata [3]. It has several local names in
India, including Ranshabar, Makad shenguli, Shindala makadi [1], Kullee Mooliyan, Karallamu,
and Yungmaphallottama [2,3].
HISTORY OF USE
Caralluma fimbriata has been in use for centuries in India. It is commonly used as a vegetable in
semi-arid regions of India. It is eaten raw or cooked with spices. It is also used in pickles and
chutneys. Caralluma is also classified as famine food; in arid and semi-arid regions, when no food
is available, it is consumed as a substitute for food. Indian tribals are known to chew chunks of C.
fimbriata to suppress hunger while on a day’s hunt. The cactus is used among the tribals in South
India to suppress appetite and enhance endurance. They make their living as hunters, wood col-
lectors, plant collectors, and foragers, and they do not eat or carry cooked food with them when
they go into the forests to hunt. To relieve their hunger and to ensure that they have the endurance
necessary for long forays into the forest, they chop off the stems of this succulent and chew a
handful of them during the hunt. The tribesmen state that their energy levels are maintained without
food and water and that they do not feel any fatigue or tiredness. Daily consumption of C. fimbriata
by the tribesmen in this manner is estimated to be about 100 g [3].
443
FIGURE 34.1 Flower of Caralluma fimbriata.
FIGURE 34.2 Stem of Caralluma fimbriata.
ACTIVE INGREDIENT, PREPARATION OF EXTRACTS,

AND MODE OF ACTION OF CARALLUMA FIMBRIATA
The key constituents (Figure 34.3) of Caralluma fimbriata are pregnane glycosides, saponin gly-
cosides, and bitter principles. A standardized extract of C. fimbriata (Slimaluma™) developed by
Gencor Pacific, Ltd., in partnership with Green Chem, India, was designed and developed based
on the traditional usage of the herb. A full-spectrum aqueous alcoholic extract of the herb was
developed to ensure that all of the vital constituents of the herb were present in the product. High-
pressure liquid chromatography and other techniques were used to validate the profile of the raw
herb, dried herb, and final extract to ensure and verify that consumption of 100 g of the herb by
the tribals was equivalent to consumption of 1 g of the standardized extract. The extract was
standardized for pregnane glycosides, saponin glycosides, and bitter principles.
When we eat, the nerves from the stomach send a signal to the hypothalamus in the brain. This
is the part of the brain that controls appetite. When the stomach is full, the hypothalamus signals
the brain to stop eating. When a person is hungry, the hypothalamus sends a signal to the brain
that food is needed. It appears as though Caralluma fimbriata extract inhibits this hunger mechanism
of the hypothalamus. The pregnane glycosides contained in C. fimbriata interfere with the signaling
mechanism and create a signal on their own which fools the brain into thinking that the stomach
is full, even when the person has not eaten.
Role of Caralluma fimbriata in Weight Management 445
O CH3 HO CH3
OH OH
XO XO
Caratuberside A Caratuberside B
X = Gal[3-OMe, 6-deoxy](4 → 1)Glu
Pregnane Glycoside Molecular Formula Molecular Weight

Caratuberside A C34H57O12 657.819
Caratuberside B C34H59O12 659.835
Pure Caratuberside A is a white crystalline substance.

Melting point is 170–171°C
Rotation is [α] at 20°C D+60° (C=0.66 in methanol)
Pure Caratuberside B is a white crystalline substance.

Melting point is 182–158°C (dec)
FIGURE 34.3 Pregnane glycosides of Caralluma fimbriata extract. (Courtesy of Green Chem, Bangalore,
India.)
One reason why most weight-loss programs fail is because of the fatigue caused by the loss
of weight, which forces dieters back to their old eating habits and results in a rebounding weight
gain. Caralluma fimbriata extract, however, has demonstrated in controlled clinical trials that it
helps participants to feel more energetic while inducing a gain in lean muscle mass and loss of fat.
It appears that this happens because the extract inhibits fat synthesis by blocking the formation of
acetyl co-enzyme A and malonyl co-enzyme A, which are the building blocks of fat synthesis. The
extract also seems to increase the burning of fat by the body. This makes more energy available to
the body which makes the person tend to be more active. It is a well-known fact that muscle cells
burn more calories than fat cells. When more energy is available to the body, muscle cells burn
energy faster. Muscle cells are heavier than fat cells but they are also more dense than fat cells, so
they occupy less space; consequently, a person with more lean muscle cells appears trimmer and
more compact.
SAFETY EVALUATION OF CARALLUMA FIMBRIATA

The Caralluma fimbriata extract was put through two human clinical trials to validate its safety
and efficacy. The first clinical trial was done in Bangalore, India, at St. John’s National Academy
of Health Sciences. The full-spectrum aqueous alcoholic extract of the herb described above was
used in the study. The extract dosage was 1 g a day, administered as two doses of 500 mg each 30
to 45 minutes before the two main meals of the day. The participants consisted of 50 overweight
and obese subjects (body mass index [BMI] > 26); of these, 25 received the active compound and
25 received a placebo (Table 34.1). The study was randomized, double blind, and placebo controlled.
Over 8 weeks, the subjects were tested for weight loss, anthropometry, body fat composition, BMI,
net weight, and systemic functions (Table 34.2). During the study, no changes were made in diet,
but all subjects were advised to walk 30 minutes in the morning and evening. The adverse events
TABLE 34.1
Results of the Indian Clinical Study
Experimental Group
Parameter (Mean ± SD; n = 25)
Age (years) 38.6 ± 7.8
Body weight (kg) 79.5 ± 16.9
Height (cm) 160.9 ± 9.1
Body Mass Index (kg/m2) 30.6 ± 5.5
Waist circumference (cm) 96.9 ± 11.6
Hip circumference (cm) 106.3 ± 11.4
Percent body fat (%) 34.6 ± 5.6
a Calculated from the sum of four skin-fold measurements
and applying the formulae of Durnin and Womersley [11].
Note: No significant differences were observed between

the physical characteristics of the subjects of the two
groups (independent t-test).
Source: Kurpad, A.V. et al., Use of Caralluma fimbriata

Extract on Appetite and Weight Control, St. John’s National
Academy of Health Sciences, Bangalore, India.
were minor and limited to mild upset of the gastrointestinal tract. Importantly, these adverse events
were present equally in the active and placebo groups. Constipation and flatulence subsided within
a week and were attributed to the gelatin capsules more than the cactus ingredients in the capsules.
Examination of fasting and postprandial glucose, total cholesterol, low-density lipoprotein (LDL),
high-density lipoprotein (HDL), triglycerides, serum creatinine, blood urea nitrogen (BUN), total
protein, serum albumin, total bilirubin, conjugated bilirubin, aspartate aminotransferase (AST) and
alanine aminotransferase (ALT), alkaline phosphatase, gamma-glutamyl transpeptidase (γ-GT), and
hemoglobin failed to reveal any overall toxicity from the extract. Blood pressure and electrocar-
diography also showed no toxic reactions secondary to ingesting C. fimbriata. Statistically signif-
icant differences for body weight, BMI, waist circumference, hip circumference, body fat, blood
pressure, and hunger levels were found between time points in the experimental group, but differ-
ences in the blood sugars and lipid profile (Table 34.3) did not show any significance [5].
A second clinical study was performed under the auspices of the Western Geriatric Research
Institute (Los Angeles, CA). The subjects were taken from two active practices in the Los Angeles
area. The subjects were randomly assigned to either the active group or a placebo group. The trial
was carried out on 26 patients, 9 of whom were males. They ranged in age from 31 through 73.
One patient from each category did not show up for the final visit (dropouts). All patients signed
an informed consent. The substance was administered as one capsule to be taken 30 minutes before
each meal. Each subject was weighed before and after completion of the study, height was ascer-
tained at each visit, and the waist was measured in inches as well as the hips. The hips were
measured at the widest girth, and the waist was measured at the umbilicus. In addition, blood
pressure was measured in a standard fashion at the brachial artery in the left upper extremity. From
the weight and height measurements, the BMI of each subject was ascertained. Patients were
instructed not to change their daily activity pattern (exercise) or their food intake. Almost every
patient taking the active ingredient lost significant weight, but almost no weight loss was observed
in patients on placebo (Table 34.4). Out of the patients on the actives, 83% lost weight. Patients
with a higher BMI lost more weight. Out of the patients on the actives, 72% reduced their waist
by 0.5 to 3 in., and 28% felt an increase in energy while on the active substance [6]. These two
TABLE 34.2
Anthropometric Parameters of the Subjects at Baseline, Month 1,
and End of Study
Baseline Month 1 End of Study
Parameter
(Mean ± SD) (Mean ± SD) (Mean ± SD)
Body weight (kg) 79.5 ± 16.9 78.3 ± 16.5b 77.5 ± 16.0b,c
Body mass index (kg/m2) 30.6 ± 5.5 30.2 ± 5.6b 29.9 ± 5.6b.c
Waist circumference (cm) 96.9 ± 11.6 95.1 ± 12.0b 93.9 ± 11.3b,c
Hip circumference (cm) 106.3 ± 11.4 105.8 ± 11.5 105.0 ± 11.6b,c
Percent fat (%)a 34.6 ± 5.6 34.2 ± 5.3 33.4 ± 5.6b
a Calculated from the sum of two, three, or four skinfold measurements and applying the
formulae of Durnin and Womersley [11].
b Mean value was significantly different from that of baseline (ANOVA for repeated measures
with post hoc tests; p < 0.05).

c Mean value was significantly different from that of month 1 (ANOVA for repeated measures
with post hoc tests; p < 0.05).
Source: Kurpad, A.V. et al., Use of Caralluma fimbriata Extract on Appetite and Weight
Control, St. John’s National Academy of Health Sciences, Bangalore, India.
TABLE 34.3
Biochemical Parameters of the Subjects at Baseline, Month 1, and
End of Study
Parameter
Fasting blood sugar (mg/dL) 89.8 ± 16.8 89.3 ± 10.3 88.9 ± 10.4
Post prandial sugar (mg/dL) 110.9 ± 35.3 108.3 ± 25.2 108.6 ± 27.2
Total cholesterol (mg/dL) 192.5 ± 27.1 191.0 ± 25.9 191.8 ± 27.0
HDL cholesterol (mg/dL) 65.9 ± 11.0 63.6 ± 10.0 64.1± 9.95
LDL cholesterol (mg/dL) 120.0 ± 39.8 118.0 ± 27.9 115.7 ± 30.3
Serum triglycerides (mg/dL) 111.9 ± 52.0 112.1 ± 55.0 110.3 ± 51.5
Note: No significant differences were found in the biochemical parameters at various time
points.
clinical trials showed that the use of C. fimbriata extract along with dietary and physical activity
changes may provide an effective method of weight reduction.
In addition to the human studies, which demonstrated safety and efficacy, safety studies on
animal models were performed to evaluate the long-term chronic effects and mutagenicity. An acute
oral toxicity study conducted at St. John’s National Academy of Health Sciences on Wistar rats
did not demonstrate any mortality or toxicity nor did a preliminary study with a lower dose of 2
g per kg body weight or a very high dose of 5 g per kg body weight. Body weight, feed, and water
intake in all of the treated rats were comparable with those of the control group [7]. Similarly, a
subchronic toxicity study conducted at the Bombay College of Pharmacy, India, on Wistar rats
showed no mortality or chronic effects at 90 mg/kg bodyweight (equivalent to the recommended
TABLE 34.4
Appetite and Food Intake Assessment
Parameter
Experimental group (n = 25)
Thoughts of food (%) 34.5 ± 24.3 36.2 ± 21.6 33.2 ± 23.6
Feeling of fullness (%) 33.3 ± 19.3 41.7 ± 20.5 40.5 ± 21.9
Urge to eat (%) 44.0 ± 25.3 39.3 ± 21.5 34.5 ± 21.2
Hunger (%) 47.6 ± 22.6 39.2 ± 21.4 27.9 ± 18.8a
Energy intake (kcal/day) 2276.5 ± 202.3 — 2088.8 ± 183.4a
Fat intake (g/day) 59.0 ± 6.4 — 54.3 ± 3.9a
Carbohydrate intake (g/day) 360.9 ± 26.1 — 340.5 ± 23.7a
Protein intake (g/day) 62.9 ± 6.3 — 59.3 ± 7.2a
Placebo group (n = 25)

Thoughts of food (%) 33.1 ± 20.3 33.6 ± 15.3 32.0.2 ± 17.5
Feeling of fullness (%) 37.8 ± 26.9 36.6 ± 17.9 38.6.3 ± 21.2
Urge to eat (%) 35.3 ± 25.3 35.2 ± 17.5 33.5 ± 19.71
Hunger (%) 41.9 ± 24.1 41.6 ± 17.3 40.7 ± 18.9
Energy intake (kcals/day) 2303.6 ± 107.9 — 2299.0 ± 10.9.0
Fat intake (g/day) 61.7 ± 2.8 — 60.9 ± 3.9
Carbohydrate intake (g/day) 377.9 ± 21.1 — 376.8 ± 21.3
Protein intake (g/day) 59.1 ± 4.5 — 59.3 ± 4.8
a Mean value was significantly different from that of baseline.
Note: The appetite assessment was carried using visual analog scales, and the results are
expressed as a percentage of the scale. Significant differences between time points were
assessed using ANOVA for repeated measures with post hoc corrections. The food intake
assessment was carried out using food frequency questionnaires at baseline and at the end
of the study, and significant differences between time points were assessed using the paired
t-test with post hoc corrections.
human dosage of 1 g a day) [8]. Mutagenicity studies (Ames test) utilizing the Salmonella typh-
imurium reverse mutation test were conducted at Intox Pvt., Ltd., India, and researchers concluded
that the product was nonmutagenic in all five strains of S. typhimurium [9].
CONCLUSION
Obesity is indeed becoming a menace, having assumed epidemic proportions. The physiological
and psychological problems caused by obesity are enormous. A proper diet and exercise plan
combined with efficacious and safe supplementation seems to be the way to proceed as a first step
toward combating obesity. Controlling weight by reducing calorie intake seems to be a vital factor
in this jigsaw puzzle. The extract of Caralluma fimbriata could fill the role of an ideal, clinically
tested, safe, and efficacious appetite suppressant for the control of calorie intake, leading to reduction
in body weight.
REFERENCES
[1] Laddha, K.S., Report, Medicinal Natural Products Research Laboratory, University of Mumbai,
Matunga, Mumbai, India.
[2] Jayashree, K.S., Report, Dravyaguna Dept., Ayurvedic Holistic Center, Bangalore, India.
[3] Wealth of India: A Dictionary of Indian Raw Materials and Industrial Products, Vol. 3, Vedams, New
Delhi, India, 1992, pp. 266–267.
[4] Jeyachandran, V., Report, Tagore Arts College, Pondicherry, India.
[5] Aroumougame, S., Report, Society for Health, Environment and Research for Biodiversity,
Pondicherry, India.
[6] Kurpad, A.V. et al., Use of Caralluma fimbriata Extract on Appetite and Weight Control, St. John’s
National Academy of Health Sciences, Bangalore, India.
[7] Lawrence, R.M. and Choudhary, S., Caralluma fimbriata in the Treatment of Obesity, Western Geriatric
Research Institute, Los Angeles, CA.
[8] Venkataraman, B.V., Suresh, S., and Kurpad, A.V., Acute Oral Toxicity of Caralluma fimbriata in
Rats, Department of Pharmacology, St. John’s Medical College, Bangalore, India, 2004.
[9] Jagtap, A. et al., Subchronic Oral Toxicity Study of Caralluma fimbriata Extract, Bombay College of
Pharmacy, Mumbai, India, 2005.
[10] Deshmukh, N.S. and Naik, P.Y., Mutagenicity Study of Caralluma fimbriata Extract by Salmonella
typhimurium Reverse Mutation Test, Intox Pvt., Ltd., Maharashtra, India, 2004.
[11] Durnin, J. and Womersley, J., Body fat assessment from total body density and its estimation from
skinfold thickness: measurements on 481 men and women aged from 16 to 72 years, Br. J. Nutr., 32,
77–97, 1974.
35 Role of Medium-Chain
Triglycerides in
Weight Management
Mary G. Enig
CONTENTS
Introduction ....................................................................................................................................451
History of Food Fats and Oils in the U.S. Diet ............................................................................452
Changes in the Food Fats Used in the United States During the Past Century...........................453
Fat Functions and Structure...........................................................................................................453
Major Classes of Lipids.................................................................................................................453
Definition of the Term “Omega” ...................................................................................................454
Essential and Non-Essential Fatty Acids.......................................................................................454
Fatty Acid Categories Found in Food ...........................................................................................455
Medium-Chain Fatty Acids: Lauric Acid ......................................................................................455
Importance of Lauric Oil Composition (Coconut Oil, Palm Kernel Oil).....................................455
Coconut as a Commercial Source of Lauric Acid ........................................................................456
Medium-Chain Fats as Functional Foods......................................................................................457
Medium-Chain Fatty Acids and Thermogenesis ...........................................................................458
Biochemical Functions and Weight Loss from Medium-Chain Fats............................................459
Immune-Enhancing Properties of Medium-Chain Fatty Acids.....................................................459
Beneficial Effects of Coconut Oil on Atherosclerosis Risk Factors.............................................460
Conclusion......................................................................................................................................460
References ......................................................................................................................................460
INTRODUCTION
Low-fat diets, which have been promoted by U.S. government agencies and various health orga-
nizations, have not prevented obesity and other health problems [1–3]. In the United States, the
food fats that are abundant are high in trans-fatty acids or omega-6 fats and relatively low in
omega-3 fatty acids as well as missing medium-chain saturated fatty acids such as lauric acid [1,2].
Anti-saturated fat rhetoric has been instrumental in most of the above changes, and protective fats
have been lost [1,2]. Lipids make up a diverse group of biological moieties known for their solubility
primarily in nonpolar solvents such as chloroform, benzene, and hexane. This solubility mimics
the behavior of lipids in mammalian tissues [1].
451
TABLE 35.1
Recommended List of Fats and Oils Most Appropriate for Domestic
or Commercial Use
Domestic/Household Use
For frying: animal tallows, coconut oil, or stable mixtures (blends) of oils such as coconut
oil, sesame oil, and olive oil (1/3 each) (can substitute sunflower seed oil or peanut oil
for the olive oil; coconut oil is necessary in the mix for lauric acid; sesame oil is necessary
in the mix for sesamin)
For baking: any natural fat or oil that the recipe calls for with the caveat that the recipe
should be from a good natural foods cookbook
For salad dressings: any natural, non-genetically modified organism (GMO), cold-pressed,
unrefined liquid oil (e.g., olive oil, mixtures of flaxseed and olive oils, canola oil, or
soybean oil)
For spreads: butter and coconut butter
Commercial Use
For frying: coconut oil (if the food is low moisture), palm oil, sunflower oil with added
sesame oil, tallow
For bakery goods: butter, coconut oil, lard, palm oil, tallow
For salad dressings: any natural, non-GMO, cold-pressed, unrefined liquid oil
For spreads: butter and coconut butter
HISTORY OF FOOD FATS AND OILS IN THE U.S. DIET

There was a time when a cookbook or a treatise on cookery discussed the use of different fats
based on the qualities those fats bestowed to the foods they were part of. The special flavor
imparted to a sauce by olive oil, the superior flavor and texture imparted to a crust or pudding
by beef tallow (suet) or lard, the subtle flavor of Chinese foods fried in peanut oil, and the
distinctive flavoring of coconut oil in Polynesian cooking were all important to the cook. That
emphasis is almost completely gone today. No longer is the cook encouraged to salvage the fat
that cooks out of the meat by turning it into gravy to top the potatoes or the rice or the homemade
biscuit (and chances are the biscuit is no longer homemade) [1]. Table 35.1 provides a list of
recommended fats and oils that are most appropriate for domestic and commercial use. Any
discussion about fats today, in cookbooks or in magazines devoted to food and cookery, is likely
to be negative and reflect the anti-saturated-fat propaganda that started about 40 years ago in the
United States and spread to most of the world where the United States has influenced the food,
nutrition, and biomedical communities. As a result, nearly every article about fats and oils in the
diet begins with a faulty premise. That faulty premise is that cholesterol and the saturated fats
are the culprits for the myriad of chronic ailments that afflict modern populations. This premise
was basically invented in the late 1950s for the purpose of protecting the margarine and shortening
industry from the challenges that were newly emerging from some of the scientific critics of
hydrogenation who saw this as the cause of the epidemic of heart attacks. This chain of events
has been reviewed by Hastert [4] in a 1983 article on hydrogenation. The resulting misinformation
that was generated has virtually removed the safe and important natural fats from the diets of
many people and has replaced these desirable fats with various partially hydrogenated fats and
oils, or with a myriad of nonfood stabilizers, extenders, and emulsifiers in the low-fat and no-
fat versions of traditional foods.
Role of Medium-Chain Triglycerides in Weight Management 453
TABLE 35.2
Fats and Oils in the U.S. Food Supply: 1890 vs. 2000a
1890 2000
Lard tallow (suet)
Soybean oil (usually partially hydrogenated)
Chicken fat
Rapeseed oil (e.g., canola oil; usually partially hydrogenated)
Butter fat
Cottonseed oil
Olive oil
Peanut oil
Palm oil
Corn oil
Coconut oil
Palm oil
Peanut oil
Coconut oil
Cottonseed oil
a Listed in descending order of market share.
CHANGES IN THE FOOD FATS USED IN THE UNITED STATES

DURING THE PAST CENTURY
Fats and oils in the U.S. food supply come from several sources. Either they are added fats, such
as table spreads, shortenings, and salad and cooking oils, or they come from the fat component of
meat and dairy products, from nuts and seeds, or from vegetable and fruit tissues. Added fats in
the form of oils, shortenings, spreads (butter and margarine), salad dressing, etc. are listed in
government documents such as those published by U.S. Department of Agriculture (USDA) and
the Commerce Department as “table and cooking fats” [1]. In the late 1800s, commercial shortenings
advertised to the housewife were fats such as cotolene (a blend of cottonseed oil and beef tallow),
refined leaf lard, or coconut butter (oil). These commercially available fats, as well as fat rendered
from beef, poultry, chicken, and pork in the home, were used for frying and as shortening in baking.
Butter and cream were valued for table use as well as for cooking and baking. In addition to
cottonseed oil and coconut oil, olive oil and poppy seed oil were listed as principal vegetable oils.
Table 35.2 shows the major changes in the use of fats and oils in the U.S. food-supply chain during
the last 100-plus years [1,2].
FAT FUNCTIONS AND STRUCTURE

Fat provides energy for immediate use by cells and is stored as fat for later use. Saturated fat is a
major fuel for heart, kidney, and skeletal muscle; it has a protein-sparing action during growth; it
cushions vital organs; it maintains body temperature through thermal regulation (insulation, brown
fat); it promotes healthy skin; it has protective barrier function; and it carries fat-soluble vitamins
and aids in their absorption [1,2,12]. Fat is a major part of brain (white matter), where it forms the
covering for nerve tissue. Fat forms special structures (cellular and subcellular lipid membranes),
and it performs special functions (such as the regulation of enzyme activity) [1,2,12].
MAJOR CLASSES OF LIPIDS

The three major classes of lipids are neutral lipids, phospholipids, and steroids. The lipids soluble
in nonpolar medium are typically the triglycerides, which are neutral lipids. Triglycerides are formed
from three molecules of fatty acids and one molecule of glycerol. The human body uses fatty acids
from food to build tissue and to make phospholipids and steroids for lipid function [1–4]. A major
group of fatty acids is the essential fatty acids, and these fatty acids are represented by omega-6
and omega-3 fatty acids. The term “essential” refers to the fact that these groups of fatty acids are
essential to the function and structure of the human body and must be obtained in the diet [1–4].
DEFINITION OF THE TERM “OMEGA”

Fatty acids are identified by the families to which they belong. Families differ from classes, and
the word “omega” is used to describe a particular family of fatty acids. Omega-6 fatty acids are a
family of polyunsaturated fatty acids where the first fatty acid in the metabolic lineup is linoleic
acid, an 18-carbon fatty acid with two double bonds where the first double bond occurs at the sixth
carbon–carbon bond. One omega-6 fatty acid is an essential fatty acid (linoleic acid), but the other
omega-6 fatty acids are not necessarily essential, although they are conditionally essential. Examples
of omega-6 fatty acids include γ-linolenic acid, dihomo-γ-linolenic acid, and arachidonic acid [1–3].
Omega-3 fatty acids belong to the family of polyunsaturated fatty acids, where the first fatty
acid in the metabolic lineup is α-linolenic acid. This fatty acid is an 18-carbon fatty acid found in
a number of foods such as leafy greens and many seeds. Other omega-3 fatty acids are more
essential because the body needs them in amounts that are not always readily made from the
18-carbon α-linolenic acid. These are the 20- and 22-carbon fatty acids called eicosapentaenoic
acid and docosahexaenoic acid, respectively [1,2].
Monounsaturated fatty acids are referred to as omega-9, the most common of which is oleic
acid. Monounsaturated fatty acids are not essential in the same way that polyunsaturated fatty acids
are essential because they are readily made by the tissues when they are needed. They are, however,
necessary fatty acids, and, under conditions of severe essential fatty acid deprivation, oleic acid is
elongated and desaturated to make mead acid [1,2].
Saturated fatty acids are not given a designation of “omega” because they are not unsaturated.
Saturated fatty acids come in basic lengths referred to as long, medium, and short. The most
common of the saturated fatty acids found in foods and made in tissues is palmitic acid. Palmitic
acid is a long-chain saturate that is 16 carbons long and it is the de novo fatty acid. Stearic acid is
a long-chain saturate that is common but is not found in large amounts in food [1,2]. The most
important medium-chain fatty acid is the 12-carbon saturate lauric acid. Lauric acid is found in
very small amounts in foods except as a major fatty acid in certain fats and oils called lauric oils,
which include coconut oil and palm kernel oil, as well as human and animal milks [1,2].
ESSENTIAL AND NON-ESSENTIAL FATTY ACIDS

Linoleic acid is an omega-6 essential fatty acid; it is essential because the body cannot build or
function without it or its metabolites and cannot always manufacture the various other fatty acids.
Omega-3 fatty acids are essential for building other structures and for other functions [1,2]. In the
metabolic lineup, linoleic acid becomes arachidonic acid, which is important for many functions
including certain proinflammatory and antiinflammatory ones. Sometimes linoleic acid is needed
by the body to manufacture special prostaglandins to fight certain inflammatory processes. When
the metabolic lineup fails to form γ-linolenic acid or dihomo-γ-linolenic acid, the body needs to
obtain the fatty acid as a conditionally essential fatty acid [1,2]. Another essential omega-3 fatty
acid is α-linolenic acid. These neutral lipids are the usual storage fats, but they also are part of the
body’s normal metabolism [1,2].
Some fatty acids that belong in the neutral lipid category are not natural or useful except to
the food industry. These are the trans-fatty acids (TFAs), formed by the partial hydrogenation
process. They are formed from polyunsaturated fatty acids such as omega-6 oils and from any
omega-3 fatty acids present in the original oils. In the United States, most of the trans-fatty acids
are formed from omega-6 oils, because the most common oils in the United States are omega-6
oils such as soybean oil [1,2,10,11].
Fatty acids range from 3 carbons to nearly 30 carbons in length. Generally, the fatty acids are
even numbered, except for small numbers of fatty acids of bacterial origin found in ruminant fats.
Three-carbon fatty acids are found in dairy foods, and four-carbon fatty acids are also primarily
found in animal milk [1,2]. The saturated fatty acids are almost all even numbers of carbons in
length, but the saturated fatty acids in dairy foods are commonly seen as small amounts of odd-
number-chain saturated fatty acids [1,2]. The major saturated fatty acids found in many foods vary
and include palmitic acid.
FATTY ACID CATEGORIES FOUND IN FOOD

For labeling purposes, food fats are classified as saturated, monounsaturated, trans, or polyunsat-
urated [1,2]. Fatty acid categories are widely distributed in natural foods and in animal and human
tissues. Table 35.3 provides a list of saturated fatty acids ranging in length from 3 carbons to 30
carbons, monounsaturated fatty acids, and polyunsaturated fatty acids.
MEDIUM-CHAIN FATTY ACIDS: LAURIC ACID

The unfortunate attitude toward the consumption of fats has had a particularly devastating effect
on the coconut oil industry, as coconut oil is the major source of medium-chain fatty acids in the
diet. Coconut oil is one of the most saturated of the natural fats, one of the oldest in use, and one
of the most desirable of the natural fats to include at least small amounts of in a person’s diet. It
is considered a lauric fat [5]. Today, we have ended up with a situation where the fats that have
been used for centuries are out, and the fabricated fats that should be out are in. The emphasis is
on low fat, but most of the foods that are being marketed today are filled with fat. Usually, this fat
is a partially hydrogenated fat that has such a high melting point that it is not always noticed by
the consumer when the food containing it is eaten.
IMPORTANCE OF LAURIC OIL COMPOSITION

(COCONUT OIL, PALM KERNEL OIL)
Most of the people in the United States have been given some unfortunate propaganda regarding
the properties of lauric oils and their health effects [11]. Coconut oil contains 27.5% long-chain
saturated fatty acids, 65% medium-chain saturated fatty acids, and the balance unsaturated fatty
acids. Of the medium-chain saturated fatty acids, approximately 55% are lauric acid and capric
acid, which are antimicrobial fatty acids. Lauric acid, the major medium-chain saturated fatty acid
in coconut oil, is found in mother’s milk, and it protects babies from viral and bacterial infections.
(Cottonseed oil contains approximately 28.5% long-chain saturated fatty acids but no lauric acid.)
Heart disease is currently recognized to be multifactorial and to be caused by, among other
things, such substances as oxidized fats, cytomegalovirus, Helicobacter pylori, homocysteine, and
various toxic chemicals, as well as other inflammatory components. The increased cholesterol levels
are related to the body’s attempt to heal the lesions. As a pathologist who is an expert on athero-
sclerosis has pointed out, the cholesterol does not cause an atheroma any more than the white blood
cells cause an abscess; they are both trying to heal. Cholesterol is one of the body’s major repair
substances [1,2,11].
Lauric oils (of which coconut is the most widely grown) do not become oxidized (only
polyunsaturated fatty acids can become oxidized) [1–3,11]. The monoglyceride of lauric acid (which
the body makes when lauric oils are eaten) kills cytomegalovirus and Helicobacter pylori and thus
would be an appropriate treatment or preventative substance in heart disease. Also, a number of
studies showed that heart disease patients who were fed coconut oil got better, so it is clear that
there is no reason to repeat misinformation. Even Harvard medical school researchers have taken
out a patent to use lauric oils to treat disease [1,2,11].
TABLE 35.3
Fatty Acid Categories Found in Food
and as Part of Animal/Human Tissues
Fatty Acids Length of Carbon Chain
Saturated Fatty Acids

Short-chain saturated fatty acids
Propionic acid 3C
Butyric acid 4C
Caproic acid 6C
Medium-chain saturated fatty acids
Caprylic acid 8C
Capric acid 10 C
Lauric acid 12 C
Long-chain saturated fatty acids
Myristic acid 14 C
Palmitic acid 16 C
Stearic acid 18 C
Very-long-chain saturated fatty acids
Arachidic acid 20 C
Behenic acid 22 C
Lignoceric acid 24 C
Cerotic acid 26 C
Montanic acid 28 C
Melissic acid 30 C
Unsaturated Fatty Acids

Short-chain unsaturated fatty acid
Crotonic acid 4 C=C
Long-chain monounsaturated fatty acids
Palmitoleic acid 16 C=C omega-9; omega-7
Oleic acid 18 C=C omega-9
Long-chain polyunsaturated fatty acids
Linoleic acid 18 C=C omega-6
α-Linolenic 18 C=C=C omega-3
γ-Linolenic 18 C=C=C omega-6
Stearidonic 18 C=C=C=C omega-6
Very-long-chain unsaturated fatty acids
Arachidonic acid 20 C=C=C=C omega-6
Adrenic acid 22 C=C=C=C omega-6
Eicosapentaenoic acid (EPA) 20 C=C=C=C=C omega-3
Docosapentanoic acid 22 C=C=C=C=C omega-3
Docosahexanoic acid (DHA) 22 C=C=C=C=C=C omega-3
Nisinic acid 24 C=C=C=C=C=C=C omega-3
COCONUT AS A COMMERCIAL SOURCE OF LAURIC ACID

Coconut (Cocos nucifera L.) is one of the most important palms providing food. It differs
from palms such as oil palms (with which it should not be confused) and date palms. Coconut
products are shipped to parts of the world where the coconut does not grow and are considered
TABLE 35.4
Largest Producers of Coconut
Asia Africa
Philippines Benin
Indonesia Cape Verde
India Comoros Islands
Sri Lanka Cote d’Ivoire
Malaysia Ghana
Thailand Mozambique
Vietnam Tanzania
Kenya
The Americas
Somalia
Mexico
Oman
Brazil
Jamaica The Pacific Islands
Caribbean Islands Papua New Guinea
Dominican Republic Solomon Islands
El Salvador Vanuatu
Federated States of Micronesia
an important food import [6–9]. Coconut palms grow throughout the world in the wet or humid
tropics and have been given the name the “tree of life” [6,7]. They spread on the waters from
island to island and from coast to coast in the tropical areas of the continents. The trees are
grown individually along the coast and in groves, where they are tended by the owners of the
land. Coconut is grown on approximately 12 million hectares spread over at least 86 countries
around the world [10]; Table 35.4 provides a list of the largest producers of coconut. Most of
the larger countries produce a commercial grade of coconut oil and other coconut products
from copra; however, many of the coconut growers are actually raising organic coconut. These
growers are small holders, and with some encouragement they have converted their production
to organic oils. This is especially true for the small island countries. The coconut oil, coconut
milk and cream, and dried coconut products from many of the small countries continue to be
available in American and Canadian markets and are of good quality [6–9]. Oil palms (Elaeis
guineensis) originated in the rain forests of Africa and now grow largely in plantations around
the world. The fruits of the oil palm provide a stable oil that differs from the lauric oil of the
coconut. The seed in the oil palm is a kernel, which provides an oil called palm kernel oil,
which is a lauric oil similar to coconut oil [8–10]. Other palms include babassu, which grows
in the wild in Brazil and has a fruit that provides an oil that has a composition similar to
coconut. While we are not likely to find babassu oil on the market in North America, it is
traded with Brazil and it is always possible that bakery goods such as crackers could enter the
market. It is useful to know that products made with babassu oil would be a source of medium-
chain saturates [6–8].
Date palms should not be mixed up with the oil palms or coconut; they grow in dry areas and
are a useful carbohydrate food but they do not provide any fat or oil in their fruit and thus are not
a source of medium-chain fats [7,8].
MEDIUM-CHAIN FATS AS FUNCTIONAL FOODS

Functional foods provide a health benefit over and beyond the basic nutrients [12]. This is exactly
what desiccated coconut and coconut oil do. As a functional food, coconut has fatty acids that
provide both energy (nutrients) and raw material for antimicrobial monoglycerides (functional
component) when it is eaten. Desiccated coconut is about 69% coconut fat. Palm kernels are not
large enough to provide a desiccated component [4–9,12]. Approximately 50% of the fatty acids
in coconut fat are lauric acid. Lauric acid is a medium-chain fatty acid that provides additional
benefits when it is converted to monolaurin in the human or animal body [11–15]. Monolaurin is
the antiviral, antibacterial, and antiprotozoal monoglyceride used by the human or animal to destroy
lipid-coated viruses such as human immunodeficiency virus (HIV), herpes, cytomegalovirus, influ-
enza, various pathogenic bacteria (e.g., Listeria monocytogenes and Helicobacter pylori), and
protozoa such as Giardia lamblia [16]. Some studies have also shown some antimicrobial effects
of the free lauric acid [16].
Approximately 6 to 7% of the fatty acids in coconut fat are capric acid. Capric acid is another
medium-chain fatty that has a similar beneficial function when it is converted to monocaprin in
the human or animal body [1,2,11]. Monocaprin from the fat in coconut has been shown to have
an antiviral effect against HIV and is being tested for antiviral effects against herpes simplex
and antibacterial effects against Chlamydia. Dr. Halldor Thormar is an Icelandic scientist who
showed that monolaurin, which comes from the fat in coconut, kills lipid-coated DNA and RNA
viruses, including HIV and herpes viruses, as well as other microorganisms such as Gram-positive
bacteria. He has just announced the potential effectiveness of monocaprin dissolved in a gel in
killing HIV and plans to continue testing monocaprin against Chlamydia and herpes simplex
virus [12,16].
A variety of research published from 2003 to today supports the importance of coconut oil
[8–10]. A few researchers have known for some time that derivatives of coconut oil (lauric acid
and monolaurin) are safe antimicrobial agents that can either kill completely or stop the growth of
some of the most dangerous viruses and bacteria [11,16]. Many bacteria have become resistant to
antibiotics but not to herbal oils, such as oregano oil and lauric acid, the major fatty acid from
coconut oil which the body turns into the monoglyceride monolaurin. Monolaurin has been shown
to be useful in the prevention and treatment of severe bacterial infections, especially those that are
difficult to treat or are antibiotic resistant. Herbal treatment of difficult bacteria such as Staphylo-
coccus aureus has been studied in the United States by such research groups as Preuss’ group at
Georgetown University Medical Center [16].
It has been asked whether the consumption of trans-fat alters the coating of lipid viruses in an
adverse manner, leading to mutation. No research has been conducted on this topic, but the
consumption of trans-fat has been shown to alter other lipid bilayer membranes to the disadvantage
of the organ system [11].
MEDIUM-CHAIN FATTY ACIDS AND THERMOGENESIS

Animal studies have shown that a diet containing medium-chain triacylglycerols (MCTs) results
in diet-induced thermogenesis, which leads to less body fat accumulation compared to diets
containing long-chain triacylglycerols (LCTs) [15]. A study in humans used a comparative protocol
to measure diet-induced thermogenesis by feeding 5 to 10 g of MCTs to healthy humans. The
results suggested that the intake of MCTs caused greater diet-induced thermogenesis than the intake
of LCTs, regardless of the meal containing the MCTs [14]. In a double-blind, crossover protocol
designed to test the different effects of MCT vs. LCT in overfed males ages 22 to 44, the MCTs
stimulated thermogenesis to a greater extent than LCT and resulted in excess dietary energy. This
increased energy expenditure was considered most likely due to lipogenesis in the liver and provided
evidence that excess energy derived from MCTs is stored with lesser efficiency than equivalent
excess energy derived from dietary LCTs [13]. When the thermic effects of MCTs were studied in
both lean and obese subjects to evaluate postprandial thermogenesis after the ingestion of mixed
meals, the results showed that postprandial thermogenesis was enhanced in both lean and obese
subjects when LCTs in a mixed meal were replaced by MCTs [17].
BIOCHEMICAL FUNCTIONS AND WEIGHT LOSS

FROM MEDIUM-CHAIN FATS
Because medium-chain fatty acids (MCFAs) are oxidized to produce energy and are not stored in
adipose tissue as are long-chain fatty acids (LCFAs), MCFAs raise the body temperature and
effectively use more energy. Researchers have shown that fatty acids that are more likely to be
oxidized are less likely to be stored in adipose tissue. Research by Bray et al. [3] indicates that the
most highly oxidized fatty acid is the MCFA lauric acid (as noted previously, coconut oil is almost
50% lauric acid). This research was conducted in male humans using labeled fatty acids. The
cumulative oxidation of lauric acid was 41% over the 9-hour test period, whereas oxidation of the
LCFA stearic acid was 13%. In critical reviews of research on MCFA metabolism [18–23], it was
found that the intermediary metabolism (i.e., oxidation) of fatty acids differs depending on the
chain length and degree of unsaturation. MCFAs differ in metabolism from LCFAs, as indicated
by data for both animals and humans that demonstrate increases in postprandial energy expenditure
even after short-term feeding of MCFAs. It was concluded that MCFAs hold potential as weight-
loss agents. Studies in both lean and obese humans have reported a postprandial thermic effect
from a mixed meal with 30 g of MCTs plus 8 g of LCTs that was significantly greater than the
thermic effect of 38 g of LCTs alone [17]. In a review from France [5], researchers demonstrated
that, when comparing LCT-fed animals with MCT-fed animals, the final body weight was signifi-
cantly reduced by all the regimens that provided at least 50% of the fat energy as MCTs. According
to this research group, the threshold of 50% energy had to be reached to obtain a reproducible
body-weight-reducing effect, a threshold that they do not feel is practical in human feeding.
IMMUNE-ENHANCING PROPERTIES OF
MEDIUM-CHAIN FATTY ACIDS
Fats in our diet affect our immune systems in several ways. A major factor is the presence in our
food supply of trans-fatty acids [24]. Another is the extent of processed and incomplete foods in
our diets. A third is the amount of virus load in our environment and systems. Different aspects of
a diet affect different parts of the immune system (e.g., helper T cells, proinflammatory cytokines,
immunoglobulins) [24]. Many of the good effects from coconut oil and its derivatives, such as
monoglycerides of medium-chain saturated fatty acids, are indirect and some of the scientific
pathways can only be postulated; also, their actions are different in different people [11,24].
Coconut, in the form of desiccated coconut in foods such as macaroons and coconut oil as it
is added to baked goods or snack foods such as popcorn or used in the home for cooking, is a
major source of the lauric acid used by the body to make the antimicrobial monoglyceride mono-
laurin. Lauric acid has its own antimicrobial properties. Humans need an antiviral, antibacterial,
and antiprotozoal component such as monolaurin, which the human body can make if it receives
adequate amounts of lauric acid [11,24].
Viruses that are pathogenic to humans and are known to be inactivated or destroyed in the body
by monolaurin include the HIV virus, measles virus, herpes viruses (including cytomegalovirus),
vesicular stomatitis virus, visna virus, influenza virus, pneumonovirus, synsitial virus, and rubeola
virus. Bacteria that are pathogenic to humans and are known to be inactivated or destroyed in the
body by monolaurin include Listeria monocytogenes, Helicobacter pylori, Staphylococcus aureus,
numerous streptococci (including groups A, B, F, and G), Gram-positive organisms, and some
Gram-negative organisms if pretreated with chelator. Protozoa that are pathogenic to humans and
are known to be inactivated or destroyed in the body by monolaurin include Giardia lamblia [11,16].
Verification of these immune-enhancing properties is somewhat complex, as it has not been
examined or measured in homogeneous groups. As an example, consider a person who has a low-
grade infection from a virus that is not active. That person should be evaluated individually for the
immune response, but in a study that person will most likely be included in a group of other
individuals who are harboring different viruses, and the effect of monolaurin on the interleukins
(the immune factors) might be the same or different among them. Most of the research conducted
thus far has not been designed to answer specific questions regarding immunity.
One important paper discusses the potential effect of monolaurin and consequently coconut oil
in a rather general manner (i.e., monolaurin modulates immune cell proliferation) and describes
the mechanism that monolaurin is thought to exert on the cell membrane that leads to the inhibition
of a variety of toxins being produced by various group A streptococci and staphylococci [11,24].
Monolaurin has been shown to block toxic shock syndrome; thus, it is especially important for
women to have an adequate intake of coconut oil in their diets, even if they do not need to lose
weight [11,24].
BENEFICIAL EFFECTS OF COCONUT OIL

ON ATHEROSCLEROSIS RISK FACTORS
Published studies in laboratory animals (Sprague–Dawley rats) have demonstrated the beneficial
effects of consuming virgin coconut oil [6–9]. In one study [9], virgin coconut oil obtained by the
wet process lowered total cholesterol, triglycerides, phospholipids, and low-density lipoproteins
(LDLs). In serum and tissues, very-low-density lipoprotein (VLDL) cholesterol levels were lowered
and high-density lipoprotein (HDL) cholesterol was increased. The polyphenol fraction of virgin
coconut oil was also found to prevent in vitro LDL oxidation. The results in this study were interpreted
as being due to the biologically active polyphenol components present in the oil. Another study done
in women showed that coconut-oil-based diets lowered levels of postprandial tissue plasminogen
activator and lipoprotein(a) [8]. The researchers found that levels of serum lipoprotein(a), an impor-
tant heart disease marker previously thought to be unaffected by various forms of dietary fat intake,
were lowered when the subjects consumed a high-saturated-fat diet based on coconut oil and
somewhat lowered when they consumed a diet slightly lower in saturated fat based on monounsat-
urated oil.
CONCLUSION
Overall, these studies suggest that medium-chain triglycerides offer a significant number of health
benefits and may serve as novel, natural therapeutics in weight management.
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[17] Scalfi, L., Coltorti, A., and Contaldo, F., Postprandial thermogenesis in lean and obese subjects after
meals supplemented with medium-chain and long-chain triglycerides, Am. J. Clin. Nutr., 53, 1130,
1991.
[18] Bourque, C., St.-Onge, M.P., Papamandjaris, A.A., Cohn, J.S., and Jones, P.J., Consumption of an oil
composed of medium-chain triacylglycerols, phytosterols, and N-3 fatty acids improved cardiovascular
risk profile in overweight women, Metabolism, 52, 771, 2003.
[19] Papamandjaris, A.A., White, M.D., Raeini-Sarjaz, M., and Jones, P.J., Endogenous fat oxidation during
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Disord., 24, 1158, 2000.
[20] Papamandjaris, A.A., MacDougall, D.F., and Jones, P.J., Medium-chain fatty acid metabolism and
energy expenditure: obesity treatment implications, Life Sci., 62, 1203, 1998.
[21] St.-Onge, M.P. and Jones, P.J., Greater rise in fat oxidation with medium-chain triglyceride consump-
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36 Anti-Obesity
Marine Lipids
by
Kazuo Miyashita
CONTENTS
Introduction ....................................................................................................................................463
Anti-Obesity Lipids and Lipid-Related Compounds ....................................................................464
Anti-Obesity Effect of Marine Lipids ...........................................................................................464
Anti-Obesity Through UCP Expression ........................................................................................465
Anti-Obesity Activity of the Edible Seaweed Carotenoid Fucoxanthin.......................................467
Reducing Effect of Fucoxanthin and Fucoxanthinol on Adipocyte Differentiation.....................470
Conclusion......................................................................................................................................472
References ......................................................................................................................................472
INTRODUCTION
The rise in the prevalence of obesity is now recognized as a worldwide problem, with ominous
implications for public health and health-related costs. It may be the second-most important
preventable cause of death, exceeded only by cigarette smoking. Obesity is a potent risk factor for
type 2 diabetes, hypertension, and dyslipidemia, comorbidities that markedly increase the risk of
cardiovascular disease. The parameters generally considered to explain the rise in obesity include
the increase in food availability, greater dietary fat content, increased energy density of foods, and
decreased physical activity. The simplicity of the energy balance equation has led to an inappropriate
focus on obesity as being either a problem of food intake control or energy expenditure; however,
in practice, a rather more holistic and integrative approach is required.
Epidemiologic evidence strongly supports the role of exercise. The impact of vigorous physical
activity in preventing excess fat accumulation is readily recognized; however, the influence of
modest levels of physical activity is less obvious. Less attention has focused on sedentary behaviors.
Both physical activity levels and sedentary lifestyle contribute to the development of obesity. The
body has only a limited capacity to adjust metabolic energy expenditure to offset changes in energy
intake to maintain body energy stores. Changes in energy expenditure are generally seen as a
secondary consequence of alterations in body weight and lean mass. Thus, regulation of total energy
intake in the short term has relatively minor effects on energy expenditure. On the other hand,
long-term regulation of food intake (more than 1 year) leads to a remarkably good adjustment of
energy intake to energy expenditure, as energy imbalances are generally less than 1 to 2% of energy
turnover. Changes in dietary composition in the long term can also have a pronounced effect on
the fuel mixture burned by the body. This can have important effects on body composition and the
regulation of appetite, the interaction of which determines the steady-state body weight maintained
by an individual in the long term.
463
Ingestion of either protein or carbohydrate is accompanied by a rapid increase in the oxidation

of each. By contrast, consumption of dietary fat does not promote its own oxidation. The fat stored
in adipose tissue provides an energy reserve. In evolution, the human body has been compelled to
develop regulatory mechanisms that give higher priority to the control of its carbohydrate economy
than to the control of fat metabolism. Intake levels and the ratio of these macronutrients are very
important to control body weight and to prevent obesity. Although lipids can be stored far more
efficiently than other nutrients, data accumulated from experimental animal and human studies
clearly support a beneficial role for dietary lipids and lipid-related compounds in weight manage-
ment. This chapter is mainly concerned with the anti-obesity effects of marine lipids and seaweed
carotenoids. An effort is also made to outline the mechanism responsible for these effects.
ANTI-OBESITY LIPIDS AND LIPID-RELATED COMPOUNDS

Based on the nature of fat digestion and absorption, diacylglycerol (DG) with a 1,3-configuration
[1,2] and medium-chain triacylglycerol (MCT) [3] have been used for the prevention of obesity.
Several studies have demonstrated that conjugated linoleic acid (CLA) reduces body fat accumu-
lation in growing animals but not all CLA isomers contributed to this effect equally [4–6]. Among
CLA isomers studied, trans-10,cis-12-18:2 induced body fat loss. The reported mechanism of this
CLA action includes stimulation of lipolysis, reduction of lipid synthesis, and direct action on
adipocytes [7,8]. Because CLA isomers, as well as other polyunsaturated fatty acids (PUFAs), are
recognized as natural peroxisome proliferator-activated receptor (PPAR) ligands, investigating how
these isomers modulate transcription factors and their target genes could lead to elucidation of the
anti-obesity effect of CLA [9–12].
Caffeine is a naturally consumed substance that is widely contained in beverages. It has
thermogenic properties and increases the metabolic rate in humans [13–17]. This effect can be
explained by stimulation of the secretion of catecholamines, such as noradrenaline, from the nerve
endings. Noradrenaline stimulates β3-adrenergic receptor (β3-AR) and then induces promotion of energy
expenditure through uncoupling protein 1 (UCP1) expression in brown adipose tissue (BAT) (Figure
36.1) [18–21]. Capsaicin, the major pungent principle of red pepper, also upregulates UCP1 in BAT
by the release of catecholamines such as noradrenaline [22–25]. Green tea extract is reported to increase
energy expenditure and fat oxidation in humans [26]. The tea extract contains caffeine and catechin.
Epigallocatechin gallate, a main tea catechin, promotes fat oxidation and decreases fat synthesis but
does not activate β3-AR [27]. The anti-obesity activity of green tea extract can be attributed to the
effects of UCP1 upregulation by caffeine and to the lipid metabolism control by catechin.
ANTI-OBESITY EFFECT OF MARINE LIPIDS

Eicosapentaenoic acid (EPA; 20:5n-3) and docosahexaenoic acid (DHA; 22:6n-3) are the two typical
fatty acids of marine lipids. These two long-chain PUFAs have been shown to cause significant
biochemical and physiological changes in the body. Most of these changes exert a positive influence
on human nutrition and health [28]. DHA is an important constituent of the membrane phospholipids
of the brain and retina that usually occupies the sn-2 position of these phospholipid moieties. The
health benefits of EPA and DHA include protection from hypertension, cancer, diabetes, neuro-
psychiatric disorders, and autoimmune diseases. The role of EPA and DHA in alleviating cardio-
vascular diseases has been demonstrated in hundreds of in vivo and in vitro experiments, in addition
to several clinical trials [29]. The cardioprotective effects of EPA and DHA include modifying
serum triacylglycerol levels by increasing lipoprotein lipase [30] and alteration of the catabolism
of apo B-containing lipoprotein or chylomicron remnants [31].
The effect of EPA and DHA on lipid metabolism is strongly correlated to the anti-obesity effect
of marine lipids. Some papers have described the reducing effect of fish oil on the abdominal fat
pad [32,33]. Parrish et al. [32] reported that lard-fed rats had 77% more fat in perirenal fat pads
Anti-Obesity by Marine Lipids 465
Sympathetic
nervous
Noradrenaline
PUFA ( EPA and DHA) Caffeine, Capsaicin
-AR Gs AC cAMP
R Retinoids
Lipolysis HSL PKA
CREB
? RXR
FFA
PGC-1
PPAR
mRNA PGC-1 PGC-1

R T3 R
Heat UCP1 PPAR RXR TR RXR
UCP1 gene
Mitochondria Nuclear
Brown adipose cell
FIGURE 36.1 Possible mechanism for upregulation of BAT UCP1 by food components.
and 51% more fat in epididymal fat pads compared with fish-oil-fed rats. The same result was
obtained by Kawada et al. [34], who also found that the expression of UCP1 in interscapular brown
adipose tissue (IBAT) was significantly higher in rats fed the fish-oil diet compared to the lard-fed
group (Figure 36.2). In IBAT mitochondria, substrate oxidation is poorly coupled to adenosine
triphosphate (ATP) synthesis because of the presence of UCP1, thereby leading to energy dissipation
(i.e., heat production). Kawada et al. [34] suggested that the intake of PUFAs found in fish oil,
such as EPA and DHA, causes UCP induction and enhancement of thermogenesis, resulting in
suppression of the excessive growth of abdominal fat pads. PUFAs from vegetable oils also
suppressed the excessive accumulation of adipose tissue as compared to animal fats [35,36];
however, the activity of PUFAs from vegetable oils was less than that of EPA and DHA from fish
oil [34]. Our study supports these results in terms of the higher anti-obesity effect of EPA and
DHA in fish oils (Figure 36.3) [37].
ANTI-OBESITY THROUGH UCP EXPRESSION

A great deal of interest has been focused on adaptive thermogenesis by UCP families (UCP1,
UCP2, and UCP3) as a physiological defense against obesity, hyperlipidemia, and diabetes [38,39].
UCPs are found in brown adipose tissue (UCP1, UCP2, and UCP3), white adipose tissue (UCP2),
skeletal muscle (UCP2 and UCP3), and brain (UCP4 and UCP5) [39,40]. UCP2 and UCP3 are
members of the mitochondrial anion carrier superfamily with high homology to UCP1, a well-
characterized uncoupling protein that plays a key role in facultative thermogenesis in rodents [41].
Interest in UCPs increased with the discovery of proteins similar to UCP1, including UCP2 and
UCP3. These proteins are expressed in tissues besides BAT and, thus, are candidates to influence
energy efficiency and expenditure [39,42]. Metabolic rate, metabolic efficiency, and obesity are
integrated properties of the whole animal. Researchers have produced mice lacking UCP2 [43] and
180
a
160
UCP protein (% of control diet)

140
120
100
80
60
40
20
0
Control Fish oil
FIGURE 36.2 UCP expression in BAT of control and sardine-oil-fed rats. aSignificantly different from control
(p < 0.05). The experimental diets contained 10% of either lard (control) or fish oil. Main fatty acids of the
fish oil were DHA (27.7%), 16:0 (18.1%), 18:1n-9 (12.0%), and EPA (7.2%). (Adapted from Kawada, T. et
al., J. Agric. Food Chem., 46, 1225–1227, 1998.)
80 120 15
(A) (B) (C)
100
60
b
(g/kg of body weight)
80
Abdominal fat pad
10 a
mg/dl
mg/dl
40 60
a
40 5
20
20
0 0
0
Control Sardine Control Sardine Control Sardine
FIGURE 36.3 Plasma lipids and abdominal fat weight of rats fed control (soybean oil) and sardine oil. (A)
Plasma total cholesterol; (B) plasma triacylglycerol; (C) abdominal fat weight. a,bSignificantly different from
control (a, p < 0.05; b, p < 0.01). (Adapted from Toyoshima, K. et al., J. Agric. Food Chem., 52, 2372–2375,
2004.)
UCP3 [44,45], but, surprisingly, despite a lack of UCP2 or UCP3, no consistent phenotypic
abnormality was observed in the knockout mice that were not obese and had normal thermogenesis.
These results suggest that UCP2 and UCP3 are not major determinants of metabolic rate under
normal conditions but instead have other functions [39,43,46–51]. Indeed, unexpected physiological
or pathological implications of UCP2 and UCP3 function (such as possible UCP2 involvement in
diabetes and in apoptosis) could also be implicated [39]. UCP3 has a diminished thermogenic
response to the drug 3,4-methylene dioxy methamphetamine (MDMA) [51]. Apart from UCP2 and
UCP3, it is certain that UCP1 can potentially reduce excess abdominal fat [52].
Involvement of BAT in cold-induced thermogenesis is well established, and data from rodents
have also demonstrated its role in diet-induced thermogenesis [53,54]. Thermogenesis in BAT is
due to UCP1. UCP1 is a dimeric protein present in the inner mitochondrial membrane of BAT that
dissipates the pH gradient generated by oxidative phosphorylation, releasing chemical energy as
heat. UCP1 is exclusively expressed in BAT, where the gene expression is increased by cold,
adrenergic stimulation, β3-agonists, retinoids, and thyroid hormone [55]. The thermogenic activity
of BAT is dependent on UCP1 expression levels controlled by the sympathetic nervous system via
noradrenaline (Figure 36.1) [52,56–58]. As a consequence of noradrenaline binding to the adipocyte
plasma membrane, protein kinase (PKA) is expressed, and then cAMP response element-binding
protein (CREB) and hormone-sensitive lipase (HSL) are expressed. HSL stimulates lipolysis, and
free fatty acids liberated serve as substrates in BAT thermogenesis [58]. They also act as cytosolic
second messengers that activate UCP1 as PPARγ ligand. The same activity is expected in dietary
polyunsaturated fatty acids [59]. The anti-obesity effect of dietary EPA and DHA may be partly
due to their control of PPARγ expression [34]. DHA and EPA inhibit cyclooxygenase, thereby
reducing the amount of prostaglandins and increasing the lipoxygenase activity. This in turn results
in higher production of hydroxyeicosatrienoic acid (HETE) and leukotriene B4. Eicosanoids can
act as transcriptional regulators of UCP. The anti-obesity effect of fish oil may, in part, be correlated
to the regulatory effect of both PUFA on eicosanoid formation. Although regulation of the sympa-
thetic nervous system via noradrenaline is the physiologically most significant effect, a series of
other factors may influence UCP1 gene expression [60]. Thyroid hormones are essential for
regulated UCP1 expression [55]. Also, activators of PPARγ such as pioglitazone [61] and probably
essential fatty acids [62] activate UCP1 gene expression, as do retinoids, probably through both
retinoid X receptors (RXRs) and retinoic acid receptors (RARs) [63,64].
ANTI-OBESITY ACTIVITY OF THE EDIBLE

SEAWEED CAROTENOID FUCOXANTHIN
Uncoupling protein 1 is a key molecule for anti-obesity. UCP1 expression is known to be a
significant component of whole body energy expenditure, and its dysfunction contributes to the
development of obesity. Adult humans, however, have very little BAT, and most of their fat is stored
in white adipose tissue (WAT). A potential breakthrough discovery for the development of an ideal
therapy for obesity would be the regulation of UCP expression in tissues other than BAT by food
constituents. UCP1, usually expressed only in BAT, has also been found in the WAT of mice
overexpressing Foxc2, a winged helix gene, with an accompanying change in steady-state levels
of several WAT- and BAT-derived mRNAs [65]. This result suggests the possibility of UCP1
expression in human WAT, which would be an increasingly attractive target for the development
of anti-obesity therapies. As the key molecular components become defined, screening for food
constituents that increase energy dissipation is becoming a more attainable goal. From this view-
point, the anti-obesity effect of an edible seaweed carotenoid (fucoxanthin) is very interesting, as
its activity depends on the protein and gene expressions of UCP1 in WAT [66].
In a study on the anti-obesity effect of fucoxanthin, lipids were separated from the edible
seaweed wakame (Undaria pinnatifida), one of the most popular edible seaweeds in Japan and
Korea. Undaria lipids, containing 10% fucoxanthin, significantly reduced the weight of WAT
(perirenal and epididymal abdominal adipose tissues) of both rats and mice (Figure 36.4). Further-
more, the body weights of mice fed 2% Undaria lipid were significantly (p < 0.05) lower than
those of the control group, although no significant differences were observed in the mean daily
intake of diet between the both groups. To confirm the active component of Undaria lipids,
fucoxanthin and Undaria glycolipids (the main fractions of the lipids) were administered to obese
KK-Ay mice. The dietary effects of both fractions on the WAT weight of obese mice is shown in
Figure 36.5. The WAT weight of fucoxanthin-fed mice was significantly lower than that of control
15
(A) (B)
WAT (g/100g body weight)

15
WAT (g/1kg body weight)

a
a 10
10
5
5
0 0
Control Undaria Undaria Control Undaria Undaria
(0.5%) (2%) (0.5%) (2%)
FIGURE 36.4 Weight of WAT of rats (A) and mice (B) fed Undaria lipids and control diet. aSignificantly
different from control (p < 0.01). A diet was prepared according to the recommendations of the American
Institute of Nutrition (AIN-93G). The dietary fats for rats were 7% soybean oil (control), 6.5% soybean oil
+ 0.5% Undaria lipids, and 5% soybean oil + 2% Undaria lipids. Those for mice were 13% soybean oil
(control), 12.5% soybean oil + 0.5% Undaria lipids, and 11% soybean oil + 2% Undaria lipids. (Adapted
from Maeda, H. et al., Biochim. Biophys. Res. Commun., 332, 392–397, 2005.)
20
WAT (g/100g body weight)
16
a
12
0
Control Fucoxanthin Glycolipid
FIGURE 36.5 Weight of WAT of mice fed fucoxanthin, Undaria glycolipids and control diet. aSignificantly
different from control (p < 0.01). The dietary fats were 13% soybean oil (control), 12.6% soybean oil + 0.4%
fucoxanthin, and 11.2% soybean oil + 1.8% Undaria glycolipid. (Adapted from Maeda, H. et al., Biochim.
Biophys. Res. Commun., 332, 392–397, 2005.)
mice; however, no difference was observed in the WAT weight of mice fed the Undaria glycolipids
and those fed the control diet. This result indicates that fucoxanthin is the active component in the
Undaria lipids resulting in the anti-obesity effect.
Because of its capacity for uncoupled mitochondrial respiration, BAT was implicated as an
important site of facultative energy expenditure in small rodents. This led to speculation that BAT
normally functions to prevent obesity. In mice fed 2.0% Undaria lipids, the BAT weight was
significantly greater than for the control mice; however, no significant difference was observed in
UCP1 expression among the three different dietary groups. Thus, the decrease in abdominal fat
pad weight found in mice fed Undaria lipids could not be explained only by energy expenditure
in BAT mitochondria by UCP1. As shown in Figure 36.6, UCP1 expression was found in the WAT
(A) a
UCP1 / GAPDH
a
UCP1 5
-Actin
0
Control Undaria Undaria
(0.5%) (2%) Control Undaria
(2%)
(B) a 2
UCP2 / GAPDH
15
UCP1 / -Actin
10
1
5
0 0
Control Undaria Undaria Control Undaria
(0.5%) (2%) (2%)
FIGURE 36.6 UCP1 and UCP2 expression in WAT of mice fed Undaria lipids and control diet. (A) Western
blot analysis of UCP1; (B) UCP1 protein expression; (C) UCP1 mRNA expression; (D) UCP2 mRNA
expression. aSignificantly different from control (p < 0.05). (Adapted from Maeda, H. et al., Biochim. Biophys.
Res. Commun., 332, 392–397, 2005.)
of mice fed Undaria lipids, although little expression was found in the WAT of the control mice.
Expression of UCP1 mRNA was also found in the WAT of mice fed Undaria lipids, but little
expression in that of control (Figure 36.6). On the other hand, UCP2 expression in WAT decreased
due to feeding Undaria lipids as compared with control (Figure 36.6). These results show that the
decrease in WAT weight of mice fed Undaria lipids may not be due to the thermogenesis through
UCP1 expression in WAT but through UCP2 expression. UCP1 expression in WAT was also found
in fucoxanthin-fed mice, but little expression of UCP1 was found in the WAT of mice fed Undaria
glycolipids and control diets (Figure 36.7). This result confirmed the anti-obesity activity of
fucoxanthin through upregulation of UCP1 expression in WAT.
15 a
UCP1/β-Actin
10
0
Control Fucoxanthin Glycolipid
FIGURE 36.7 UCP1 expression in WAT of mice fed fucoxanthin, and Undaria glycolipids. aSignificantly
different from control (p < 0.05). (Adapted from Maeda, H. et al., Biochim. Biophys. Res. Commun., 332,
392–397, 2005.)
HO OCOCH3
C
O
H
O
HO
Fucoxanthin
HO OH
C
O
H
O
HO
Fucoxanthinol
FIGURE 36.8 Structures of fucoxanthin and fucoxanthinol.
REDUCING EFFECT OF FUCOXANTHIN AND FUCOXANTHINOL

ON ADIPOCYTE DIFFERENTIATION
Fucoxanthin has a unique structure including an allenic bond and a 5,6-monoepoxide in the molecule
(Figure 36.8). It is a major marine carotenoid found in edible seaweeds such as Undaria pinnatifida,
Hijikia fusiformis, and Sargassum fulvellum. In Southeast Asian countries, some seaweeds contain-
ing fucoxanthin are often used as a food source. As described earlier, fucoxanthin demonstrates an
anti-obesity effect through a very interesting molecular mechanism, and it also has also anticarci-
nogenic effects [67], apoptotic effects in cancer cells [68–70], antiinflammatory effects [71], and
radical scavenging activity [72]. Fucoxanthin is easily converted to fucoxanthinol in human intes-
tinal cells and in mice [73], suggesting that the active form of fucoxanthin in the biological system
would be fucoxanthinol (Figure 36.8).
As shown in Figure 36.9, fucoxanthin and fucoxanthinol inhibited intercellular lipid accumulation
during adipocyte differentiation of 3T3-L1 cells. Both carotenoids also decreased glycerol-3-phos-
phate dehydrogenase activity, an indicator of adipocyte differentiation [74]. The effects of fucoxan-
thinol were stronger than those of fucoxanthin. When 3T3-L1 cells treated with fucoxanthin and
fucoxanthinol, PPARγ (a regulator of adipogenic gene expression) was downregulated by both caro-
tenoids in a dose-dependent manner (Figure 36.10). These results suggest that fucoxanthin and
fucoxanthinol inhibit the adipocyte differentiation of 3T3-L1 cells through downregulation of PPARγ.
This study [74] indicated that fucoxanthinol might be the active compound for the anti-obesity
effect induced in vivo by fucoxanthin administration. It is noteworthy that PPARγ levels were down-
regulated in 3T3-L1 cells treated with fucoxanthinol and fucoxanthin. PPARγ has an important role
in the early stages of 3T3-L1 cell differentiation, because it is a nuclear transcription factor that
regulates adipogenic gene expression [75]. Regulation of PPARγ would be one of the expected
mechanisms underlying the anti-obesity effect of dietary fucoxanthin. Catechin [76], sterols [77],
tannic acid [78], phenolic lipids [78], and red yeast rice extracts [80] also inhibit 3T3-L1 differenti-
ation. Retinoids inhibit the early stage of differentiation of 3T3-L1 cells [81]. Some of these com-
pounds, however, have low absorption and have not been fully investigated for their anti-obesity
effects in vivo. Because fucoxanthin accumulates as metabolites (including fucoxanthinol) in the white
adipose tissue of mice, dietary fucoxanthin might be a useful natural compound for the prevention
of obesity.
120
100
Relative value (%)

a
(OD 490 nm )
80
a
60
40
20
0
Control 10 μM 25 μM
Fucoxanthin
120
100
Relative value (%)
80
(OD 490 nm)
60
a
40
a
a
20
0
Control 2.5 μM 5 μM 10 μM
Fucoxanthinol
FIGURE 36.9 Effect of fucoxanthin (A) and fucoxanthinol (B) on lipid accumulation of 3T3-L1 cells during
adipocyte differentiation. 3T3-L1 cells were treated with fucoxanthin or fucoxanthinol in differentiation
medium for 120 hr. The intercellular lipid accumulation was determined by oil red O staining. The values (n
= 3) are expressed as absorbance at 490 nm. aSignificantly different from control (p < 0.01). (Adapted from
Maeda, H. et al., Int. J. Mole. Med., 18, 147–152, 2006.)
10
8
PPAR / - Actin
0
e l
yt ro ) 2.5 M 5 M 2.5 M 5 M
p oc o nt yte
di C po c
ea di Fucoxanthin Fucoxanthinol
Pr (A
FIGURE 36.10 Expression of PPARγ in 3T3-L1 cells treated with fucoxanthin and fucoxanthinol. The PPARγ
protein expression level was normalized to the β-actin level and expressed as the value relative to preadipocyte
PPARγ levels. (Adapted from Maeda, H. et al., Int. J. Mole. Med., 18, 147–152, 2006.)
CONCLUSION
In contrast to rodents, humans have only minute amounts of BAT, thus the contribution of BAT to
the regulation of energy balance in humans may be less than in rodents; however, if the expression
of UCP1, a key molecule for BAT thermogenesis, can be activated in tissues other than BAT by
food constituents, then this would be potential anti-obesity therapy for humans. Both protein and
mRNA expression of UCP1 in the WAT of fucoxanthin-fed mice along with a reduction in UCP2
mRNA expression have been reported [66]. This finding could provide new directions for dietary
anti-obesity therapy. Although an enormous amount of data exists on thermogenesis in BAT through
UCP1 expression, little information is available on UCP1 expression in WAT induced by a diet.
An excessive accumulation of fat in WAT induces some diseases such as type 2 diabetes. Direct
heat production by fat oxidation in WAT, therefore, will reduce the risk of these diseases in humans.
Although fucoxanthin has been reported to have an anti-obesity effect, further investigations
are necessary to evaluate the mechanisms. The underlying mechanisms need to be evaluated to
understand the relation of fucoxanthin activity to UCP1 expression pathways in WAT. Vegetables
have carotenoids that have a structure similar to that of fucoxanthin; hence, comparative studies
on the anti-obesity effects of carotenoids with a structure similar to that of fucoxanthin will be of
continued interest to researchers working on the dietary effects of carotenoids. The need of the
hour is to bring such challenging areas into the research fold and evaluate these carotenoids
individually and in combination with other nutrients. Such studies may encourage the development
of novel approaches to anti-obesity therapies.
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37 Dairy Foods, Calcium,

and Weight Management
Michael B. Zemel
CONTENTS
Introduction ....................................................................................................................................477
Mechanisms....................................................................................................................................478
Other Dairy Components........................................................................................................480
Modulation of Central Adiposity............................................................................................482
Animal Studies...............................................................................................................................483
Clinical Data ..................................................................................................................................483
Randomized Clinical Trials ...........................................................................................................484
Observational and Epidemiological Studies..................................................................................486
Dietary Calcium Modulation of Obesity-Induced Oxidative Stress .............................................487
Summary and Conclusions ............................................................................................................488
References ......................................................................................................................................489
INTRODUCTION
Thermodynamics and energy balance are clearly the core factors involved in our current obesity
epidemic, as modest increases in energy intake coupled with reduced physical activity have resulted
in a substantial net positive energy balance and progressive weight gain. It is equally clear, however,
that we operate with varying degrees of energetic efficiency, defined as the conversion of food
energy to useful work or energy storage, and that this variability in energetic efficiency results in
corresponding variability in susceptibility to the consequences of a chronic imbalance between
energy intake and expenditure. The consequence of a chronic positive energy balance, obesity, is
well understood as a complex genetic trait, with multiple genes interacting to confer relative
susceptibility (increased energetic efficiency) or resistance (decreased energetic efficiency) to a
positive energy balance; however, the metabolic pathways operated by these genetic factors may
also be modulated by specific nutrients or dietary patterns.
Although there is no doubt regarding the primacy of energy balance in addressing the obesity
epidemic, the additional effects of specific nutrients and foods on modulation of energy efficiency
may still have substantial impact on weight gain and obesity incidence; for example, a caloric excess
of as little as 25 kcal/day could lead to an annual weight gain of 1 kg. This value is well within the
caloric range likely to be influenced by food components. A large number of food components have
been proposed to contribute to healthy weight management. These include conjugated linoleic acid,
medium-chain triglycerides, green tea, caffeine, and capsaicin [1], but the reported effect for each
of these is modest at best, with support limited to a small number of conflicting reports [1]. In
contrast, a substantial and largely consistent body of data has emerged over the last 6 years indicating
that dietary calcium and dairy foods modulate adipocyte lipid metabolism, energy efficiency, and
energy partitioning between adipose tissue and muscle, resulting in a meaningful anti-obesity effect.
477
This effect is supported by a clear mechanistic framework, retrospective and prospective epidemi-
ological and observational studies, secondary analysis of past clinical trials originally conducted
with other primary endpoints (e.g., skeletal, cardiovascular), and prospective clinical trials.
MECHANISMS
A compelling mechanism for the anti-obesity effect of dietary calcium was provided by our studies
of the mechanism of action of the agouti gene in regulating murine and human adipocyte metabolism
[2–21]. These studies demonstrated a key role for intracellular Ca2+ in the regulation of adipocyte
metabolism, resulting in modulation of adipocyte triglyceride stores; intracellular Ca2+ is regulated
by calcitrophic hormones which provides the primary mechanistic basis for the anti-obesity effect
of dietary calcium.
This regulation of adipocyte lipid metabolism by intracellular Ca2+ provides the key framework
for the dietary calcium modulation of adiposity. We have found that both parathyroid hormone
(PTH) [4] and 1,25-(OH)2-D [22,23] stimulate rapid increases in human adipocyte intracellular
Ca2+; accordingly, suppression of these hormones by increasing dietary calcium facilitates reparti-
tioning of dietary energy from lipid storage to lipid oxidation and thermogenesis. Although both
PTH and 1,25-(OH)2-D both modulate adipocyte intracellular Ca2+, a growing body of evidence
indicates that 1,25-(OH)2-D plays a pivotal role in modulation of lipid metabolism; however,
evidence to exclude a significant additional role for PTH is insufficient. Human adipocytes possess
membrane (non-genomic) vitamin D receptors that transduce a rapid intracellular Ca2+ response to
1,25-(OH)2-D3 [23,24]; consequently, 1,25-(OH)2-D3 treatment of human adipocytes results in the
coordinated activation of fatty acid synthase expression and activity and suppression of lipolysis,
leading to an expansion of adipocyte lipid storage [22,24,25]. It should be noted, however, that,
although these data provide a plausible mechanism of action based on in vitro studies in human
adipocytes, the direct effect of calcitrophic hormones on human adipocyte metabolism has not yet
been assessed utilizing in vivo techniques, such as microdialysis.
Nonetheless, a potential role of 1α,25-(OH)2-D3 in human obesity is suggested by other data.
Polymorphisms in the nuclear vitamin D receptor (nVDR) gene are associated with the susceptibility
to obesity in humans [26,27], and several lines of evidence demonstrate an alteration of the vitamin
D–endocrine system in obese humans, with an increase in circulating 1α,25-(OH)2-D3 levels
[28,29]. These observations, coupled with the direct effects of 1α,25-(OH)2-D3 on adipocyte lipid
metabolism, strongly implicate the increase in 1α,25-(OH)2-D3 found on low-calcium diets as a
contributory factor to excess adiposity.
In addition to regulating adipocyte metabolism via a non-genomic membrane receptor (the
membrane-associated rapid response to steroid, or MARRS, protein [23,30,31]), 1α,25-(OH)2-D3
also acts via the classical nuclear vitamin D receptor in adipocytes to inhibit the expression of
uncoupling protein 2 (UCP2) [32]. Also, suppression of 1,25-(OH)2-D3 levels by feeding high-
calcium diets to mice results in increased adipose tissue UCP2 expression and attenuation of the
decline in thermogenesis which otherwise occurs with energy restriction [25], suggesting that high-
calcium diets may also affect energy partitioning by suppressing 1,25-(OH)2-D3-mediated inhibition
of adipocyte UCP2 expression. The role of UCP2 in thermogenesis is not clear, however, and the
observed thermogenic effect may be mediated by other, as of yet unidentified mechanisms. More-
over, the thermogenic effects of dietary calcium and dairy products have not yet been demonstrated
in humans. Nonetheless, in addition to inducing a mitochondrial proton leak, UCP2 serves to
mediate mitochondrial fatty acid transport and oxidation, suggesting that 1,25-(OH)2-D3 suppression
of UCP2 expression may still contribute to decreased fat oxidation and increased lipid accumulation
on low-calcium diets [32].
Limited human data support these proposed mechanisms. We have found that increasing dietary
calcium via isocaloric substitution of three daily servings of dairy (without changing dietary
macronutrient composition) results in significant increases in circulating glycerol, reflecting an
Dairy Foods, Calcium, and Weight Management 479
increase in net lipolysis, compared to low-dairy diets under both eucaloric and hypocaloric condi-
tions [33,34]. Melanson et al. [35] conducted a randomized controlled crossover study of the effects
of low- and high-dairy diets on substrate oxidation in a room calorimeter under conditions of both
energy balance and acute energy deficit. The high-dairy diets significantly suppressed circulating
1,25-(OH)2-D3 levels but had no effect on substrate oxidation under zero energy balance conditions;
however, under energy-deficit conditions, the high-dairy diet resulted in a significant increase in
24-hour fat oxidation, from 106 to 136 g/day, without significantly affecting protein or carbohydrate
oxidation. This suggests that high-dairy diets may augment the effects of energy restriction on fat
mobilization and oxidation and thereby increase the effectiveness of energy-restricted diets in
successful weight management.
Consistent with these findings, Gunther et al. [36] recently demonstrated that chronic consump-
tion (1-year) of a dairy-rich, high-calcium diet resulted in a substantially greater increase in
postprandial fat oxidation following either a low- or high-calcium liquid meal challenge. Interest-
ingly, they noted that the 1-year change in fasting levels of serum PTH was significantly correlated
with the 1-year change in postprandial fat oxidation, suggesting that dietary calcium suppression
of PTH may have permitted increased levels of fat oxidation. Although this evidence is suggestive
of a role for PTH, 1,25-(OH)2-D3 levels were not measured, and it is possible that the observed
correlation may have resulted from PTH modulation of 1,25-(OH)2-D3 levels.
Recent data demonstrate that 1,25-(OH)2-D3 modulation of adipocyte apoptosis may also
contribute to the anti-obesity effect of dietary calcium [37]. This effect is mediated, in part, via
inhibition of UCP2 expression and a consequent increase in mitochondrial potential, a key regulator
of apoptosis, and in part via 1,25-(OH)2-D3 regulation of cytosolic Ca2+ and of Ca2+ flux between
endoplasmic reticulum and mitochondria [37;unpublished data]. Consequently, adipocyte apoptosis
is significantly impaired in association with increased 1,25-(OH)2-D3 levels in mice fed low-calcium
diets, while there is a marked increase in adipocyte apoptosis in mice fed high-calcium or high-
dairy diets [37]. Although this appears contrary to multiple published reports that indicate a pro-
apoptotic effect of 1,25-(OH)2-D3 in other tissues, this apparent discrepancy is the result of dosing
differences. The literature that supports a pro-apoptotic effect of 1,25-(OH)2-D3 utilizes supraphys-
iological concentrations (≥100 nM), and we are able to demonstrate a similar pro-apoptotic effect
(resulting from mitochondrial Ca2+ overload) in adipocytes at these very high levels of 1,25-
(OH)2-D3. In contrast, physiological concentrations exert an anti-apoptotic effect in human adipo-
cytes, primarily due to suppression of UCP2 expression [37;unpublished data]. Figure 37.1 depicts
the role of 1,25-(OH)2-D3 in regulating adipocyte apoptosis, and Figure 37.2 provides an integrated
summary of 1,25-(OH)2-D3 modulation of adipocyte lipid metabolism.
Increasing dietary calcium may also result in increased fecal fatty acid excretion, and, accord-
ingly, it is possible that the resultant increase in fecal energy loss also contributes to the anti-
obesity effects of dietary calcium. In support of this concept, Papakonstantinou et al. [38] dem-
onstrated that feeding a high-calcium diet to rats produced a substantial increase in fecal fat and
energy excretion, and they attributed the observed reduction in adiposity to fecal energy loss,
although a marked decrease in circulating 1,25-(OH)2-D3 was found, as well. More recently,
Jacobsen et al. [39] reported that a short-term increase in calcium intake from 500 to 1800 mg/day
increased fecal fat excretion ~2.5-fold, from 5.9 to 14.2 g/day; however, although such an increase
in fecal fat loss would clearly contribute to a reduction in energy balance, it required a larger
level of calcium (1800 mg vs. 1200 mg used in clinical trials of calcium and obesity) to produce
a quantitatively small effect (8.3 g additional fecal fat, representing a 75-kcal/day loss) which is
insufficient to explain the magnitude of the effects observed in clinical trials (discussed later in
this chapter). Nonetheless, the modest reduction in net energy balance resulting from this mech-
anism may have a pronounced effect in maintaining healthy weights and promoting weight loss
over an extended period of time, and the contributory role of increased fecal fat loss should not
be overlooked. Indeed, we have found that high-calcium and high-dairy diets exert a substantially
greater anti-obesity effect in obese mice on a high-fat diet compared to those on a low-fat diet,
Ca2+
(Low dose) 1 ,25(OH) 2D3
(High dose) Calcium influx channels
[Ca2+]c
SERCA
Mitochondria
ER
[Ca2+]er
UCP2
Ca release channels (RyR/IP)3R
2+
[Ca ]m
ATP
Apoptosis
FIGURE 37.1 1,25-(OH)2-D modulation of apoptosis. Low (physiological) doses of 1,25-(OH)2-D inhibit
apoptosis by inhibiting uncoupling protein 2 (UCP2) and thereby restore UCP2-induced lost mitochondrial
potential and ATP reduction, protecting adipocytes from apoptotic death. The reduction in mitochondrial
calcium levels found with lower doses of 1,25-(OH)2-D may further contribute to this anti-apoptotic effect.
In contrast, high levels of 1,25-(OH)2-D cause markedly greater increases in cytosolic [Ca2+]c, probably
resulting in increased [Ca2+]er. Because endoplasmic reticulum (ER) can open their Ca2+ release channels in
response to elevations in [Ca2+]c and contribute to Ca2+-induced Ca2+ release (CICR), the high Ca2+ levels
achieved at these contact sites favor Ca2+ uptake into mitochondria, which is usually located nearby the ER.
Calcium overload in mitochondria in turn triggers apoptosis.
and we attribute the additional effect to increased fecal energy loss in the mice on the high-fat
diets [40]. Earlier human studies also demonstrated that large increases in dietary calcium (2 to
4 g/day) result in statistically significant, but modest, increases in fecal fat loss [41–43]; for
example, a supplement of 2 g calcium increased fecal fat excretion from 6.8 to 7.4% of total fat
intake [42]. In contrast, to achieve a clinically meaningful (albeit modest) contribution to weight
loss, the pancreatic lipase inhibitor orlistat must produce approximately a 30% inhibition of total
dietary fat absorption vs. the approximately 1 to 2% found with dietary calcium. Thus, while
calcium inhibition of fat absorption appears to contribute to an anti-obesity effect, this effect is
too small to solely explain the observed effects.
Dairy products have also been proposed to impact energy balance and obesity risk by affecting
satiety, and whey-derived peptides do appear to exert a satiety effect [44], although increased
satiety with milk or dairy-based meals has not been consistently found [44–47]. The increased
satiety of dairy products has also been attributed to the satiating effect of protein; however, clinical
trials that have demonstrated the effects of calcium and dairy on adiposity and weight loss have
been primarily conducted at a fixed level of protein intake. Moreover, the animal studies that have
demonstrated these effects have not found measurable differences in energy intake between low-
and high-calcium diets or between low- and high-dairy diets (discussed in a subsequent section
of this chapter).
OTHER DAIRY COMPONENTS

Although the aforementioned mechanisms explain dietary calcium inhibition of adiposity, data from
clinical trials, rodent studies, and population studies all indicate a substantially (~twofold) greater
effect of dairy vs. supplemental sources of calcium in attenuating adiposity. Accordingly, it is
Calcitriol
Ca2+
1,25(OH)2D3-MARRS
[Ca2+]i
Nucleus
nVDR RXR de novo lipolysis

DR3 lipogenesis
UCP2 Mitochondria
Apoptosis
Metabolic Efficiency
FIGURE 37.2 Role of 1,25-(OH)2-D and dietary calcium in modulating adipocyte lipid metabolism. Calcitriol
(1,25-(OH)2-D) acts via the membrane vitamin D receptor (MARRS protein) to stimulate Ca2+ influx. Increased
Ca2+ influx exerts lipogenic and antilipolytic effects. Calcitriol also acts via the nuclear vitamin D receptor
(nVDR) to suppress the expression of uncoupling protein 2 (UCP2). Reduced UCP2 levels lead to increased
mitochondrial potential, increased metabolic efficiency, and reduced adipocyte apoptosis. Dietary calcium
inhibits each of these mechanisms by suppressing 1,25-(OH)2-D levels.
important to identify the additional components of dairy that may be responsible for this augmen-
tation. Our preliminary studies in mice isolate a portion of this additional dairy-derived bioactivity
to the whey fraction [48]. Likely candidates for this additional bioactivity include the branched-
chain amino acid content of dairy protein and specific bioactive whey-derived peptides.
Dairy contains a number of bioactive compounds, which may act either independently or
synergistically with calcium to affect lipogenesis, lipolysis, lipid oxidation, or energy partitioning.
Among these, the significant angiotensin-converting enzyme (ACE) inhibitory activity contained
in whey protein may be relevant to adipocyte lipid metabolism. Angiotensin II upregulates adi-
pocyte fatty acid synthase expression [49], and ACE inhibition mildly attenuates obesity in both
mice and in hypertensive patients. Consequently, because adipose tissue has an autocrine
renin–angiotensin system, it is possible that a whey-derived ACE inhibitor may contribute to the
anti-obesity effects of dairy.
In support of these concepts, a whey-derived ACE inhibitor significantly augmented the effects
of dietary calcium on weight and fat loss in energy-restricted mice [48]; however, the combination
of the calcium and ACE inhibitor was markedly less potent than either milk or whey in reducing
body fat. Moreover, milk and whey both substantially preserved skeletal muscle mass during energy
restriction while calcium and the calcium/ACE inhibitor combination were without effect. Although
calcium plays a significant role in weight management, and this effect is enhanced by whey-derived
ACE-inhibition, these factors are not sufficient to fully explain the effects of dairy. An evaluation
of whey-derived mineral mix vs. calcium carbonate indicates that the other minerals contained in
whey do not contribute to the anti-obesity effects of whey, as the milk-derived mineral mix exerted
an effect comparable to that of calcium carbonate [48; unpublished data].
Although it may be tempting to speculate that the protein content of dairy may play a role in
mediating the anti-obesity effect, studies demonstrating an anti-obesity effect of dairy products in
both rodents and humans have maintained constant levels of protein intake. Accordingly, the protein
content of dairy and whey per se cannot be responsible for the additional bioactivity; however, the
amino acid composition of dairy protein may play a role. Dairy proteins have a high protein quality
score and contain a high proportion (~26%) of branched-chain amino acids (BCAAs) [50,51]. In
addition to supporting protein synthesis, the BCAAs (leucine, isoleucine, and valine) play specific
metabolic roles as energy substrates and in the regulation of muscle protein synthesis, and their
potential to participate in these additional metabolic processes is limited by their availability, with
first priority provided to new protein synthesis [50]. Accordingly, only diets that provide leucine
at levels that exceed the requirements for protein synthesis can fully support the intracellular leucine
levels required to support additional signaling pathways [50]. The abundance of leucine in both
casein and whey is of particular interest, as it plays a distinct role in protein metabolism and a
pivotal role in the translation initiation of protein synthesis [52]. Accordingly, the high concentration
of BCAAs, and leucine in particular, in dairy products may be an important factor in the reparti-
tioning of dietary energy from adipose tissue to skeletal muscle [53–55]. This suggests that an
interaction between the high levels of calcium in dairy in combination with the BCAA content of
dairy protein, possibly in concert with other dairy-derived bioactive compounds, may work in
synergy to minimize adiposity and maximize lean mass.
We have recently demonstrated that calcium-depleted milk retains approximately half of the
anti-obesity bioactivity of intact milk and that most of the non-calcium/non-ACE-inhibitory
bioactivity can be recapitulated by increasing the BCAA content of the low-calcium/non-dairy
diet to the level found in milk [unpublished data]. Although the role of BCAA in the preservation
of muscle mass is clear, the effects of leucine and other BCAAs on adipose tissue metabolism
are unclear and are currently under investigation; at present, we propose that the effects of BCAA
on adiposity are likely to represent the additional energetic cost of BCAA-stimulated protein
synthesis. Notably, in addition to stimulating muscle protein synthesis via the mammalian target
of rapamycin (mTOR) pathway, leucine has recently been demonstrated to stimulate hypothalamic
mTOR signaling, resulting in decreases in food intake and body weight [56]; this suggests that
leucine may play a role in satiety as well as in protein synthesis and energy partitioning between
fat and muscle.
MODULATION OF CENTRAL ADIPOSITY

Both rodent and human studies demonstrate a shift in the distribution of body fat loss on high- vs.
low-calcium diets during energy restriction. In rodents, high-calcium and high-dairy diets produce
a preferential loss of visceral adipose tissue [22,25], and clinical trials demonstrate a preferential
loss of fat from the trunk region (i.e., an increase in trunk fat loss as a percentage of total fat loss)
[7,34,35,58]. Recent studies describing the role of autocrine production of cortisol by adipose tissue
provide a likely mechanism for this effect, as well.
Human adipose tissue expresses significant 11β-hydroxysteroid dehydrogenase-1 (11β-HSD-1),
which can generate active cortisol from cortisone, and visceral adipose tissue exhibits greater
11β-HSD-1 expression than does subcutaneous adipose tissue [59,60]. Further, selective overexpres-
sion of 11β-HSD-1 in the white adipose tissue of mice results in central obesity [61,62], while
homozygous 11β-HSD-1 knockout mice exhibit protection from features of the metabolic syndrome
[63]. We have recently found 1,25-(OH)2-D3 to exert both short-term and long-term regulation of
11β-HSD-1 in human adipocytes, resulting in an ~twofold increases in 11β-HSD-1 expression and
up to sixfold increases in net cortisol production [64]. Thus, the increase in 1,25-(OH)2-D3 found
on low-calcium diets is likely to cause selective expansion of visceral adipose tissue, and the observed
selective loss of central adiposity on high-calcium and high-dairy diets appears to be attributable to
a reduction in cortisol production by visceral adipocytes [64]. We have recently confirmed this in
aP2-agouti transgenic mice. When mice were fed low-calcium diets, 11β-HSD-1 expression was
markedly higher in visceral vs. subcutaneous adipose tissue; however, a high-calcium diet suppressed
11β-HSD-1 expression such that no difference was observed between visceral and subcutaneous
adipose tissue 11β-HSD-1 expression in the mice fed a high-calcium diet [65].
ANIMAL STUDIES
We have confirmed the anti-obesity effect of dietary calcium and dairy products in a series of
studies conducted in transgenic mice that express the agouti gene in adipose tissue under the control
of the aP2 promoter, similar to the human pattern of expression of agouti and other obesity-
associated genes [22,25,41,49,66,67]. These mice are not obese when fed standard chow diets but
are susceptible to adult-onset diet-induced obesity. They respond to low-calcium diets with accel-
erated weight gain and fat accretion, while high-calcium diets markedly inhibit lipogenesis, accel-
erate lipolysis, increase thermogenesis and adipocyte apoptosis, and suppress fat accretion and
weight gain in animals maintained at identical caloric intakes [22]. Further, low-calcium diets
impede body fat loss, and high-calcium diets markedly accelerate weight and fat loss in transgenic
mice subjected to identical levels of caloric restriction [25,41,49,66,67]. One report, however,
indicates a lack of effect of increasing calcium intake on body weight and body fat in rats and
mice [68]. The reason for this difference is not apparent but may be related to the use of older
animals with more fully established obesity, as well as the lack of an energy restriction protocol.
Studies in other animal models (Zucker lean and obese rats, Wistar rats, and spontaneously hyper-
tensive rats) confirm the observation that increased calcium intake lowers body weight and fat
content [8,69,70].
Dietary calcium and dairy also alter the partitioning of dietary energy during refeeding following
weight loss in aP2-agouti transgenic mouse model [71]. Although post-obese mice fed a low-
calcium diet rapidly regained all of the weight and fat that had been lost, refeeding high-calcium
diets prevented the suppression of adipose tissue lipolysis and fat oxidation that otherwise accom-
panies post-dieting repletion and markedly increased indices of skeletal muscle fat oxidation [71].
Consequently, although animals refed low-calcium diets rapidly regained all of the weight and fat
that had been lost, animals refed high-calcium diets exhibited a 50 to 85% reduction in weight and
fat gain. Moreover, dairy exerted markedly greater effects than supplemental calcium on fat oxi-
dation and fat gain [71]. These data are supported by both clinical trials and observational data, as
described in the next sections.
CLINICAL DATA
The original concept of calcium and dairy modulation of body composition and weight management
emerged from data from a hypertension clinical trial, with subsequent corroboration via secondary
analysis of other clinical trials originally conducted with skeletal outcomes and finally prospective
clinical trials to evaluate the effects of calcium and dairy on adiposity. In the hypertension study,
dietary calcium was increased from ~400 to ~1000 mg/day in obese African Americans without
altering dietary energy or macronutrient content. Although body weight did not change, a 4.9-kg
reduction in body fat was observed [22], which led to the subsequent mechanistic investigations
already described.
Heaney and colleagues [72–74] reanalyzed a series of calcium intervention studies originally
designed with primary skeletal endpoints but which support a calcium–body weight linkage. In an
analysis of nine studies, including three controlled trials and six observational studies, a significant
negative association between calcium intake and body weight was noted for all age groups studied
(third, fifth, and eighth decades of life), the odds ratio for being overweight was 2.25 for young
women below median calcium intake compared to those above median calcium intake [72], and
the controlled trials supported this relationship [72–74]. Overall, increased calcium intake was
consistently associated with reduced indices of adiposity (body weight, body fat, or weight gain);
the aggregate effect was that each 300-mg increase in daily calcium intake was associated with a
3-kg lower weight in adults and a 1-kg decrease in body fat in children.
In contrast, a secondary analysis of three 25-week randomized clinical trials originally con-
ducted to evaluate skeletal outcomes during weight loss did not demonstrate an effect of increased
calcium intake on body weight or fat loss in subjects counseled to follow an energy-restricted diet;
however, the authors noted that the calcium groups consistently lost more weight and fat, and they
suggested that these studies did not have sufficient statistical power to detect these small effects
[75]. Similarly, Reid et al. [76] assessed the results of a study originally designed to assess the
effects of calcium on fracture incidence and found no effect of supplementary calcium on body
weight or body composition, although they observed a trend toward greater weight loss with calcium
supplementation in those with the lowest baseline calcium intakes (<600 mg/day).
Notably, both of the aforementioned secondary analyses [75,76] evaluated the effects of sup-
plementary calcium. In contrast, Lin et al. [77] conducted a retrospective analysis of a 2-year
prospective study of 54 normal-weight Caucasian women originally conducted to assess the impact
of exercise on skeletal outcomes. They found the dietary calcium-to-energy ratio and the dairy
calcium-to-energy ratio to be significant negative predictors of changes in both body weight and
body fat [77]; however, the reported effects appeared to be specific to dairy sources, as dairy calcium
predicted changes in body weight and body fat, but nondairy calcium did not [77]. Thus, the failure
to find a significant effect in retrospective analysis of calcium supplementation trials may result,
in part, from the use of calcium supplements rather than dairy sources. Indeed, we have found
dairy sources of calcium to be substantially more effective than supplementary sources in controlling
adiposity in prospective studies of both mice and humans, as discussed earlier in this chapter. Lin
et al. [77] also noted an important interaction between dietary calcium and energy intake in
predicting changes in body fat, as calcium (but not energy) intake predicted changes in body weight
and body fat for women below the median energy intake (1876 kcal/day), and energy intake alone
predicted changes in weight and fat in women at higher levels of energy intake. This is consistent
with the concept that energy balance is the predominant predictor of adiposity, with calcium and
dairy effects being evident primarily when the energy balance is controlled; clinical trial data
(discussed in the next section) further support this concept.
An inverse relationship between energy-adjusted dietary calcium intake and body mass index
was also reported in lactose-tolerant, but not lactose-intolerant, African-American women [78].
Although the reason for the lack of effect in the lactose-intolerant group cannot be definitively
inferred from this cross-sectional study, the lactose-intolerant group exhibited a uniformly low
calcium intake, presumably due to an aversion to dairy products, and the lack of women with
adequate calcium intakes in this group therefore precluded a clear relationship emerging as it did
for the lactose-tolerant women.
RANDOMIZED CLINICAL TRIALS

We have conducted several clinical trials to evaluate the effects of dietary calcium and dairy on
adiposity; to date, all available randomized clinical trial data available are from adults. In the first
trial [58], 32 obese adults were maintained on balanced caloric-deficit diets (500 kcal/day deficit)
and randomized to (1) the control group (0 to 1 serving per day and 400 to 500 mg calcium per
day supplemented with placebo), (2) a high-calcium diet (control diet supplemented with 800 mg
calcium per day), or (3) a high-dairy diet (3 to 4 servings of milk, yogurt, and/or cheese per day
for a total calcium intake of 1200 to 1300 mg/day). Control subjects lost 5.4% of their body
weight over a 24-week study; this loss was increased to 8.6% on the high-calcium diet and to
10.9% on the high-dairy diet (p < 0.01). Fat loss (determined via dual-energy x-ray absorptiometry
[DEXA]) followed a similar trend, with the high-calcium and high-dairy diets augmenting the fat
loss found on the low-calcium diet by 38% and 64%, respectively (p < 0.01). This was accompanied
by a marked change in the distribution of body fat loss [58], as fat loss from the trunk region
represented 19% of the total fat lost on the low calcium diet. This was increased to 50% of the
fat lost on the high-calcium diet and 66% on the high-dairy diet; this effect has now been explained
via calcium/1,25-(OH)2-D modulation of adipose tissue cortisol production [64,65], as discussed
earlier in this chapter. These findings demonstrate that increasing dietary calcium from suboptimal
to adequate levels can enhance the efficacy of an energy-restricted diet in weight and fat loss,
while a markedly greater enhancement is found when dairy foods are used compared to calcium
supplements [58].
The effects of dairy in augmenting weight and fat loss secondary to caloric restriction have
been confirmed in additional clinical trials. A recent follow-up clinical trial of 34 obese subjects
consuming a diet supplemented with three servings of yogurt (total calcium intake of ~1100 mg/day)
compared to a placebo control group (calcium intake of 400 to 500 mg/day) on a balanced calorie-
deficit diet (–500 kcal/day) for 12 weeks supports these findings [33]. Both groups lost weight, but
the yogurt group lost 61% more fat (4.43 vs. 2.75 kg) and 81% more trunk fat (3.16 vs. 1.74 kg)
than the control group (p < 0.001). Similar to the first clinical trial, the fraction of fat lost from
the trunk was markedly higher on the yogurt diet vs. control (60.0 vs. 26.4%). Moreover, a
significant 31% reduction in the loss of lean tissue mass during energy restriction was observed in
the yogurt group compared to the control group. No adverse effects on any serum lipid fraction
were observed in either of these trials, and both trials demonstrated an improvement in insulin
sensitivity, glucose tolerance, and blood pressure in the dairy groups [33,58].
These findings have been extended in a multi-center trial of 105 overweight and obese adults
conducted at the University of Tennessee, Purdue University, the University of California–Davis,
and Ohio State University [61]. The design was similar to the first clinical trial, with subjects
randomized to low-calcium, high-calcium, and high-dairy groups on a balanced deficit (–500
kcal/day) diets for 12 weeks. Although the calcium supplement exerted little effect, the high-dairy
diet resulted in significant, marked (~twofold) increases in fat loss and trunk fat loss, similar to
that seen in the first trial [58]; however, in contrast to the first clinical trial, the calcium supplement
was without significant effect.
We have also replicated these findings in a 6-month clinical trial in obese African-Americans
[34], with essentially similar findings. Inclusion of three daily servings of dairy into a balanced
deficit diet with no alterations in dietary macronutrients resulted in an approximately twofold
increase in weight, fat, and trunk fat loss vs. those maintained on a low-dairy diet. These findings
were extended to a 6-month study of obese African-American adults in the absence of an energy
deficit [34]. Isocaloric substitution of three daily servings of dairy products into the diets of obese
African-American adults maintained on eucaloric diets for 6 months resulted in a 5.4% reduction
in total body fat and a 4.6% decrease in trunk fat (p < 0.01 for both) in the absence of any change
in body weight, while the control group maintained on a low-calcium/low-dairy diet with identical
macronutrient composition exhibited no significant changes in total body fat or trunk fat [34].
Summerbell et al. [79] conducted a 16-week, randomized, placebo-controlled weight-loss trial
evaluating three isoenergetic diets: a conventional balanced deficit diet, a milk-only diet, or a milk
diet with a single designated food added. They reported markedly greater weight loss in both milk-
based diets (9.4 and 7.0 kg) compared to the conventional diet (1.7 kg) despite all subjects being
prescribed the same level of energy restriction. Although the authors attributed the observed differ-
ences to the novelty of the milk-based diets possibly contributing to a greater level of compliance
[79], there was no evidence to support that hypothesis and, in light of the data presented here, it is
proposed that the increased weight loss was, in part, due to the effects of the milk on adiposity.
Bowen et al. [80] reported that dairy failed to enhance weight loss during 12 weeks of energy
restriction in subjects on high-protein diets; however, that work utilized a much higher level of
protein intake than that used in the aforementioned trials (34% of energy vs. 18%), making a direct
comparison difficult, as higher protein intakes have been shown in some studies to be associated
with greater weight loss. Indeed, the weight loss found by Bowen et al. was approximately twice
as high (9.7 vs. 4.99 kg) as that found in the control group in the 12-week study discussed earlier
in this chapter [34]. At this higher rate of weight loss (0.8 kg/week), a maximal rate of fat
mobilization may already be approached, making additional increments due to dairy (or other
factors) unlikely. Moreover, the baseline calcium intakes in the Bowen study were considerably
higher (899 and 787 mg/day for men and women, respectively, assigned to the dairy protein diet,
and 935 and 737 mg/day, respectively, for those assigned to the mixed protein diet) than in the
aforementioned clinical trials [34,58], in which baseline calcium intakes were <600 mg/day. This
was considered critical to ensure that the effects of correcting suboptimal intakes were studied
rather than the effects of supplementing near-adequate intakes.
Thompson et al. [81] conducted a 48-week trial comparing the effects of a moderate-dairy diet
(two daily dairy servings) and a high-dairy diet (four daily dairy servings) on weight and fat loss
in energy-restricted obese subjects. Although all groups lost weight and fat, no treatment-specific
effects were observed; however, the energy prescription was periodically readjusted for those
subjects who were not demonstrating adequate weight loss. After accounting for these adjustments,
among subjects who adhered to the study protocol, those on the high-dairy diet achieved their
weight loss while consuming a statistically significant 100 to 150 kcal/day more than those on the
low-dairy diet. The outcome of this study may have also been affected by the threshold effect, as
previous clinical trials had evaluated the effects of increasing dairy and calcium from clearly
inadequate levels (less than one daily dairy serving and less than 600 mg calcium per day), but
this study utilized relatively low calcium and dairy intakes of 800 mg/day and two dairy servings
per day. Nonetheless, among adherent subjects, comparable weight loss was attained by the high-
dairy group despite consuming significantly more energy than the low-dairy group [81].
Harvey-Berino et al. [82] reported no effect of dairy on weight or fat loss in 44 overweight
and obese adults for one year using a design comparable to that for our previous clinical trials (low
dairy/400 to 500 mg calcium per day vs. high dairy/1200 to 1400 mg calcium per day). Although
all subjects were prescribed a 500-kcal/day daily deficit, the high-dairy group reported only a 314-
kcal/day deficit (calculated from presented data as energy intake at baseline minus energy intake
at months 3 and 12 of intervention) at 3 months and a 224-kcal/day deficit at 12 months, while the
low-dairy group achieved a 442-kcal/day deficit at 3 months and a 402-kcal/day deficit at 12 months.
Thus, although no statistically significant difference in energy intake was reported between the
low- and high-dairy groups, the low-dairy group had a 41% greater energy deficit at 3 months and
a 79% greater energy deficit at 12 months while achieving similar weight and fat loss as the high
dairy group.
Finally, preliminary data demonstrate that a eucaloric high-dairy diet markedly attenuates regain
of body weight following successful weight loss compared to a low-dairy diet (3.03 vs. 1.02 kg
weight regain on low- vs. high-dairy diet; p < 0.05) [83]. Similarly, the high-dairy diet attenuated
the regain of body fat (1.959 vs. 0.773 kg on low- vs. high-dairy diet; p < 0.01), and trunk fat
(1.546 vs. 0.218 kg on low- vs. high-dairy diet; p < 0.01), indicating that dairy-rich diets attenuate
short-term (12-week) weight, fat, and trunk fat regain following weight loss. Longer term assess-
ments are needed to fully evaluate this phenomenon and are currently in process.
OBSERVATIONAL AND EPIDEMIOLOGICAL STUDIES

Although only a limited number of clinical trials have been performed to date, these clinical data
are supported by multiple lines of evidence, including observational data noting an inverse relation-
ship between dietary calcium and/or dairy and body weight and/or body fat in children and adoles-
cents [84–88], younger and older women [77,78,89], and African-American women [78], as well as
by epidemiological data from NHANES I [89], NHANES III [22], NHANES 1999–2000 [90], the
Continuing Study of Food Intake of Individuals (CSFII) [90], the HERITAGE study [91], the Quebec
Family Study [92], the CARDIA study [93], and the Tehran Lipid and Glucose study [94].
Although most studies reporting the relationship between dietary calcium and dairy and
indices of adiposity are in adults, a few studies have been done on children and adolescents
[84–88,95–97]. Although one study recently reported no relationship between dietary calcium
or dairy consumption in a longitudinal assessment of adolescent females [95], the authors noted
that dairy consumption was significantly higher for their study cohort compared to that reported
by CSFII for a nationally representative survey of the same age group (428 vs. 269 g/day of
milk and milk products). Moreover, the overall reported median dairy intake was 2.9 servings
of dairy and 827 mg of dairy-derived calcium per day. Accordingly, it is possible that this cohort
represented a relatively high dairy-consuming population and therefore was sufficiently above
a yet-to-be determined threshold of dairy intake to observe an effect on indices of adiposity. In
contrast, several other studies of children and adolescents suggest a protective effect of dairy
[84–88,96].
A significant inverse relationship between dietary calcium and body fat was reported in a
5-year longitudinal study of preschool children studied from 2 months of age (R2 = 0.51) [84].
The group subsequently extended these longitudinal findings to 8 years of age [85]. Overall, in
predictive equations that explain 26 to 34% of the variability in body fat, variations in dietary
calcium explained 7 to 9% of the variability in adiposity [85]. Notably, these longitudinal data
strongly suggest that dairy and calcium intake within the first year of life are significant inverse
determinants of body fat levels at age 8 [84,85]. Consistent with these findings, longitudinal data
from the Framingham Children’s Study indicate that higher intakes of calcium early in life (ages
3 to 5) were associated with decreased gain of body fat over time (early adolescence), with dairy
servings being more strongly correlated to reduced body fat than dietary calcium per se [96]. It
is important to interpret such findings within the context of overall energy balance; for example,
Berkey et al. [97] recently reported that adolescents who consume excess calories from milk
exhibit higher gains in body mass index than those who do not; however, when adjusted for
energy intake, this effect was not evident.
The associations between dairy intake and incidence of the major components of the insulin
resistance syndrome (IRS), including obesity, was evaluated in a 10-year population-based pro-
spective study of 3157 African-American and Caucasian adults [93]. Overweight individuals who
consumed the most dairy products had a 72% lower incidence of IRS compared to those with the
lowest dairy intakes. Moreover, the cumulative incidence of obesity in those who started the study
in the overweight category was significantly reduced from 64.8% in those consuming the least
amount of dairy foods to 45.1% in the highest dairy-food-consuming group. Notably, the inverse
relationship between dietary calcium and either IRS or obesity incidence in the CARDIA study
was explained solely by dairy intake and was not altered by adjustment for dietary calcium,
indicating the presence of an additional effect of dairy beyond the mechanisms already cited for
dietary calcium in modulating adiposity and obesity risk; this is consistent with both the experi-
mental animal and clinical trial data which also suggest that other dairy components, in addition
to calcium, contribute to an anti-obesity effect.
DIETARY CALCIUM MODULATION OF

OBESITY-INDUCED OXIDATIVE STRESS
Reactive oxygen species (ROS) production is increased in obesity [98–101]. In the past, the
expanded adipose tissue mass that characterizes obesity has been principally considered as a simple
fuel reservoir to supply nonesterified fatty acids (NEFAs) to meet the energy requirements of
peripheral organs. This simplistic concept has been modified, however, following the discovery
that adipose tissue also functions as an endocrine organ and produces a variety of bioactive proteins
(adipokines) and is a significant source of reactive oxygen species. ROS and systemic oxidative
stress are implicated as causative factors in systemic inflammation and in tissue damage resulting
from obesity, diabetes, and atherosclerosis and are recognized as key factors contributing to the
physiological processes of aging.
We have shown that adipocyte ROS production is modulated by mitochondrial uncoupling
status and cytosol Ca2+ signaling, and 1,25(OH)2-D3 regulates ROS production in cultured murine
and human adipocytes [102]. Thus, we have proposed that increased 1,25(OH)2-D3 contributes to
Positive effect
Negative effect 1, 25(OH)2D 3
adipocyte
nucleus
UCP
Ca 2+ Ca 2+ Ca 2+
??
ROS
Mitochondria
FIGURE 37.3 Schematic illustration of effects and mechanisms of calcitriol (1,25-(OH)2-D3) on reactive
oxygen species (ROS) production and adipocyte proliferation. Physiological doses of calcitriol increase ROS
production by inhibiting UCP2 expression and stimulating intracellular calcium influx. Dietary calcium inhibits
ROS via suppression of calcitriol.
systemic oxidative stress by inhibiting adipocyte uncoupling protein 2 (UCP2) expression and
increasing cytoslic Ca2+ signaling, thereby increasing ROS production. Accordingly, because dietary
calcium suppresses 1,25(OH)2-D3, high-calcium diets would be anticipated to correspondingly
decrease adipose tissue ROS production and systemic oxidative stress (Figure 37.3). In support of
this concept, we have recently reported that high-calcium diets inhibited adipose tissue NADPH
oxidase expression (a key source of intracellular ROS) and resulted in a striking 64% reduction in
visceral adipose tissue ROS production in mice [65]. A similar pattern was evident in skeletal
muscle, which exhibited a significant increase in UCP3 expression and a corresponding decrease
in NADPH oxidase expression [65]. These findings indicate a potentially important role of dietary
calcium in attenuating obesity-induced oxidative stress and suggest that, in addition to exerting an
anti-obesity effect, calcium may play a significant role in suppressing a key mediator of obesity-
induced morbidity [65].

An anti-obesity effect of dietary calcium and dairy foods is evident from animal studies, obser-
vational and population studies, and randomized clinical trials. Moreover, a strong theoretical
framework is in place to explain the effects of dietary calcium on energy metabolism. The
supporting mechanisms include dietary calcium supplementation correcting suboptimal calcium
intakes and thereby preventing the endocrine (PTH and 1,25-(OH) 2-D) response, which favors
adipocyte energy storage and inhibits adipocyte loss via apoptosis. Dietary calcium appears to
further promote energy loss via formation of calcium soaps in the gastrointestinal tract, thereby
reducing net energy absorption. Dietary calcium appears to be responsible for ~50% of the
antiobesity bioactivity of dairy. The additional dairy bioactivity has not been fully identified, but
major components are the ACE inhibitory activity of dairy and the high concentration of BCAA
in dairy. Animal studies indicate that the BCAA content of dairy is largely responsible for the
repartitioning of dietary energy from adipose tissue to skeletal muscle during weight loss,
resulting in greater preservation of skeletal muscle and accelerated loss of adipose tissue during
negative energy balance. Finally, high-calcium diets suppress obesity-induced oxidative stress
and may thereby contribute to a reduction in obesity comorbidity independently of the direct
anti-obesity effect.
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38 Lessons from the Use

of Ephedra Products
as Dietary Supplements
Madhusudan G. Soni, Kantha Shelke,
and Rakesh Amin
CONTENTS
Introduction ....................................................................................................................................495
History of Ephedra.........................................................................................................................496
Chemistry .......................................................................................................................................496
Variations in Alkaloid Content ......................................................................................................496
Pharmacological Action of Ephedra ..............................................................................................497
Contraindications of Ephedra Constituents ...................................................................................498
Pharmacokinetics ...........................................................................................................................498
Human Observations......................................................................................................................499
Clinical Studies .......................................................................................................................499
Case Reports and Adverse Event Reports..............................................................................499
The Story and Lessons...................................................................................................................501
References ......................................................................................................................................503
INTRODUCTION
Sales trends of herbal products in the United States suggest a dramatic increase in the use of these
products. According to industry reports, consumers spend approximately $14 billion a year on
dietary supplements. It has been estimated that as many as 2 to 3 billion doses of dietary supplements
containing ephedrine alkaloids are consumed each year in the United States [3,27]. Among the
products containing ephedrine alkaloids, Ephedra sinica (Ma huang) is the most commonly used
plant source. Ephedrine and related alkaloids found in ephedra can also be produced synthetically.
Ephedra products have been extensively used for weight loss, weight management, and energy
enhancement. Dietary supplements containing ephedra extract generally contain 6 to 8% ephedrine
alkaloids.
Beginning in the 1990s, concerns over the safety of ephedra and products containing ephedra
began to be publicly raised in the United States. The U.S. Food and Drug Administration (FDA)
received over 1000 reports of adverse effects (including over 100 deaths) related to the consumption
of ephedra-containing dietary supplements. Because of continued and growing health concerns over
the years, on February 6, 2004, the FDA issued a final rule prohibiting the sale of dietary supple-
ments containing ephedrine alkaloids (ephedra), and the rule became effective 60 days from the
date of publication. Many advocates for the use of ephedra maintained that it was safe in low doses.
The proponents of ephedra use challenged the FDA prohibition, and a federal district judge limited
495
the scope of the FDA’s ban; however, the FDA is arguing to try to restore the ban. The objective
of this review article is to highlight the controversy surrounding the safety in use of ephedra as a
dietary supplement and the lessons learned.
HISTORY OF EPHEDRA
Ephedra sinica is an herb that has been used in traditional Chinese medicine for over 5000 years
and is considered the world’s oldest medicine. It is used as a stimulant and for the management of
bronchial disorders [4]. Ancient Aryans from India discovered that ephedra or the Soma plant could
be used as an energizer cum euphoriant. The use of ephedra juice for longevity has been mentioned
in the Rigveda (the oldest of sacred Sanskrit Vedas) [45,46]. Historically, ephedra has been recom-
mended for colds and flu, coughing, wheezing, nasal congestion, fever, chills, headaches, edema,
hyperhydrosis, and bone pains. Ephedra, also known as Ma huang, is an evergreen perennial herb
native to central Asia and is now widely distributed and cultivated throughout the temperate and
subtropical zones of Asia, Europe, and the Americas. The Ephedra genus includes more than 40
species. The majority of these Ephedra species contain the alkaloid ephedrine [15,43]. In 1885, its
active ingredient, ephedrine, was isolated from the ephedra plant and was also chemically synthe-
sized. Because of the pharmacological activity of ephedra, ephedrine was recommended as the
treatment of choice for asthma. Currently, standardized ephedrine/pseudoephedrine preparations
are commonly used around the world in the treatment of asthma [15].
CHEMISTRY
The primary compound of interest in commercially cultivated Ephedra plant species is the alkaloid
ephedrine. In addition to ephedrine, ephedra plants also contain other alkaloids. The yield of
alkaloids in ephedra plants ranges from 0.5 to 2.5%, of which 30 to 90% is ephedrine. In some
ephedra species, pseudoephedrine has also been found. Generally, ephedrine and pseudoephedrine
constitute more than 80% of the alkaloid content of the dried herb [44]. Additional alkaloids found
in ephedra include N-methylephedrine, N-methylpseudoephedrine, norpseudoephedrine, and
norephedrine. Ephedrine in its natural form exists as the L isomer (laevorotatory), but the synthetic
compound is generally a racemic mixture of L and D isomers. Generally, the fruits and roots of
the ephedra plant are devoid of alkaloids. The astringent taste of ephedra products is due to the
large amounts of tannins present in the plant.
VARIATIONS IN ALKALOID CONTENT

The alkaloid content of the commercially available ephedra products varies considerably and
depends on the Ephedra species, geographical location, parts used (aerial, stem, leaf, or a combi-
nation of stem and leaf), and harvesting and extraction techniques. Because of the natural variations
in the alkaloid contents of the Ephedra plant, significant inter-product and intra-product variability
has been reported in ephedra products [6,28,29,32]. In a series of studies, Gurley et al. [28–32]
investigated the quantitative variations in alkaloid contents in commercially available ephedra
products. The alkaloid content in these products varied by as much as fivefold, with different brands
exhibiting lot-to-lot variations ranging from 44 to 260%. These investigators also noted that several
commercially available ephedra products do not report the amount of ephedrine on the label [31,32].
The total alkaloid content in ephedra products varied considerably and ranged from 0.0 to 18.5
mg/dosage unit. Gurley et al. [32] reported that the ephedrine and pseudoephedrine levels in these
products also varied and ranged from 1.1 to 15.3 mg and 0.2 to 9.5 mg/unit dose, respectively. In
addition to their variable alkaloid content, ephedra products may also contain intentionally added
Ephedra Safety 497
ingredients, such as guarana, St. John’s wort, chromium picolinate, kola nut, White Willow bark,
diuretics, or cathartics. Additionally, herbal supplements have been shown to contain undeclared
pharmaceuticals, toxic herbs, or heavy metals [32,58]. Thus, it is likely that the differences in the
alkaloid content, other ingredients, and contaminants found in ephedra products affect the pharma-
cological and toxicological action of these products.
PHARMACOLOGICAL ACTION OF EPHEDRA

For over 2000 years, ephedra has been used to treat bronchial asthma, cold and flu, chills, fever,
lack of perspiration, headache, aching joints and bones, nasal decongestion, and cough and wheezing
[7,43]. Ephedra is approved by the German Commission E for the treatment of respiratory tract
diseases with mild bronchospasms [7]. The use of ephedra preparations for the treatment of nasal
decongestion due to hay fever, common cold, rhinitis, and sinusitis and as a bronchodilator in the
treatment of asthma is also recognized by the World Health Organization [68].
The pharmacological action of ephedra is dependent on its chemical composition and particu-
larly on the levels of ephedrine. As ephedrine is the primary alkaloid present in the majority of
Ephedra species, the effects of ephedrine can represent the expected pharmacological action of
ephedra. The pharmacological action of ephedrine has been extensively investigated in human and
animal studies. Although the individual alkaloids have similar pharmacological activity, they vary
significantly in potency [13] and thus alter the net effect. Lee et al. [41,42] reported that the potency
of adrenergic activity and the cytotoxicity of ephedra extracts correlate with the ephedrine content;
however, the cytotoxicity of all ephedra extracts could not be completely accounted for by their
ephedrine content alone.
Both ephedrine and pseudoephedrine have been shown to target the adrenergic receptors, the
same receptors targeted by adrenaline. The pharmacological action of ephedrine is comparable to
amphetamine but at about one fifth the potency. As a mixed sympathomimetic agent, ephedrine
enhances the release of norepinephrine from sympathetic neurons and stimulates α- and β-receptors.
Ephedrine stimulates heart rate and thus increases cardiac output. It causes peripheral constriction,
leading to an increase in peripheral resistance. Ephedrine is known to relax bronchial smooth
muscle; hence, it is used as a decongestant and for the temporary relief of shortness of breath
caused by asthma. The onset of the pharmacological effects of ephedrine is generally evident within
an hour of ingestion. The alkaloids from ephedra are known central nervous system stimulants;
oral administration of a 50-mg dose of ephedrine has been shown to stimulate the central nervous
system [10].
In a number of studies, various cardiovascular effects attributed to ephedrine have been reported.
In a double-blind study, Tashkin et al. [59] reported that in patients with obstructive airway disease
ephedrine at a dose of 25 mg produces a significant increase in specific airway conductance 1 hour
following ingestion. Heart rate was significantly increased at 2 to 5 hours, and the bronchodilatory
effect lasted for over 4 hours. Hoffman and Lefkowitz [35] reported that ephedrine stimulates the
heart rate and cardiac output and variably increases blood pressure. In a double-blind study, Nuotto
[49] investigated the psychophysiological effects of ephedrine in healthy volunteers. A single oral
dose of ephedrine (25 mg) increased the heart rate and systolic blood pressure and reduced diastolic
blood pressure without affecting psychomotor performance. Drew et al. [21] reported that ingestion
of a single dose of 60 to 90 mg of ephedrine produced a diastolic blood pressure of 90 mmHg and
higher in healthy volunteers. A maximum change in heart rate of 12 beats/min was noted after
ingestion of 90 mg ephedrine. A significant increase in blood pressure was noted at two to three
times the recommended dose of 15 to 30 mg of ephedrine [13]. Based on results from several
single-oral-dose studies, Chau and Benrimoj [14] attributed the discrepancies in cardiovascular
effects to the varying methodologies of the studies with respect to the parameters analyzed and the
time intervals assessed.
CONTRAINDICATIONS OF
EPHEDRA CONSTITUENTS
Ephedrine, the active ingredient of ephedra, is contraindicated for individuals with heart disease,
hypertension, coronary thrombosis, impaired circulation of the cerebrum, glaucoma, diabetes,
thyroid disease, autonomic insufficiency, pheochromocytoma, chronic anxiety or psychiatric dis-
orders, or enlarged prostate [19,36]. Ephedrine is also contraindicated for patients treated with
monoamine oxidase (MAO) inhibitors, as the combination may cause severe, possibly fatal, hyper-
tension [18,36]. Special populations, such as neonates and breast-fed infants, pregnant women,
children, and the elderly, may be at increased risk of toxicity from ephedrine and related agents
because of increased sensitivity to the effects of sympathomimetic stimulation. Anastario and
Haston [2] reported increased fetal heart rate and beat-to-beat variability following intramuscular
administration of ephedrine for the treatment of maternal hypotension.
PHARMACOKINETICS
Ephedrine, the primary active ingredient of ephedra, is completely absorbed from the gastrointes-
tinal tract within 2 to 2.5 hours [69,70]. In humans, ephedrine is primarily excreted via urine;
within 24 hours of administration, approximately 95% of the ephedrine may be excreted
unchanged (55 to 75%) or as metabolites [19]. The serum half-life of ephedrine is reported to
be 2.7 to 3.6 hours [52]. Available studies suggest that the biotransformation of ephedrine takes
place through aromatic hydroxylation, N-demethylation, and oxidative deamination pathways.
Approximately 8 to 20% of the administered ephedrine is metabolized by N-demethylation to
norephedrine, and 4 to 13% undergoes oxidative deamination resulting in the formation of
1-phenylpropan-1,2-diol and further side-chain oxidation to benzoic acid and hippuric acid
[56,69,70]. The pharmacokinetics of other ephedrine-related alkaloids in ephedra, including
pseudoephedrine and phenylpropanolamine, are similar to ephedrine. As ephedrine contains
ionizable groups, its urinary excretion depends on pH, with excretion increasing in acidic urine
and decreasing in alkaline urine [48,69,70].
Following oral ingestion, large inter-individual variations in plasma levels of ephedrine have
been reported. White et al. [67] reported that absorption of ephedrine in normotensive subjects is
much slower when it is given as a component of an ephedra product compared to its pure form.
Comparative absorption of ephedrine following ingestion of pure ephedrine or ephedra products
revealed that ingestion of an ephedra product had approximately twice the Tmax (time to maximum
plasma concentration). In a subsequent study by the same group, pharmacokinetic parameters for
botanical ephedrine were found to be similar to those for synthetic ephedrine [30].
Haller et al. [34] studied the pharmacokinetics and pharmacodynamics of a dietary supplement
containing ephedra and guarana. In this study, 80 healthy adults orally ingested a single dose of a
dietary supplement containing 20 mg ephedrine alkaloid and 200 mg caffeine. Following the
administration, plasma and urine levels of ephedrine alkaloids and caffeine, heart rate, and blood
pressure were monitored for 14 hours. The Tmax for ephedrine and pseudoephedrine were similar
(2.4 hours), but the Tmax of caffeine was shorter (1.5 hours). The half-life of ephedrine was
determined to be 6.1 hours. The plasma clearance and elimination half-lives of ephedrine, pseu-
doephedrine, and caffeine from this study were similar to values reported for drug formulations.
The half-life of ephedrine and pseudoephedrine in one subject with a high urinary pH was prolonged.
At 90 minutes after the ingestion, a significant increase in mean systolic blood pressure was
observed, and at 6 hours after the ingestion the heart rate reached a maximum change of 15 beats/min
above baseline. The investigators concluded that the disposition characteristics of botanical products
are similar to their synthetic pharmaceutical counterparts.
Ephedra Safety 499
HUMAN OBSERVATIONS
CLINICAL STUDIES
In several clinical studies, ephedrine has been extensively investigated alone or in combination with
caffeine, particularly for its effect on body weight reduction. Ephedrine is taken along with caffeine,
as the combination has been shown to result in greater body weight decrease compared to ephedrine
alone. Reductions in body weight following the combined intake of ephedrine and caffeine have
been attributed to both decreased food intake and increased energy expenditure [5,7,22,23,47,62].
None of the studies reported any serious, unanticipated toxicity.
In a multi-center, randomized, double-blind, placebo-controlled trial, Boozer et al. [9] studied
the safety and efficacy of an herbal supplement. In this trial, 167 subjects were randomized to
placebo (84) or herbal treatment (83). Herbal treatments composed of Ma huang (90 mg/day
ephedrine) and kola nut (192 mg/day caffeine) were given to subjects for 6 months for weight loss.
Alterations in blood pressure, heart function, body weight, and body composition were monitored.
Significant beneficial effects of the herbal supplement on body weight, body fat, and blood lipids
were noted. The herbal supplement produced no adverse events, and only minimal side effects,
consistent with the known pharmacological action of ephedrine and caffeine, were noted. In a
previous study by these authors, ingestion of a herbal dietary supplement containing 72 mg/day
ephedrine alkaloids and 240 mg/day caffeine resulted in short-term weight and fat loss [8]. In both
the studies, small persistent increases in heart rate without any evidence of cardiac arrhythmias
were noted. In other studies, the increase in heart rate was also noted following acute treatment
with ephedrine and caffeine [5] or with ephedra [67].
In another 8-week study with an ephedra formulation (dose not specified), Kaats et al. [38]
also reported weight reduction without any significant changes in blood pressure or resting heart
rates; however, the details of the study were limited. In a 2-week double-blind trial, Kalman et al.
[39] investigated the cardiovascular effects of an ephedra/caffeine supplement in 27 overweight
healthy adults. In this study, the subjects were given ephedra (335 mg standardized for 20 mg
ephedrine alkaloid), guarana (910 mg containing 200 mg caffeine), and bitter orange (5 mg
synephrine). Ingestion of the supplement did not produce any noticeable cardiovascular adverse
effects. Contrary to these observations, but based on adverse events reports, Haller and Benowitz
[33] and Samenuk [55] speculated that a link might exist between the consumption of low levels
of ephedra alkaloid and arrhythmias.
In a recent report, Shekelle et al. [57] evaluated 52 controlled clinical trials of synthetic
ephedrine or botanical ephedra used for weight loss or athletic performance. A meta-analysis was
performed in which weight-loss clinical trials with at least 8 weeks of follow-up data were included.
Studies of athletic performance were not included, as these studies used a wide variety of inter-
ventions. The use of synthetic ephedrine, ephedrine plus caffeine, or ephedra plus botanicals
containing caffeine was found to be associated with two to three times the risk of nausea, vomiting,
psychiatric symptoms such as anxiety and change in mood, autonomic hyperactivity, and palpita-
tions, as compared with placebo.
CASE REPORTS AND ADVERSE EVENT REPORTS

Case reports on ephedra are available in the published literature. Several cases of psychiatric illness
have been reported following the consumption of ephedra [11,20,37,40,61]. In addition, Zaacks et
al. [71] reported hypersensitivity myocarditis associated with ephedra use in a 39-year-old male.
Powell et al. [53] reported nephrolithiasis in a 27-year-old male using an energy supplement
containing ephedra extract. Warner and Lee [65] reported a case of Leber hereditary optic neurop-
athy in a patient using ephedra alkaloids at the time of onset. Vahedi et al. [64] reported an ischemic
stroke in a 33-year-old male who consumed ephedra extract together with creatinine monohydrate
for bodybuilding. A Naval reservist taking high doses of Ephedra sinica was found to have high
blood pressure [66]. Theoharides [60] reported the sudden death of a 23-year-old male that was
related to ingestion of an ephedra-containing drink. Autopsy revealed myocardial necrosis and
cellular infiltration. Other case reports have described ventricular arrhythmias or myocardial inf-
arction in individuals consuming supplements containing ephedrine [50,51,72].
The case reports in the literature do not allow for determination of the overall incidence of
different adverse events possibly associated with the use of ephedrine or for all of the patient
populations that might be at risk from the use of these types of products. The available case reports
support the notion that the use of ephedrine is contraindicated for individuals with a history of
cardiovascular diseases, as ephedrine has been shown to have a pharmacologically stimulatory
effect on heart rate and cardiac output. Few case reports, however, have been published describing
serious adverse events in individuals without preexisting medical conditions. As ephedra-containing
products may also contain other stimulants or may be consumed with other stimulants, the exact
role of ephedra or the ephedrine alkaloids in these adverse events has been difficult to determine.
In addition to the published case reports, thousands of adverse reports were submitted by
consumers and healthcare workers to the FDA or manufacturers of ephedra products. To determine
the risk to consumers posed by products containing ephedra, at least four groups have independently
reviewed adverse event reports filed with the FDA or the manufacturers related to the use of
supplements containing ephedra alkaloids. In an initial investigation, Haller and Benowitz [33]
reviewed 140 reports of adverse events of ephedra that were submitted to the FDA between 1997
and 1999. Among these reports, 31% were “definitely” or “probably” related to the use of supple-
ments containing ephedra alkaloids, and another 31% were deemed to be “possibly” related.
Approximately, 47% of the events involved the cardiovascular system and 18% were related to the
central nervous system. The adverse events included hypertension, palpitations and/or tachycardia,
stroke, and seizures. Ten events resulted in death, and 13 events produced permanent disability.
The investigators determined that the use of ephedra products might pose a health risk to some
individuals.
Samenuk [55] also assessed adverse event reports filed with the FDA from 1995 to 1997. Of
the 926 cases of possible ephedra-related toxicity, these investigators identified 37 serious cardio-
vascular events. In these cases, the use of ephedra was temporally related to stroke (16 reports),
myocardial infarction (10), or sudden death (11). The use of ephedra was reported to be within the
manufacturers’ dosing guidelines in all serious cardiovascular events but one case. The investigators
concluded that the use of ephedra is temporally related to stroke, myocardial infarction, and sudden
death.
The Council of Responsible Nutrition [16] also investigated a total of 1173 adverse events filed
with the FDA. The database identified 69 reports of death following ephedra use. From the total
of 1173 reports, 121 were selected for further evaluation, and 47 were considered to contain serious
adverse events that included cases of stroke and stroke-like symptoms (15), seizures (13), cardiac
arrest (15), and 2 individuals who collapsed. Among the 121 cases, 8 were reports of death: 6 were
cardiovascular, 1 occurred in an automobile accident, and 1 was a spontaneous abortion. Four of
the six cardiovascular subjects were using ephedra with other performance-enhancing products,
such as caffeine. Autopsy results revealed that one patient had atherosclerotic cardiovascular disease
and another had myocardial disease due to chronic catecholamine use. Of the six patients, one
individual suffered from asthma. The report concluded that, based on the available information, it
was not possible to determine whether or not any unexpected toxicological effects occurred due to
the ephedra-containing dietary supplements.
The Texas Department of Health received reports of over 500 adverse events, including 7 deaths
due to myocardial infarction or stroke in patients who consumed supplements containing ephedrine
[12]. One of the makers of ephedra-containing weight loss supplements has turned over nearly
1500 consumer complaints to the FDA. These complaints included 14 alleging serious adverse
events (10 strokes, 2 heart attacks, and 2 seizures).
Ephedra Safety 501
The authors of the RAND [54] report reviewed 1820 case reports provided by the FDA, more
than 18,000 consumer complaints reported to a manufacturer of ephedra-containing dietary supple-
ments, and 71 cases reported in the published literature. The authors stated that the majority of the
cases were not well documented and hence decisions could not be made about the potential rela-
tionship between the use of ephedra-containing dietary supplements or ephedrine and the adverse
events. Of the available reports, 241 cases from the FDA, 43 cases from a manufacturer, and 65
cases from the published literature were analyzed. From these reports, adverse events with prior
ephedra consumption included 2 deaths, 3 myocardial infarctions, 9 cerebrovascular/stroke events,
3 seizures, and 5 psychiatric cases; adverse events with prior ephedrine consumption included 3
deaths, 2 myocardial infarctions, 2 cerebrovascular/stroke events, 1 seizure, and 3 psychiatric cases.
Approximately 50% of the events were noted in individuals 30 years of age or younger. Of the
remaining cases, 43 cases were identified as possible events with prior ephedra consumption and 7
cases as possible events with prior ephedrine consumption. The findings of this analysis raise
concerns about the risks posed by ephedra supplements; however, the majority of the case reports
were not documented sufficiently to support an informed judgment about the relationship between
the use of dietary supplements containing ephedra or ephedrine and the adverse event in question.
THE STORY AND LESSONS

As early as 1995, the FDA convened a special working group to evaluate the potential health effects
associated with dietary supplements containing ephedrine alkaloids [24]. Based on the group’s
recommendations, on June 4, 1997, the FDA proposed a rule to: (1) limit the total daily intake of
ephedrine alkaloids to 24 mg/day or 8 mg/6-hour period; (2) have the label state that the product
should not be used for more than 7 days; (3) prohibit the use of ephedrine alkaloids with substances
known to have a stimulant effect; and (4) require a specific warning label [25]. The proposed rule
was based on “serious illnesses and injuries, including multiple deaths, associated with the use of
dietary supplement products that contain ephedrine alkaloids.”
The FDA received over 15,000 comments in response to its proposed rule. The quality of
scientific information and adverse event reports supporting the rule was challenged by industry
groups and the Small Business Administration’s Office of Advocacy. The House Committee on
Science asked the General Accounting Office (GAO) to examine: (1) the scientific basis for the
FDA’s proposed rule, and (2) the Agency’s adherence to the regulatory analysis requirements for
federal rulemaking [27]. Following its investigations, the GAO concluded that, although the FDA
had justifiable concerns, the legitimacy of the adverse events reports to form the basis for the FDA’s
recommendation was questionable.
Following the criticism, on April 3, 2000, the FDA withdrew certain provisions of the proposed
rules, such as limiting the ingredient level and duration of use for these products [26]; however,
the FDA did not withdraw the proposed prohibition on the use of other ingredients with stimulant
effects with dietary supplements containing ephedra alkaloids. Subsequent to the FDA’s withdrawal,
additional reports of adverse events and case reports on ephedra safety continued to appear (see
Human Observations section). Bent et al. [73] found that the sale of products containing ephedra
accounts for only 0.82% of herbal product sales; however, their reported adverse events represent
64% of all adverse reactions to herbs in the United States. The investigators concluded that the use
of ephedra poses a greatly increased risk of adverse reactions compared with other herbs. Because
of increasing concerns that the use of dietary supplements containing ephedrine alkaloids (ephedra)
presents an unreasonable risk of illness or injury, on February 6, 2004, the FDA issued a final rule
prohibiting the sale of supplements containing ephedra.
Advocates for ephedra challenged the ability of the FDA to ban ephedra completely without
conclusively demonstrating danger at low doses. Based on inadequate safety data at lower doses,
on April 14, 2005, a federal district court in Utah struck down the FDA ban on ephedra. The court
determined that the use of a risk–benefit analysis by the FDA was against the intent of Congress
in passing the Food, Drug, and Cosmetic Act [1]. Although the ruling is specific only to Utah, it
calls into question the FDA ban in general. The ruling places the FDA in a unique situation. The
majority of evidence regarding ephedra risks is based on higher use levels or its use in combination
with other stimulants. Because the FDA placed a universal ban, it would be unethical to conduct
human studies of lower doses in order to establish safety.
The clinical trials of ephedra and its principle alkaloid, ephedrine, support the safety of ephedra,
but studies investigating adverse event reports and case studies raise concerns about the risks
associated with the use of ephedra [33,55]. The adverse event studies do not establish a direct
causal relationship between the injuries reported and the intake of ephedra. The adverse event
reports are voluntary and anonymous, thus making the reporting system somewhat unreliable.
Although some genuine adverse events may be underreported, false reports can be included, creating
erroneous information in the database. The differential conclusions drawn from the results of clinical
studies and from the adverse events analysis raise important question. Given that some of the
adverse events probably reflect real problems, it is important to understand the other contributing
factors. The adverse events of ephedra may be affected by other factors such as the dosage, duration,
underlying sensitivity, simultaneous use of other stimulants, contaminants, inconsistent potency, or
a combination of these factors. Some of these factors are discussed below:
• Dosage, duration, and user demographics — Overuse (both dosage and duration) of this
dietary supplement because of its conceived benefits is quite possible; thus, ephedra has
a potential for abuse. User characteristics such as sex, age, and race or ethnicity can also
affect the action of ephedra. Several reports of adverse events suggest the possibility of
ephedra overuse. Gurley et al. [32] concluded that the increased incidence of ephedra
toxicity results from accidental overdose, often prompted by exaggerated off-label claims
and a belief that “natural” products are inherently safe [32].
• Specifications — Marketed ephedra products are subject to variations because of differ-
ences in plant species (strain) and varying growth, harvest, and storage conditions. These
variations are likely to yield markedly different quantities of the active alkaloids, making
it difficult for consumers to find standardized products. In one study, the total alkaloid
content of ephedra products varied from 0 to 18.5 mg/dosage unit [32]. Available infor-
mation also demonstrates discrepancies between label claims for the ephedrine content
and the actual amount of ephedrine, as well as lot-to-lot variations in ephedrine content.
These variables are likely to add to the differential pharmacological effects of ephedra.
Recently, the U.S. Pharmacopoeia (USP) has initiated a service to test and certify dietary
supplements for ingredient contents and concentrations per label claim.
• Individual sensitivity — Inter-individual differences in the response to ephedra have been
reported. It is likely that some individuals may have inherent sensitivity to ephedra. It
is also possible that peoples with special health challenges may react differently to
ephedra. White et al. [67] reported wide variations in the blood pressure of individuals
taking ephedra.
• Drug and other product interactions — Because of the known pharmacological interac-
tions between ephedra and other products, individuals with a history of a psychiatric
illness, especially if being treated with monoamine oxidase inhibitors or other prescrip-
tion drugs, must consult a qualified healthcare provider before taking supplements. People
with underlying heart conditions, hypertension, diabetes, or thyroid disease should avoid
ephedra use, as the combination of ephedra and caffeine or caffeine-containing herbs
may lead to an increased heart rate and blood pressure [63].
In summary, as a result of several well-publicized adverse events and the FDA action, dietary
supplements containing ephedra has generated controversy. The findings that led to the FDA banning
the use of ephedra-containing dietary supplements and challenges by the manufacturers offer some
Ephedra Safety 503
lessons for the scientific community, regulatory agencies, healthcare practitioners, consumer advo-
cates, marketers, and the civil courts. As a plant product, the content of its pharmacologically active
constituents may be influenced by differences in species and strain, as well as in growth, harvest,
and storage conditions. In an effort to enhance its perceived weight-loss and body-building effects,
ephedra products are subject to the addition of a variety of adulterants, both economic and effica-
cious. Simultaneous use of drugs, dietary supplements, alcohol, illicit substances, and certain foods
(caffeine-containing products) can also influence the desired physiologic outcome. The adverse
events of ephedra appear to be affected by such factors as overuse, inconsistent potency (specifi-
cations), individual sensitivity, interactions with drugs and other products, and contaminants. Con-
trary to the analysis of adverse events, preclinical and clinical studies support the safety of ephedra
products. The FDA ban on the sale of all ephedrine-alkaloid dietary supplements, its challenge,
and the court ruling to limit the scope of the ban affect FDA procedures for creating rules and its
enforcement powers. The controversy still continues to swirl around ephedra, as the FDA is arguing
in trying to restore the ban.
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39 Dietary Supplementation
in Weight Loss:
A Dietitian’s Perspective
Betty Wedman-St. Louis
CONTENTS
Introduction ....................................................................................................................................507
Food vs. Dietary Supplements.......................................................................................................507
RDA and Weight Loss ...................................................................................................................508
Making Wise Food Choices...........................................................................................................508
Biochemical Individuality..............................................................................................................508
Environmental Factors ...................................................................................................................509
Nutrition Protocols.........................................................................................................................509
Nutritional Supplements ................................................................................................................509
Why Dietary Supplements .............................................................................................................510
Guidelines for Supplements in Weight Loss .................................................................................510
Weight-Loss Surgery......................................................................................................................510
Evidence-Based Dietetics Practice ................................................................................................511
References ......................................................................................................................................511
INTRODUCTION
Over the past 30 years in dietetics practice, many diets and weight-loss schemes have come and
gone. During this period, it has become increasingly apparent that healthy and effective long-range
programs for weight loss should combine a nutritious diet, dietary supplement use, and lifestyle
changes. Reduced food intake due to inactive lifestyles make dietary supplements an important
adjunct in a world of less than perfect food choices.
FOOD VS. DIETARY SUPPLEMENTS

Food is not the sole source of nutrients that the human body can use to meet its dietary requirements,
as schools of dietetics have taught for the past 50 years. Science has provided structure and function
data on vitamins, minerals, and numerous phytonutrients so they can be produced to supplement
diets when individuals cannot eat or do not choose food wisely. As a dietitian with over 30 years
of experience, I have yet to plan the perfect diet for a person that meets all the daily nutrient
requirements modified for that individual’s health needs and food preferences. Randolph [1] stated
it best when he described the difference between analytical vs. biological dietetics. Foods can be
analyzed for nutrient content and organized into a meal plan, but that does not mean that the same
food meets the biological needs of the person consuming it. Food storage, food preparation,
drug–food interactions, and individual genetic differences mean the menu and food choices must
507
be customized to the individual. Dietary supplements can be added to ensure adequacy until dietetics
research can provide more definitive answers.
RDA AND WEIGHT LOSS

Dietetics has relied on the Recommended Dietary Allowances (RDA) and government guidelines
for assessing nutritional adequacy of diets. Using the RDA is not good science for an individual
weight-loss regime. As Williams [2] pointed out: “Nutrition is for real people. Statistical humans
are of little interest.” The “average” person on which the RDA is based does not exist in weight-
loss clinics.
MAKING WISE FOOD CHOICES

Inadequate research has been done on whether most individuals can routinely select a healthy diet.
Dietetics training emphasizes cultural and lifestyle practices as determinants of food selection. If
wise food choices are learned from example at the family dinner table, then what happens when
families do not sit down to dinner or lunch or breakfast? Eating habits learned as children affect
eating patterns throughout life. As children have become less active, obesity has resulted from their
selection of highly processed foods mass produced from white flour and sugar which, according
to Haas [3], provide useless calories with few nutrients. Haas also believes that, “We require more
food on this kind of diet to obtain all our needed nutrients.” The selection of foods in the standard
American diet (SAD) generates “a diet rich in refined sugars such as high-fructose corn syrup,
saturated fat, and trans-fatty acids and low in fiber, legumes, nuts, fruits and vegetables, essential
fatty acids, essential nutrients, and phytonutrients” [4]. Unfortunately, many individuals in weight-
loss programs are unable to significantly or permanently change their eating habits or alter their
dependence on convenience foods. The self-selection of foods was studied in the 1940s before the
days of television and mass media advertising. At that time, most people ate because they were
hungry; they selected what they liked and stopped eating when they were full [2]. That is not the
case today for the thousands of weight-loss clients I have counseled.
Alcohol and sugar calories are a major factor in many obesity cases. Williams [2] reported
several examples of rat studies and their desire for alcohol with and without diets supplemented
with vitamins. Rats supplemented with vitamins did not consume alcohol like the depleted animals.
In other experiments by Williams, rats on nutrient-depleted diets consumed more sugar than when
their nutritional needs were better met. How much we can infer in human nutrition from these rat
studies is subject to debate, but when trying to establish dietary supplement protocols for individuals
it is worth keeping the animal studies in mind.
BIOCHEMICAL INDIVIDUALITY
Williams [2] broadened the perspective of nutrition requirements with his simple thesis that all
human beings are biochemically unique; therefore, we metabolize nutrients differently. Recent
scientific advances in the study of individual genetic variations have confirmed Williams’ hypothesis
of many years ago. We now know that individual nutrient needs are a function of not only genetic
differences but also differences in genetic expression, as influenced by many environmental and
lifestyle factors. Such variations may also be contributors to weight management issues, as no two
humans have the same genes — not even identical twins. Williams emphasized that chemical
reactions in the body and in specific organ systems vary in efficiency from person to person, and
these reactions are influenced by the nutritional status of every cell in the body [2]. A personalized
diet and nutrition supplementation program is needed for each individual based on that person’s
genetics, environment, and lifestyle.
Dietary Supplementation in Weight Loss: A Dietitian’s Perspective 509
ENVIRONMENTAL FACTORS
Contradictory diet and nutrition advice for weight loss appears daily in print and electronic media.
Not long ago, an individual came into my office raving about buying “healthy” margarine instead
of butter as her weight-loss goal of the week. When I asked why she had decided to do so (because
the caloric differences are insignificant), her reply was that a television ad had stated that it was
healthier and she thought she could use more on her baked potato. As Nestle [5] stated, “Making
a high-fat, high-calorie table spread appear to be a health food seems a pessimistic approach to
dietary change; it assumes that consumers will ignore advice to cut down on high-calorie table
fats.” Nestle further discusses the economic impact of these margarines with a quotation from The
London Times [6]: “Eating four daily teaspoons of Finnish wood pulp [Benecol®] disguised as a
margarine may lower cholesterol, but it will cost as much as the rest of your breakfast.”
NUTRITION PROTOCOLS
As a registered dietitian, I lacked the nutrition protocols for counseling weight-loss patients until
I met Dr. Jeffry Bland, founder and board chairman of the Institute for Functional Medicine. Bland
provided the nutrition guidelines necessary for identifying and following biomarkers in weight-
management cases. In addition to helping me recognize the extent to which chronic symptoms (i.e.,
inflammation, food sensitivity, and metabolic syndrome) can affect weight management, the institute
provided a framework for understanding the importance of the mind–body relationship in promoting
healthy weight loss [4]. Protocols are important in guiding the nutrition counselor in making
assessments with appropriate treatment plans. It has been my experience that individuals seeking
weight-loss counseling do not care about how many scientific studies promoting or not promoting
dietary supplements have been done and the outcomes. They just want to know if they can be
helped. They do not care to read the science. They only want to know that their healthcare provider
has read it and what the treatment plan involves.
NUTRITIONAL SUPPLEMENTS
Traditional clinical nutrition and dietetics resources fail to provide nutrition supplementation pro-
tocols, but Functional Medicine symposiums provide the needed resources to develop nutrition
protocols in assisting weight-loss clients. Weight issues are usually a factor in cases of rheumatoid
arthritis, systemic lupus erythematosus, multiple sclerosis, and fibromyalgia, as well as hyperlipi-
demia, metabolic syndrome, and premenstrual syndrome. All of these conditions, and numerous
others, need to be evaluated for possible nutrient deficiencies that could assist in the clinical
management of these patients [7]. As examples, when obesity was a major nutritional factor for
two multiple sclerosis cases, high doses of linoleic acid (almost 10 times the Dietary Reference
Intake) were recommended [8]. A lupus patient who wanted to lead a normal life without dialysis
challenged all the nutritional biochemistry available in standard dietetics manuals until a librarian
found a journal article describing high levels of pantothenic acid and vitamin E being used for the
treatment of lupus erythematosus [9]. Nutritional supplementation is not the standard of care, despite
increasing medical literature citations. Vanadium (vanadyl sulfate) has rarely been mentioned as
an adjunct to weight loss in syndrome X. As a result of a study by Boden et al. [10] of the effect
of vanadyl sulfate on carbohydrate and lipid metabolism, its use has become a standard of practice
for non-insulin-dependent diabetes mellitus (NIDDM) cases with elevated triglycerides.
These are only a few examples of how dietary supplements have been used to assist weight-
loss clients. As one individual boldly stated during a counseling session, “I came here to get your
professional opinion on what dietary supplements to take and how much. I’m not interested in what
the FDA or pharmaceutical studies say. I am paying you for your expertise because I don’t have
10 or 20 years until they decide nutrition may be helpful.”
WHY DIETARY SUPPLEMENTS

Five key reasons given to clients for recommending dietary supplements as part of their weight-
loss regime are:
• Food intake in the standard American diet does not meet dietary recommendations for
numerous nutrients.
• Dietary supplements are safe within a broad range of doses.
• Science had demonstrated the health benefits of high levels of some nutrients such as
folic acid and vitamin D.
• Criticism of supplement doses in excess of the RDA are overstated; “expensive” urine
and feces may result, but that is of little relevance in disease management.
• Herbs and botanicals were the original sources of pharmaceutical drugs, and they generate
many orders of magnitude fewer unplanned side effects.
A healthy diet is the keystone of good health because food provides many substances not yet
identified or available as dietary supplements. In weight-loss regimes, however, individuals may
need the placebo effect of dietary supplements [11], in addition to the enhanced nutrient benefits.
GUIDELINES FOR SUPPLEMENTS IN WEIGHT LOSS

Individualization of meal plans and nutrient supplement regimes is helpful for many tackling body
fat issues. Many people need a handy guide to selecting dietary supplements so they can evaluate
whether they are getting too high a dose when they combine different capsules, bars, and drinks.
A general guideline offered in our weight-loss clinic is provided in Table 39.1.
WEIGHT-LOSS SURGERY
Weight-loss surgery for extreme obesity is often an option for those with life-threatening chronic
diseases. An extreme diet is used to force the body to reduce excess fuel stored as body fat; however,
the surgery creates serious nutritional disorders postoperatively that are often overlooked by both
physicians and surgery survivors. The dramatic increase in bariatric surgeries from 63,000 in 2002
to 103,000 in 2003 and over 150,000 in 2004 requires that dietetics professionals be assertive in
meeting the nutritional needs of these patients [12]. Many insurance companies require nutrition
counseling before surgery but fail to see the importance of postsurgery counseling until malnutrition
becomes life-threatening. Bariatric surgery costs $25,000 to $50,000, so a reasonable use of dollars
would be to cover nutrition counseling after surgery to be sure that adequate dietary supplementation
is being followed.
Presurgery nutritional supplementation reduces mortality rates. Flum et al. [13] studied gastric
bypass surgery patients for 15 years and found that 88.2% were more likely to be alive if they had
the surgery compared to 83.7% of those who did not have the surgery; thus, gastric bypass surgery
is a cost-effective means of reducing overall mortality among the obese [14]. After the surgery, patients
consume a clear liquid diet for the first week, and liquid dietary supplements are recommended to
maintain lean muscle mass and improve immune function [12]. By week two, they are taking chewable
nutrient supplements and eating soft protein foods. Crushed prenatal supplements are highly recom-
mended for the next 6 months, but many individuals get too interested in how much weight they are
losing to stay healthy with nutrition choices. By the eighth week, each weight-loss surgery patient
should be evaluated for anemia; additional iron, folic acid, and vitamin B12 may be necessary [12].
Unfortunately, within 6 months many people begin to regain weight because they are adding high-
calorie foods back into their diet. Beverage consumption also increases calorie levels. Bariatric surgery
patients who continue to overeat postoperatively seldom reach a healthy weight and suffer nutritional
deficiencies because inadequate attention is being given to dietary supplementation.
Dietary Supplementation in Weight Loss: A Dietitian’s Perspective 511
TABLE 39.1
Dietary Supplements For Weight Loss
Ingredient Amount Ingredient Amount
Vitamin A 2000–5000 IU Biotin 500–1000 µg
Beta-carotene 10,000–20,000 IU Vitamin C 2000–5000 mg
Vitamin D 800–1000 IU Bioflavonoids 250–500 mg
Vitamin E 400–800 IU Calcium 800–1200 mg
Vitamin K 200–300 µg Chromium 400–500 µg
Thiamine (B1) 75–150 mg Copper 2–3 mg
Riboflavin (B2) 50–100 mg Iron (women) 15–25 mg
Niacinamide (B3) 75–150 mg Magnesium 400–800 mg
Pantothenic acid 250–500 mg Manganese 5–10 mg
Pyridoxine (B6) 50–100 mg Selenium 200–400 µg
Pyridoxal 5 phosphate 100–200 mg Zinc 20–50 mg
Cobalamin (B12) 500–1000 µg CoQ 10 30–100 mg
Folic acid 800–1000 µg Omega-3 fatty acids (EPA and DHA) 1000–12000 mg
EVIDENCE-BASED DIETETICS PRACTICE

As Dr. Sidney Baker stated in 1993 at the Symposium on Man and His Environment in Health and
Disease, each healthcare practitioner must determine whether “you see what you believe or believe
what you see” [15]. Nutrition counseling has given me the opportunity to believe what I see, and
dietary supplements really can make a difference in weight loss, as well as in other chronic disease
management. Dr. Mark Hyman described nutrition as being a young science: “The view of nutrition
as simply a source of energy or calories to prevent malnutrition and micronutrients to prevent
deficiency diseases is being supplanted by a new conception of nutrition in health and disease” [4].
The calories-in vs. calories-out model of weight management is too simplistic to explain the
obesity crisis. Both macro- and micronutrient components of the diet need to be evaluated with
regard to their influence on thermodynamics because calorie counting is obsolete as far as changing
eating habits. Science has shown that dietary supplements can help upgrade the metabolic processes
of detoxification and toxic overload found in many chronic diseases such as obesity [4]. The food
industry and researchers need to focus more on these uses of nutrients rather than on reducing
calories through sugar substitutes and fat replacers.
Evidence-based guidelines for additional nutrient use among Americans who spend more than
$20 billion annually on herbal and dietary supplements [16] is greatly lacking. The argument that
dietary supplements lack safety and efficacy data does not make a difference to those individuals
in weight-loss programs who seek increased energy to get physically active plus the enhanced
health and sense of well-being that they believe comes from using them. Choosing quality manu-
facturers with outstanding safety and efficacy records is essential when recommending nutritional
supplements in weight-loss programs [17].
REFERENCES
[1] Randolph, T.G., Human Ecology and Susceptibility to the Chemical Environment, Charles C Thomas,
Springfield, IL, 1962.
[2] Williams, R.J., Biochemical Individuality: The Basis for the Genetotropic Concept, Keats Publishing,
New Canaan, CT, 1956.
[3] Haas, E.M., Staying Healthy with Nutrition: The Complete Guide to Diet and Nutritional Medicine,
Celestial Arts, Berkeley, CA, 1992, pp. 375–383.
[4] Jones, D.S., Ed., Textbook of Functional Medicine, Institute for Functional Medicine, Gig Harbor,
WA, 2005.
[5] Nestle, M., Food Politics: How the Food Industry Influences Nutrition and Health, University of
California Press, Los Angeles, 2002, pp. 330–333.
[6] Rumbelow, H., Food that cuts cholesterol has a fat price, The Times (Lond.), March 30, 1999, p. 8.
[7] Levin, B., Environmental Nutrition: Understanding the Link Between Environment, Food Quality, and
Disease, HingePin, Vashon Island, WA, 1999, pp. 58–61.
[8] Bates, D., Fawcett, P.R.W., Shaw, D.A. et al., Polyunsaturated fatty acids in treatment of acute remitting
multiple sclerosis, Br. Med. J., ii, 1390–1391, 1978.
[9] Welsh, A.L., Lupus erythematosus: treatment by combined use of massive amounts of pantothenic
acid and vitamin E, Arch. Dermatol. Syph., 70, 181–198, 1954.
[10] Boden, G., Chen, X., Ruiz, J. et al., Effects of vanadyl sulfate on carbohydrate and lipid metabolism
in patients with non-insulin dependent diabetes mellitus, Metabolism, 45, 1130–1135, 1996.
[11] Lipton, B., The Biology of Belief: Unleashing the Power of Consciousness, Matter and Miracles,
Mountain of Love/Elite Books, Santa Rosa, CA, 2005.
[12] Scheier, L., Bariatric surgery: life threatening risk or life-saving procedure?, J. Am. Diet. Assoc.,
104(9), 1338–1340, 2004.
[13] Flum, D.R., Salem, L., Elrod, J.A, et al., Early mortality among Medicare beneficiaries undergoing
bariatric surgical procedures, JAMA, 294, 1903–1908, 2005.
[14] Craig, B.M. and Tseng, D.S., Cost effectiveness of gastric bypass for severe obesity, Am. J. Med.,
113, 491–498, 2002.
[15] Baker, S.M., The relationship of chemical interaction on the nutritional chain, in Proc. of Symp. on
Man and His Environment in Health and Disease, Human Ecology Research Foundation, Dallas, TX,
1993.
[16] Anon., Natural Supplements: An Evidence-Based Update, Scripps Center for Integrative Medicine,
LaJolla, CA, 2006.
[17] Poston, W.S.C. and Haddock, C.K., Eds., Food as a drug, Drugs Soc., 15(1/2), 1, 2000.
Part VII
Child Obesity and Prevention
40 Treatment and Prevention

of Childhood Obesity
and Associated
Metabolic Diseases
Michael I. Goran, Jaimie N. Davies, and Louise A. Kelly
CONTENTS
Introduction and Scope of the Problem.........................................................................................515

Primary Prevention Trials ..............................................................................................................516
Studies Using Physical Activity for Secondary Risk Reduction ..................................................517
Dietary Approaches for Secondary Risk Reduction .....................................................................519
Pharmacological Approaches.........................................................................................................521
Summary and Implications: Concept of Multiple Targets for Treatment and Prevention ...........521
References ......................................................................................................................................523
INTRODUCTION AND SCOPE OF THE PROBLEM

Over the past 20 years, the percentage of overweight adolescents in the United States has increased
more than threefold, from 5% to 16%, and the percentage of overweight in children ages 6 to 11 years
increased from 5% to 15% [67]. The prevalence of overweight is even more striking among certain
ethnic groups. In the United States, for example, recent data show that 44% of Latino and 40% of
African-American adolescents (ages 12 to 19 years) are considered overweight (above the 85th per-
centile for age and gender as defined by the Centers for Disease Control and Prevention), which is
approximately double the prevalence in Caucasians [67]. The rise in childhood obesity has been
associated with an increase in the incidence of type 2 diabetes in children and adolescents [27,65,69,78],
as well as other metabolic diseases such as the metabolic syndrome [15,16,18,57,71], polycystic ovarian
syndrome [39], and nonalcoholic fatty liver disease [33,72]. The increased prevalence and incidence
of pediatric overweight over the last 15 to 20 years and its association with metabolic diseases early
in life have prompted health organizations and scientific associations to advocate for increased attention,
resources, and research to address this emerging health crisis through prevention and treatment initia-
tives. Major health-related organizations have released policy statements and calls for action related to
pediatric obesity over the last few years, including the U.S. Institute of Medicine [51], the World Health
Organization [2], and the American Academy of Pediatrics [17,52].
In addition to these policy reports, numerous reviews have been published highlighting prom-
ising research and underscoring the need for additional study of pediatric overweight prevention
and treatment strategies [19,73,86]; however, very few intervention studies have been designed to
specifically address the underlying metabolic abnormalities. As reviewed below, most typical
weight-management programs for youth have been based on the traditional energy-balance model
515
and have utilized restrictive diets, behavior modification techniques, physical activity, and drugs,
but these approaches have generally not been successful and do not necessarily address insulin
resistance and the underlying risks beyond weight loss. In addition, a recent study shows that dieting
approaches are generally ineffective in children and adolescents and may actually promote weight
gain [32]; thus, as was concluded in a recent Cochran review, conventional approaches targeting
weight management in children have not been effective. Currently, only limited quality data on the
effects of obesity treatment programs are available, so no generalizable conclusions can be drawn
with confidence [87]. The purpose of the discussion that follows is to review intervention studies
that have addressed metabolic abnormalities related to the primary prevention of obesity and a
reduction in obesity-related chronic disease risk beyond weight reduction.
PRIMARY PREVENTION TRIALS

Very few primary prevention trials targeting obesity in children have been conducted, but several
recent studies conducted in the United States are reviewed here. Planet Health is a school-based
intervention developed and tested by investigators at the Harvard School of Public Health [38].
The school-based intervention was based around four simple health themes integrated into physical
education (PE), language, arts, math, science, and social studies classes in a sixth- to eighth-grade
curriculum. The program encourages active, inquiry-based learning; emphasizes literacy across the
curriculum; addresses national learning standards; and incorporates staff training, classroom les-
sons, PE curriculum, and incentives to teachers. The curriculum was studied in a 2-year randomized
trial in 10 public middle schools [38]. The study found an overall significant treatment effect for
obesity reduction in girls, but not boys. A significant reduction in television viewing was observed
(0.6 hr/day for girls, p < 0.001; 0.4 hr/day for boys, p < 0.001) but no significant change in moderate
to vigorous activity in either boys or girls (as measured by the Youth Activity Questionnaire). Some
significant dietary changes in girls were found, including an improvement in fruit and vegetable
intake of 0.32 servings/day, a 575-kcal/day reduction in reported energy intake, and a marginal
improvement in percent calorie intake from fat.
Another study by Robinson et al. [77] focused exclusively on a curriculum for promoting
reduced television viewing in children. A randomized pilot trial conducted in 192 third- and fourth-
grade children from two schools provided 18 classroom-based lessons over 6 months. The inter-
vention led to a significant reduction in television viewing, from 14.5 hr/wk to 8.8 hr/wk, with no
change over time in control children as measured by questionnaire. The reduction in television
viewing was associated with a small but significant reduction in body mass index (BMI) over 6
months in treatment relative to control children (18.4 to 18.7 kg/m2 in intervention vs. 18.1 to 18.8
kg/m2 in control; adjusted difference, –0.45 kg/m2; p = .002). Similar patterns were noted for triceps
skinfold thickness (adjusted difference, –1.47 mm; p = 0.002) and waist circumference (adjusted
difference, –2.30 cm; p < 0.001).
Although the two studies reviewed above used conventional curriculum strategies (paper
and pencil), the use of novel multimedia teaching approaches has been recognized as one of
the most important ways to improve the status of nutrition education in children [1], and
computer-assisted behavioral counseling has been shown to be effective in various studies in
high-school students [11], undergraduate students [56], and fourth-grade children [7]. Interactive
multimedia, therefore, offers tremendous potential as a medium to develop for the delivery of
school-based health promotion and education tools; such an approach can also incorporate
family involvement and can be designed around effective models of behavior change. One
previous study developed a multimedia game called “Squire’s Quest” and focused on improving
fruit and vegetable intake in fourth-grade children. The intervention was delivered in 10 class-
room sessions over 5 weeks and led to a significant increase in total fruit and vegetable
consumption by 1 serving per day ( p < 0.05) [7]. A family-based Internet intervention [98] has
Treatment and Prevention of Childhood Obesity and Associated Metabolic Diseases 517
also been used to promote weight loss in overweight African-American girls (11 to 15 years)
and their parents. Also, among adults an Internet weight-loss intervention was shown to be more
effective when supplemented by e-mail-based counseling [89].
A childhood obesity prevention trial by Goran and Reynolds [36] evaluated the use of a novel
interactive CD-ROM for promoting increases in physical activity and reducing obesity in young
U.S. children. The Interactive Multimedia for Promoting Physical Activity (IMPACT) curriculum
was based on an interactive, animated cartoon adventure that was based on social learning theory
and designed for fourth- and fifth-grade children. It consisted of eight weekly sessions, each
featuring two to three interactive computer-based games that were supplemented by classroom and
take-home activities. A randomized trial was conducted in four schools with before and after
measures that included height, weight, and physical activity by accelerometry and a psychosocial
questionnaire related to physical activity. No significant treatment effects on total physical activity
by accelerometry were observed, and, contrary to the hypothesis, a treatment effect was observed
with regard to a reduction in the percent of time spent in moderate-intensity activity (16.5% of
time in moderate intensity was reduced to 15% of time). A significant gender by treatment inter-
action was observed for the percentage of time spent in light-intensity activities (reduction in boys
from 78% to 75% and an increase in girls from 78% to 81%). Significant overall improvements in
behavioral outcomes related to physical activity were found, including self-efficacy (“I can do it”),
social norms (“It’s cool”), and outcome expectancies (“It’s good for me”). These subtle changes
in physical activity were related to significant gender by treatment interactions for BMI z-score (p
= 0.016) and percent body fat (p = 0.009), such that there was a significant treatment effect for
obesity reduction in girls but not boys.
This latter study [36] shows that even very subtle changes in both the qualitative and quantitative
aspects of physical activity can be beneficial for obesity prevention. The increase in light-intensity
activity in girls translated to approximately 24 minutes per day (approximately 36 kcal/day assuming
that the light activities averaged 1.7 METS), and this subtle change was sufficient to reduce obesity
indices, even though it was counteracted by a reduction in moderate-intensity activities in the region
of 8 minutes per day (approximately 20 kcal/day assuming moderate activities are 2.5 METS). The
small net increase in energy expenditure of ~16 kcal/day, or almost 1000 kcal over the 8-week
intervention, can potentially explain small changes in body weight over time [37].
STUDIES USING PHYSICAL ACTIVITY

FOR SECONDARY RISK REDUCTION
In adults, regular physical activity and high levels of physical fitness are associated with reduced
chronic disease risk [35,44,49,53,54]. Cross-sectional studies in children have shown a positive
influence of activity and fitness on disease risk [55,81], but others have shown no effect [6,42].
Unfortunately, few randomized controlled trial (RCT) intervention studies have been conducted in
youth to examine the effects of physical activity or exercise on obesity reduction and chronic disease
risk reduction. A summary of findings is presented here with a focus on effects on reducing chronic
disease risk.
Controlled intervention studies suggest that exercise intervention in children may or may not
have beneficial effects on obesity, depending on the nature and intensity of the intervention. Project
SPARK was a large-scale study that randomly assigned seven U.S. elementary schools to receive
physical education via the usual mechanisms, trained teachers, or specialized instructors [80]. A
nonsignificant trend was observed for children exposed to specialized physical education to have
lower total body fat after 2 years. Results from other school-based studies that included physical
education are controversial, with some showing no changes in obesity indices [12] and others
showing improvements [50,74,93].
Other physical activity interventions have been conducted outside of the school setting. Fer-
guson et al. [31] reported that 4 months of intensive aerobic-type exercise training without dietary
intervention (5 days a week for 4 months; 40-minute training sessions at a heart rate of >150 beats
per minute) in obese boys and girls (n = 79) resulted in significant decreases in percent body fat
(by DEXA) as well as fasting insulin and triglyceride levels over control children (p < 0.05).
Although the authors were unable to determine whether reductions in insulin and triglyceride levels
were a result of parallel decreases in body fat, these findings support the notion that increases in
moderately vigorous physical activity can lead to improvements of metabolic risk profile in over-
weight children. In contrast, another study from the same group [41], a comparison of 10-week
programs for 7- to 11-year-old obese African-American girls, found that neither aerobic training
(n = 12) nor lifestyle education (n = 10) led to improvements in fasting insulin levels. Although
some other investigations [48,97] in youth provide evidence that increased moderately vigorous
physical activity can lead to improvements in the metabolic and cardiovascular risk of overweight
children, the mechanisms of these improvements remain largely unclear. Furthermore, whether
improvements in risk profile lead to decreases in future diabetes or cardiovascular disease outcomes
has yet to be determined.
Although most studies in pediatrics have implemented aerobic training as a modality of exercise,
evidence from adults [13,14,79,91] suggests that incorporation of strength training (resistance
training) may be important for improving insulin sensitivity, body composition (increased muscle
mass and decreased fat mass), and fat redistribution (reduced visceral fat and intramyocellular lipid
[IMCL]). Resistance training has also been shown to improve insulin sensitivity and glucose
regulation in adults with impaired glucose tolerance or type 2 diabetes [20,23,83]; however, further
studies are necessary to identify whether these effects are mediated through changes in body
composition or other mechanisms. One previous adult study, for example [70], showed that improve-
ment in insulin sensitivity after resistance training disappeared once the data was normalized for
fat-free mass, suggesting that the increased glucose disposal rate was due to a mass effect rather
than an alteration in the intrinsic properties of the skeletal muscle.
Resistance training may, therefore, be an important exercise modality for overweight youth.
Several organizations, including the American Academy of Pediatrics, have recently endorsed
resistance training (with appropriate supervision and instruction) as a safe activity for children and
adolescents that provides a means of improving strength and decreasing the risk of sports-related
injuries [29]. To date, however, most resistance training studies in younger populations have focused
on issues related to safety, strength improvements, and musculature changes [28,30]. One prior
study [88] examined a 6-week program that combined a dietary intervention (low energy, 20 to
25% calories from fat, high in complex carbohydrate) with strength training in obese children. The
main outcomes in this study focused on lipid profile, which improved after the intervention (6%
reduction in total cholesterol). We have published reports on a resistance training trial with 12
overweight Caucasian girls [91,92]. This study showed that resistance training (20-minute sessions,
3 days/wk for 5 months) led to increased strength and improvement in visceral fat. Small improve-
ments in glucose tolerance and insulin levels (determined using an oral glucose tolerance test) were
noted, but these changes did not achieve statistical significance. In another study recently published
[82], 16 weeks of twice-per-week progressive resistance training in Hispanic males (15.2 ± 1.7
years; Tanner stage, 3 to 5; BMI percentile, 97.7 ± 2.8) led to a significant increase in insulin
sensitivity in the training group by 45.1 ± 24.2% vs. no change in the control group (–0.8 ± 40.7%).
The between-group difference in change score was highly significant (p < 0.001) even after
controlling for changes in body composition.
Given the increasing prevalence rates of pediatric obesity and related metabolic diseases, the
use of resistance training seems to offer good potential to improve metabolic health, and further
studies using this approach seem warranted. Moreover, resistance training may be a practical form
of exercise, especially for very overweight children who may be extremely challenged by the
difficulty in performing typical aerobic exercise interventions. In contrast, it seems very likely that
resistance training may be a form of exercise that overweight children will succeed at, and they
should be able to see quick results that will encourage them to continue in an intervention. Given
the additional benefits of aerobic exercise, interventions combining both cardiovascular and resis-
tance training could be hypothesized to have maximal benefits; however, only two studies to our
knowledge have incorporated both aerobic exercise and strength training. The Physical Activity for
Total Health (PATH) study [63] developed and evaluated the health effects of an 11-week circuit-
training intervention that consisted of 30-minute classes five times a week; the subjects (346
minority students, 14 to 17 years of age) alternated between aerobic exercise stations and strength-
training equipment. The female students in this study had significant improvements in cholesterol
(a 10% reduction) and cardiovascular fitness (a 15% increase in VO2max) compared to controls,
whereas results for the male students were not significant. A study by Watts et al. [95] found that
an 8-week circuit-training intervention, consisting of three 1-hour sessions per week, significantly
decreased abdominal and trunk fat and improved fitness and muscular strength in obese adolescents.
In summary, current research suggests that physical activity interventions in overweight youth
are efficacious for improving overall body composition [58]; however, studies are often difficult to
interpret and compare due to the diversity of methodological approaches used to assess physical
activity, differences in data analysis and reporting, and the adoption of varying definitions for what
constitutes an appropriate level of activity, all of which makes a summary and comparison of
findings difficult. Perhaps more importantly, however, physical activity interventions in overweight
youth may improve the disease risk profile of overweight children [31,40,48,90,96]. Further research
is warranted to address the many questions that remain regarding the optimal frequency, intensity,
duration, and mode of activity necessary to invoke risk profile improvement.
DIETARY APPROACHES FOR SECONDARY RISK REDUCTION

The most successful long-term studies of obesity reduction in children have been reported by
Epstein et al. [26]. The dietary component of these successful family-based behavioral interventions
have used what is called the “Traffic Light Diet,” which is based on the Food Guide Pyramid; the
diet differentiates food choices based primarily on fat content. Other expert dietary recommenda-
tions for children have been nonspecific and have promoted well-balanced, healthy meals based
on the Food Guide Pyramid [9], nutritionally balanced meals to support growth [17], and a general
emphasis on a reduction in dietary fat intake rather than on types of fat or carbohydrate in the diet.
Current clinical treatment guidelines are therefore generally based on empirical evidence and expert
opinion [8].
Remarkably few good-quality RCT studies have examined nutritional approaches for reducing
obesity and chronic disease risk factors in children. Most studies have focused on diet and weight
loss and have been conducted primarily in Caucasian children. In terms of risk reduction, most previous
studies have examined dietary intervention for lipid improvement in children. The Dietary Intervention
Study in Children (DISC) examined the effects of nutrition education on lipid profiles in 663 mostly
Caucasian children (8 to 10 years of age at baseline) over 3 years [66]. A small but significant 8%
reduction in low-density lipoprotein (LDL) cholesterol was sustained 2 years after the intervention
ended; however, both control and intervention groups showed a general trend of increasing triglyceride
levels, indicating that other dietary combinations may be required to have beneficial effects on multiple
risk factors. The Child and Adolescent Trial for Cardiovascular Health (CATCH) sought to improve
diet and physical activity in a national study involving 5000 children (mean age, 8.8 years at baseline)
from almost 100 schools. Despite improvements in self-reported diet and physical activity in schools,
effects on overall dietary intake and physical activity were very limited, and no significant changes
were observed in obesity measures, blood pressure, or cholesterol [61].
Based on our review of the literature, we conclude that more specific, targeted, and individu-
alized dietary approaches are needed for risk reduction in overweight children. Specifically, good
evidence suggests that modification of the types and quality of carbohydrates in the diet may be
effective for improving insulin sensitivity and reducing insulin secretion and may also contribute
to weight loss. This dietary strategy may be more effective than previous interventions to reduce
calories or the proportion of calories from carbohydrate in the diet [43]. In particular, diets enriched
with whole-grain carbohydrates, foods that elicit a lower glucose response, and foods higher in
fiber have been shown to have beneficial effects. In a cross-sectional study in adolescents, whole-
grain intake was associated with a lower BMI as well as improved insulin sensitivity [84]. In
addition, epidemiological studies show that the intake of whole grains is associated with protection
from type 2 diabetes [64], as well as coronary artery disease [85]. Dietary fiber, especially soluble
fiber (e.g., psyllium), has beneficial effects on blood glucose control and blood lipids [21,45,59].
Fiber intake also has beneficial effects on regulating food intake (induces satiation and satiety) and
can improve glycemic control and reduce lipids [60].
These carbohydrate effects may work through improvement in the glycemic load (a measure
of how much glucose is released into the blood after ingestion of a particular food). Foods with
low glycemic values have been hypothesized to be beneficial for reducing the risk for type 2 diabetes
because they reduce the demand for high levels of insulin secretion [43]. In both short-term [25]
and long-term [24] studies in obese children, a low glycemic index has been shown to reduce
plasma glucose and improve insulin resistance. An additional benefit is that voluntary food intake
tends to be lower after consumption of foods with low glycemic index values [76]. A recent
12-month intervention in obese children showed that promotion of a diet with a low glycemic index
led to greater weight loss and improvement in insulin resistance than did promotion of a typical
low-fat diet [24]. Another study in children has shown that a low-glycemic-index breakfast meal
led to a reduced calorie intake at lunch [94]. The low-glycemic-index approach also tackles the
issue of soda and juice intake. Replacement of sugary drinks with water or lower sugar versions
may also result in improved glucose control. In fact, a recent school-based intervention over 3 years
in Native American youth that promoted water intake and reduced consumption of sugared bever-
ages led to significant improvements in fasting glucose and insulin response [75].
Very few studies have designed and tested culturally tailored nutrition-based interventions.
Among Hispanics, evidence suggests that utilizing foods with lower glycemic index values while
retaining a Hispanic-style diet can improve glucose control and lipids in Hispanics patients with
type 2 diabetes [46,47]. We have previously shown that overweight Latino children consume
approximately 16% of their daily caloric intakes from simple sugars, and 50% of this amount comes
from sugary beverages. These high intakes of total and added sugar and sugary beverages were the
only dietary components associated with poor beta-cell function, after controlling for adiposity,
gender, and Tanner stage [22]; thus, interventions focusing on reducing sugar intake in this popu-
lation may be prudent.
We developed a 12-week nutrition intervention program focused on carbohydrate modification
(decrease in simple sugars and increase in fiber) tailored specifically for overweight Latina female
adolescents. The focus of this intervention was on identifying and promoting dietary exchanges
rather than on weight and calorie restriction; the program used a combination of customized recipes
and activities and motivational interviewing techniques. We also tested whether delivery of the
intervention would be more effective using individualized sessions in the home environment as
compared to group classes. The nutrition program resulted in significant reductions in added sugar,
sugary beverages, and refined carbohydrate intake and significant increases in dietary fiber intake.
Surprisingly, we saw no differences in dietary intake or physiological or metabolic changes between
the two intervention groups; thus, the data were pooled for further analysis. As a total sample, BMI
percentile significantly decreased from before to after the intervention (96.8 ± 4.1 to 96.3 ± 4.1;
p < 0.05), and there was a trend for a decrease in BMI (33.2 to 33.1 kg/m2; p < 0.06). These
preliminary results suggest that an extremely intensive individualized home-based program is no
more effective than a group-classroom-based format, and that the 12-week program focusing on
improving the quality of carbohydrate intake can significantly reduce obesity.
PHARMACOLOGICAL APPROACHES
Although no medications are currently approved for the management of pediatric overweight due
to safety concerns, pharmacotherapy may be appropriate for overweight youth who possess comor-
bidities (e.g., pre-diabetes, sleep apnea), and several studies have been reported. In a randomized
and controlled study [68], orlistat (a gastrointestinal lipase inhibitor) decreased BMI in obese
adolescents to a greater degree in the experimental group vs. control group (–4.09 ± 2.9 kg/m2 vs.
+0.11 ± 2.49 kg/m2, respectively; p < 0.001). In another trial [62] of 20 adolescents (mean age,
14.6 years; mean BMI, 44 kg/m2), orlistat was dosed 3 times daily (120 mg) with a multivitamin
and behavioral program (not a randomized study). Similar gastrointestinal side effects were
observed as has been observed in adults, and these decreased with time. The main outcomes were
also similar, as has previously been shown in adults (4% weight loss; 21-mg/dL reduction in
cholesterol; 17-mg/dL reduction in LDL cholesterol; 14-µU/mL reduction in fasting insulin;
15-mg/dL reduction in fasting glucose). In the concluding words of the authors, “Short-term
treatment with orlistat, in the context of a behavioral program, is well tolerated and has a side-
effect profile similar to that observed in adults, but its true benefit versus conventional therapy
remains to be determined in placebo-controlled trials.”
The other U.S. Food and Drug Administration (FDA)-approved drug for obesity, sibutramine,
has also been tested in adolescents in a randomized double-blind study (n = 82; 13 to 17 years
old). This study compared 6 months of behavior intervention with placebo vs. behavior intervention
and the drug [10]. Weight loss with the drug was significantly greater than control (8% vs. 4%),
but the medication had to be reduced or discontinued in 33 patients to manage increases in blood
pressure or other symptoms. In the concluding words of the authors, “Until more extensive safety
and efficacy data are available, medications for weight loss should be used only on an experimental
basis in adolescents and children.” Thus, these studies show that the general responses in terms of
safety and efficacy to these drugs are similar in children compared to adults, although more longer
term safety and efficacy data are needed.
Few pharmacological studies have targeted the underlying insulin resistance associated with
obesity. In one study, metformin, an insulin-sensitizing drug used for the treatment of type 2 diabetes
in both adults and children, was used to treat overweight youth with a family history of type 2
diabetes and hyperinsulinemia. In a double-blind controlled trial in 29 obese adolescents [34],
metformin (500 mg twice a day for 6 months) resulted in significant improvements in BMI and
fasting insulin but not insulin sensitivity. In another study [5], metformin was shown to improve
insulin sensitivity and lower plasma total and free testosterone in obese adolescent girls with
polycystic ovarian syndrome. Other agents that may prove beneficial in the treatment of insulin
resistance in high-risk youth are the thiazolidinediones, which are much more potent insulin
sensitizers than metformin. Thiazolidinediones have been shown to improve insulin sensitivity,
glucose tolerance, and cardiovascular risk factors in non-diabetic obese subjects with impaired
glucose tolerance [4].
In summary, pharmacotherapy may be indicated in children with comorbidities and in which
attempts to improve risk through lifestyle interventions have failed. Well-designed randomized,
controlled studies of safety and efficacy of pharmacological agents in pediatrics are needed.
SUMMARY AND IMPLICATIONS: CONCEPT OF MULTIPLE

TARGETS FOR TREATMENT AND PREVENTION
Most prior interventions for treating and preventing obesity in children have traditionally targeted
body weight and BMI through conventional approaches based on the energy-balance model (Figure
40.1). Several arguments against this approach can be made, especially in children; for example,
it may take generations to reverse the population BMI trend, short-term weight loss may be effective
Whatʼs the Target?

Food Physical
intake activity
Conventional
energy balance approach
to reduce body fat Energy
balance
Increased body fat
Ectopic fat
Alternative targets
worth considering
Insulin resistance/disease risk
FIGURE 40.1 Conventional vs. alternative targets for reducing obesity and obesity-related metabolic diseases.
but not usually sustainable, and weight loss per se does not necessarily address health and metabolic
risk factors. Finally, evidence suggests that a focus on body weight in children and adolescents is
not effective. In a large cohort study, children who reported more dieting attempts were more likely
to gain weight over a 3-year period [32]; thus, the risks of a focus on weight loss in children and
adolescents include greater weight gain, lower self-esteem (due to repeated failures), and body
image and eating disorders. Rather than focus on weight loss through energy imbalance, the pediatric
model focuses more on the notion of growing into a healthy weight; thus, weight stability in a
growing overweight child may actually be a very beneficial outcome.
Moving beyond the traditional energy-balance model, interventions designed to target specific
metabolic factors and health outcomes may be more effective, especially in high-risk groups with
elevated metabolic risk factors (Figure 40.1). One approach based on the centrally mediating role
of insulin resistance, for example, is to identify interventions for improvement in insulin sensitivity
and reducing insulin secretion. Improvement in insulin resistance as an intervention strategy may
be an efficient strategy, as this addresses multiple risk factors targeted through one common
mechanism. It remains to be tested, for example, whether or not improvement of insulin resistance
can lead to a reduced risk of type 2 diabetes and cardiovascular disease over and above any effects
on risk reduction through weight loss.
Alternative strategies using diet and exercise strategies can be designed around this concept;
for example, traditional dietary approaches (reduced calorie, low fat, low carbohydrate) have
generally been designed to lead to weight loss and have failed to recognize the data suggesting
that the quality and type of fats and carbohydrates are more important than the amount in affecting
metabolic outcomes and thereby potentially improving risk factors associated with obesity. For fat,
replacing foods high in saturated fat and trans-fatty acids with foods rich in plant-based fat sources
(mono- and polyunsaturated fatty acids, nuts, fish, soy) may be effective. With regard to carbohy-
drates, data are beginning to show that replacing sugary foods based on simple or unprocessed
carbohydrates with foods high in whole-grain or processed carbohydrates and fiber that have low
glycemic index values may be effective, not only for weight loss but also for disease risk reduction.
Based on published studies, evidence is beginning to mount that demonstrates the power and
potential effectiveness of childhood obesity prevention efforts that focus on subtle changes in the
physical activity aspects of health behavior and in particular on reductions in sedentary behavior
and increases in light-intensity activities. This approach may partly address the obvious need to
target the role of the media in childhood obesity prevention [3]. Cross-sectional and intervention
studies support the evidence that increased television viewing is associated with childhood obesity.
Children on average now are exposed to about 40,000 television advertisements a year (double that
of 1970), including 11 food commercials per hour on Saturday mornings, primarily for candy
(32%), cereal (31%), and fast food (9%). It is thus no surprise that a recent study showed that
children who watch more television tended to choose less healthy choices in a controlled trial [3].
Despite the evidence presented, there is a lack of unequivocal support for any particular treatment
or intervention, and pediatric obesity interventions still rest on expert committee recommendations
rather than evidence from clinical trials. The limited evidence available suggests that simple strategies
(reductions in television and sugar) may be just as effective as more complex interventions. Smaller
scale, proof-of-concept studies are greatly needed to develop the case for larger scale, more complex
and expensive trials. Interventions should be designed using an integrated and unified approach
based on behavioral theories to affect change. Strategies should think beyond weight and energy
balance, focusing more on target physiological outcomes (risk reduction). Because of ethnic differ-
ences in metabolic and physiologic pathways, interventions may have to be tailored to different
groups (and probably individualized as well). A major limitation impeding progress perhaps lies in
the dissonance that exists between the simplicity of the obvious obesity solutions (eat less and move
more) and the reality of the complexity of the underlying physiology, the inherent variation between
individuals and subgroups of the population, and the difficulty in translating simple health messages
to actual behavioral changes. The complexity and diversity of the problem are not being helped by
the fragmented effort that is occurring in response to this public health crisis, and a more unified
effort at the national level is necessary to tackle the childhood obesity problem.
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Part VIII
Bariatric Surgery in
Weight Management
41 Bariatric Surgery in
Obesity and Reversal
of Metabolic Disorders
Melania Manco
CONTENTS
Introduction ....................................................................................................................................531
Malabsorptive or Restrictive Procedures .......................................................................................532
Weight Loss and Energy Expenditure ...........................................................................................534
Normalization of Metabolic Inflexibility.......................................................................................534
Insulin Action and Secretion .........................................................................................................535
The Gut and Resolution of T2DM ................................................................................................536
Resolution of Hypertension ...........................................................................................................537
Resolution of Dyslipidemia ...........................................................................................................538
Polycystic Ovary Syndrome and Endocrine-Related Diseases .....................................................538
Resolution of Nonalcoholic Steatohepatitis ..................................................................................538
Conclusion......................................................................................................................................539
References ......................................................................................................................................539
INTRODUCTION
Bariatric surgery is increasingly regarded as a treatment of morbidly obese patients who have serious
comorbidities or fail on medical and behavioral weight reduction therapies. In 1991, the National
Institutes of Health Consensus Conference made a recommendation for surgery in patients having
a body mass index (BMI) of >40 kg/m2 and exhibiting a strong desire for substantial weight loss
to improve quality of life or in patients with a BMI of >35 kg/m2 plus serious comorbidities [1].
So far, several surgical procedures have been developed. The history and descriptions of the main
bariatric procedures developed to date are available at the website of the American Society of
Bariatric Surgery [2]. In particular two of them — the Roux-En-Y gastric bypass (RYGB) (Figure
41.1A) [3] and the biliopancreatic diversion (BPD) (Figure 41.1B) [4] — seem at the present to
be the most effective in the achievement of a long-term weight loss and in the resolution of obesity-
related morbidities. Comorbidities include diabetes, hypertension, dyslipidemias, nonalcoholic fatty
liver disease (NAFLD), polycystic ovary syndrome (PCOS), sleep apnea and obesity–hypoventila-
tion syndrome, cardiac dysfunction, reflux esophagitis, pseudotumor cerebri, arthritis, infertility,
stress incontinence, and venous stasis ulcers. The Consensus Development Panel endorsed only
vertical banded gastroplasty and RYGB [1]; however, in Europe and, particularly, in Italy, BPD is
very frequently performed.
In this chapter, attention is mainly focused on both BPD and RYGB, as these two techniques
share a common remarkable feature. They impressively ameliorate obesity-related insulin resistance
and diabetes, very early after surgery and independently of weight loss [5–19]. We strongly believe
531
A B
FIGURE 41.1 Schematic representation of the Roux-en-Y gastric bypass (A) and biliopancreatic diversion (B).
(Figure courtesy of the American Society for Bariatric Surgery.)
that operative risk and postoperative and late complications must be measured against the medical
benefits of massive weight loss, despite the fact that the exact mechanism explaining early diabetes
resolution has not yet been identified. Operative risk is reported to be approximately 1%, but it
may be further lowered by experienced surgeons. Postoperative complications (Table 41.1) occur
in approximately 10% of patients. Colecistectomy is strongly recommended to avoid gallstone
formation with rapid weight loss [18–20]. In our experience with post-BPD patients, operative and
late complications may be prevented by close surveillance and follow-up of patients.
To further support the emerging role of bariatric surgery as a therapeutic option in severe
obesity, it is remarkable that overall annual mortality is lower in obese patients who undergo bariatric
surgery than in morbidly obese people who do not undergo surgery for personal reasons [14,21].
We must point out, however, that no standard criteria exist for judging the best surgical option for
each patient or for evaluating the success of surgery for morbid obesity in terms of weight loss.
Also, no consensus has been reached on the management, therapy, and follow-up required after
surgery. Thus, the success of each surgical procedure in terms of weight loss and low incidence of
complications depends greatly on the ability of the surgeons, physicians, and nurses taking care of
patients after surgery.
MALABSORPTIVE OR RESTRICTIVE PROCEDURES

Surgery can induce weight loss by two obvious mechanisms: intestinal malabsorption or gastric
restriction. The types of operations are traditionally categorized based on which of these changes
they induce. Both restrictive (RYGB) and malabsorptive (BPD, with or without duodenal switch)
bariatric techniques aim at a stable reduction in total caloric assimilation. Purely restrictive bariatric
operations cause weight loss by restraining the capacity of the stomach to contain food and
constricting the flow of ingested nutrients. Gastroplasty involves placing a horizontal staple line;
a small, proximal pouch is separated from the large distal remnant, and the two parts are connected
through a narrow stoma [22]. To avoid dilation of the stoma and proximal pouch or dehiscence of
the horizontal gastroplasty, Mason [23] modified this procedure to develop vertical banded gastro-
plasty (VBG), in which the partitioning line extends upward from the angle of His. A polypropylene
band supports the stoma. Although VBG effectively limits the amount of food that can be consumed
Bariatric Surgery in Obesity and Reversal of Metabolic Disorders 533
TABLE 41.1
Main Surgical Complications of Roux-en-Y Gastric
Bypass (RYGB) and Biliopancreatic Diversion (BPD)
Complication RYGB BPD
Deep venous thrombosis Yes Yes
Anastomotic leaks Yes Yes
Internal hernias Yes Yes
Gastrointestinal bleeding Yes Yes
Intestinal obstruction Yes Yes
Wound complications Yes Yes
Staple-line disruption Yes Yes
Ulcers Yes Yes
Torsion or volvulus of the roux limb Yes —
Stomal stenosis Yes —
Biliopancreatic limb obstruction and pancreatitis — Yes
Closed loop obstruction Yes —
at one sitting and causes a 30 to 50% reduction of excess body weight within the first 1 to 2 years,
long-term results are disappointing, showing a nearly 80% failure rate after 10 years [19,24].
Patients often accommodate to gastric restriction by frequently eating small meals and calorie-dense
foods [20]. Laparoscopical adjustable gastric banding (AGB) is used extensively worldwide. This
approach involves placement of a prosthetic band around the upper stomach to partition it into a
small, proximal pouch and a large, distal remnant, connected through a narrow constriction [25,26].
Weight loss after either type of gastric banding is usually less than that expected from RYGB [19].
Roux-en-Y gastric bypass is the most effective restrictive procedure to induce and maintain
weight loss [27–31]. The stomach is divided into a small, proximal pouch and a large, distal remnant.
The upper pouch is joined to the proximal jejunum through a narrow gastrojejunal anastomosis.
The storage capacity of the stomach is reduced to approximately 5% of its normal volume, and
ingested food bypasses approximately 95% of the stomach, the entire duodenum, and a small portion
(15 to 20 cm) of the proximal jejunum. Patients can lose 35 to 40% of total body weight, and most
of this effect is maintained for at least 15 years [8,18,19]. Bypassing the stomach and duodenum
impairs the absorption of iron, calcium, thiamine, and vitamin B12; thus, supplements of these
micronutrients and periodic monitoring for deficiencies are required.
After the failure of jejunoileal bypass, which was plagued by severe and life-threatening
consequences [2], BPD is the only malabsorptive procedure currently being performed. It allows
patients to eat as much as they want, as it primarily acts through lipid malabsorption. Malabsorption
occurs because pancreatic and biliary secretions are diverted to the distal approximately 50 cm of
the ileum. Some surgeons do not perform BPD because of the increased likelihood of life-threatening
complications [19], even though they believe that this procedure promotes durable weight loss as
effectively as any bariatric procedure does, in particular RYGB. Severe complications include
protein malnutrition, hypocalcemia and metabolic bone disease, foul-smelling diarrhea, and defi-
ciencies of iron, vitamin B12, and fat-soluble vitamins [20].
In the authors’ opinion, the metabolic effects of BPD may largely outweigh its complications.
Again, we recommend very close surveillance of both BPD and RYGB patients to obtain the best
results in terms of weight loss and the lowest rate of complications. Patients are admitted to the
care unit monthly during the first 6 months of follow-up, every 3 months during the next 6 months,
and then every 6 months after a year. A dietary recall diary is required so we can check their daily
energy intake. Patients are prescribed oral supplementation of sulfate iron (525 to 1050 mg/day),
calcium carbonate (1 g/day), multivitamins, and ergocalciferol (400,000 to 1600,00 UI i.m.
monthly). Despite ergocalciferol supplementation, the prevalence of hypovitaminosis D ranges from

89 to 91% in women 10 years after BPD [32]. Intravenous iron supplementation may be required,
primarily in fertile women. BPD patients are instructed to eat freely and frequently, as compared
with post-RYGB patients, who must restrain their consumption of calorie-dense foods, including
fats, concentrated carbohydrates, ice cream, and sweetened beverages. BPD patients should con-
sume proteins at least twice a day.
WEIGHT LOSS AND ENERGY EXPENDITURE

Bariatric surgery is the most effective method to obtain major, long-term weight loss [19,20]. In
individuals genetically prone to develop obesity, any attempt to reduce body fat stores by conven-
tional weight-loss programs triggers compensatory changes in appetite and energy expenditure that
resist weight change [33]. Physiological regulation of body weight developed as a mechanism to
defend against malnutrition in times of famine; therefore, the adaptive responses to weight loss
seem to be stronger than those in response to weight gain. Nonsurgical methods are notoriously
ineffective at achieving major, long-term weight reduction. In contrast, surgery can effectively alter
this physiological system. The so-called “adipostat” regulates body weight in a manner analogous
to that by which a thermostat controls ambient temperature. No more than 5 to 10% of body weight
is lost through dieting, exercise, and the few available anti-obesity medications (e.g., sibutramine
and orlistat). Recidivism after dietary weight reduction is very common [34–37].
Bariatric surgery is able to reduce body weight by 35 to 40%. Most of this effect is maintained
for at least 10 years or longer [8,18–19]. Surgery imposes a fixed reduction in energy intake, and
energy requirements decline as subjects lose largely fat mass, as well as (to a lesser extent) fat-
free mass. The decline in body weight after surgery is a nonlinear function of time [38]. The resting
energy expenditure (REE) is a function of the fat-free mass, which represents the mass of meta-
bolically active tissues [39]. The total amount of energy expenditure (EE) results basically from
REE; energy expenditure related to physical activity (PA); non-exercise activity thermogenesis
(NEAT), which is the energy required to fidget, to maintain posture, and to perform other activities
of daily living [40]; and diet-induced thermogenesis (DIT), which is the energy consumed for
absorbing, digesting, processing, and storing nutrients.
In dieting obese individuals, the resting energy expenditure decreases [41,42], DIT is blunted,
thermogenesis is defective [43–48], and fat oxidation decreases [49–50]. These impairments in
metabolism can contribute to weight regain after dieting. In contrast, after surgery, energy intake
is constantly reduced or unchanged while energy expenditure and metabolic efficiency are both
increased. In post-BPD patients, the amount of metabolizable energy per kilogram of fat-free mass
(defined as total energy intake minus fecal and urinary losses) is not different before and after
surgery [51], but the energy required for absorption and digestion processes is greater [52]. Surgery
is also likely to positively influence NEAT, as body agility is improved after massive weight loss.
In post-BPD patients, average 24-hour lipid oxidation is improved from 69% before surgery to
97% of metabolized fats after the procedure [51]. Metabolic efficiency in the oxidation of absorbed
lipid is significantly increased.
NORMALIZATION OF METABOLIC INFLEXIBILITY

The higher efficiency in substrate oxidation suggests that the metabolic inflexibility may partially
reverse after BPD. Metabolic inflexibility, which characterizes obesity, is defined as the pathological
incapacity to utilize lipid and carbohydrate fuels as needed and to switch between them [53]. In
obese subjects, inflexibility includes: (1) impairment of the cephalic phase of the insulin secretion,
(2) failure of muscle tissue to correctly oxidize lipids at fasting and carbohydrate in the insulin-
stimulated prandial state, and (3) impaired transition of fatty acid efflux from storage in response
to a meal. Major weight loss following bariatric surgery is able to restore the early phase of insulin
secretion by type 2 diabetes mellitus (T2DM) patients [16]. Insulin secretion in response to a meal
is normalized and post-obese subjects are able to oxidize lipids or carbohydrates as needed [54].
Oxidation of lipid substrates is more efficient in the fasting status, while glucose oxidation is
increased in the insulin-stimulated condition as evaluated by the euglicemic hyperinsulinemic clamp
[56]. With regard to circulating fatty acids, post-surgery levels of circulating fatty acids are signif-
icantly lowered. In post-BPD, this effect is largely due to the massive lipid malabsorption. In RYGB
subjects, changes in eating behavior occur for unknown reasons, and these patients voluntarily
reduce the intake of calorie-dense foods, including fats [7].
We suggest that the massive reduction in dietary fats induces a dramatic reduction in circulating
and intramyocyte fat depots [56] which is associated with the reversal of insulin resistance 6 months
after surgery [56]. The elimination of lipotoxicity and normalization in lipid fuel sensing inside
the cells translate into amelioration of the action of insulin, accompanied by enhanced glucose
oxidation and a shift from lipid to glucose metabolism [57,58]. Insulin sensitivity improves in
proportion to weight loss with the use of predominantly restrictive procedures but is completely
reversed by predominantly malabsorptive approaches long before normalization of body weight
[38,60]. It is not surprising that full normalization of insulin action occurs in parallel with achieving
an ideal body weight [5,8], but it is astonishing that normalization also results in patients who do
not achieve a normal BMI [55,56]. The amount of weight lost may not be the only determinant of
metabolic improvement, and the surgical strategy used to achieve weight reduction may have an
independent effect.
Although the degree and time course of weight reduction (average weight loss of 53 kg) are
almost identical after BPD or RYGB [38], patients who have undergone BPD achieve levels of
insulin sensitivity that are double those of patients following RYGB. Normalization of insulin action
may be not complete after RYGB, despite substantial weight reduction [59]. After RYGB, the
improvement in insulin sensitivity is of the exact magnitude predicted by the general relation
between glucose disposal and BMI found in healthy normal-weight individuals [38]. In contrast,
in post-BPD patients, the levels of insulin sensitivity are almost normal at 6 months, when their
BMIs average 39 kg/m2. A further loss of approximately 15 kg over the following 18 months
increases insulin sensitivity to levels higher than those of lean controls [60].
Evidence from molecular studies is consistent with the hypothesis of lowered lipo- and gluc-
otoxicity. After BPD, the expression of acetyl-CoA carboxylase (ACC2) [61], uncoupling proteins
2 and 3 (UCP2 and UCP3) [62,63], and pyruvate dehydrogenase kinase (PDK4) [64] is downreg-
ulated, but glucose transporter 4 (GLUT4) mRNA is increased in muscle tissue [56]. The intramy-
ocyte content of malonyl-CoA decreases [51]. After RYGB, muscle expression of insulin receptors
increases, lipid depots and the fatty acyl CoA content decreases. After both RYGB and BPD, levels
of circulating adiponectin are increased [65–68], and leptin is decreased [51].
INSULIN ACTION AND SECRETION

In people with normal glucose tolerance, a decrease in insulin action is accompanied by the
upregulation of insulin secretion, and vice versa. A compensatory increase of insulin secretion
maintains normoglycemia despite decreased insulin sensitivity. After being algebraically trans-
formed, insulin secretion and sensitivity are commonly represented as a hyperbola describing the
acute insulin response (AIR) as a function of insulin sensitivity [69]. The hyperbola reflects the
natural relationship between β-cell function and insulin sensitivity, taking into the account β-cell
compensation for the insulin resistance. The disposition index represents the mathematical product
of the insulin action for the β-cell function, and it simplifies the concept of the hyperbola [70].
The disposition index is a way of measuring the ability of the β-cells to compensate for insulin
resistance. This compensation is thought to be perfect when the disposition index remains constant
in the face of decreasing insulin action; thus, it seems intuitive that β-cell function is modified for
every significant change in peripheral insulin sensitivity. Surprisingly, this is true for obese patients
who undergo malabsorptive bariatric surgery but not for T2DM patients after a hypocaloric diet,
for RYGB patients, or for those who undergo gastroplasty [38].
An innate hyperactivity of the β-cell response to feeding seems to be the cause of weight gain
rather then the consequence of weight excess. In obese and T2DM subjects, weight loss is followed
by an increase in insulin sensitivity and also an increase, rather than a decrease, in β-cell activity
[60,71]. The disposition index is unchanged in RYGB patients [72], and it increases after gastro-
plasty at a time when 25% of the initial weight is lost [73]. Because weight loss is invariably
associated with improved glycemic control, the paradoxical rise in insulin secretion is commonly
regarded as the result of removing the toxic effect of chronic hyperglycemia on β-cell function
[74–76]. Insulin hypersecretion after dieting or RYGB may also suggest that the post-obese state
reproduces the primary insulin hypersecretion of the obese state or is a consequence of the secretory
system setpoint being reset. In post-BPD patients, insulin hypersecretion is abolished even before
achievement of ideal body weight, and the depletion of intramyocyte lipid depots occurs as a
consequence of the increased β-cell glucose sensitivity.
THE GUT AND RESOLUTION OF T2DM

Resolution of diabetes has been largely demonstrated as an additional outcome of surgical treatment
for morbid obesity. The Greenville study [8] demonstrated that 82% of 165 patients with T2DM
stably remitted from diabetes after an average 14 years of follow-up. The SOS study [17], which
prospectively compared obese patients treated or not treated by surgery, showed that the number
of patients not requiring drug treatment to maintain normal glycemia after 2 years in the surgical
arm was about double that in the control group. In a recent systematic review and meta-analysis
of the data reported in the literature on bariatric surgery, Buchwald et al. [15] found a range of
effects, from 98.9% in patients after BPD or duodenal switch to 83.7% for gastric bypass, 71.6%
for gastroplasty, and 47.9% for gastric banding.
What is impressive is how rapidly the diabetes is corrected after BPD or RYGB, usually in a
matter of days. The improvement in diabetes is unrelated to the amount of weight lost and seems
to be strictly associated with the surgical manipulation of the small intestine. We have recently
observed that the normalization in β-cell function and insulin action that occurs in T2DM patients
within one week following BPD does not occur in obese subjects who undergo abdominal surgery
for gallstones, despite both groups of patients consuming no foods in the immediate period after
surgery [Guidone et al., unpublished data]. This observation eliminates the possibility that the early
improvement of diabetes may be related to the diminished meal-induced challenge of β-cells. A
more intriguing hypothesis is that manipulation of the small intestine (duodenum and proximal
jejunum) may alter the hormone milieu, and the exclusion of its large part from nutrient transit
may play a relevant role in the resolution of diabetes, apart from reduced lipotoxicity.
In a very elegant review on the mechanisms by which RYGB induces the resolution of diabetes,
Cummings et al. [7] proposed a role for ghrelin and glucagon-like peptide 1 (GLP-1). In RYGB,
ghrelin secretion is decreased and the 24-hour profile is completely flat [77]. In contrast, in patients
who have undergone BPD without duodenal switch, in spite of a flat ghrelin profile circulating
levels of the hormone increase, because the main site of ghrelin secretion, the fundus, is preserved
in this surgical procedure [78]. Ghrelin, then, does not seem to be a candidate to fully explain the
reversion of diabetes observed after either RYGB or BPD.
In RYGB, enhanced GLP-1 release is due to the earlier delivery of food to lower segments of
the gut. This effect is likely to also occur after BPD; thus, GLP-1 seems to be a more attractive
candidate, as well as the glucose-dependent insulinotropic polypeptide (GIP), to explain the ame-
lioration of glucose metabolism after bariatric surgery. GIP is synthesized and released in the
duodenum and proximal jejunum, especially in response to glucose and fat ingestion. It acts as an
insulinotropic agent with a stimulatory effect on insulin release and synthesis [79]. Defects in its
signaling pathways are considered among the most critical alterations underlying T2DM. The
incretin effect of GIP is characteristically attenuated in T2DM [80], and the expression of glucose-
dependent insulinotropic polypeptide receptor (GIPR) is also decreased [81]. GLP-1 is released by
the L cells of the distal ileum and colon, and it enhances glucose-induced insulin secretion [82].
After RYGB, levels of GIP have been found to be decreased [83] but GLP-1 was increased [84,85]
or unchanged [83,86].
Rubino et al. [83] found an exaggerated GLP-1 response following a 420-kcal meal in gastric
bypass subjects. They suggest a major role for GIP in the resolution of T2DM and speculate that in
susceptible individuals, such as diabetic patients, chronic exaggerated stimulation of the proximal gut
with fat and carbohydrates may induce overproduction of an unknown factor that causes impairment
of GIPR expression or GIP/GIPR interaction, leading to an insufficient or inappropriate insulin secretion
and the development of glucose intolerance. The duodenal–jejunal exclusion may resolve this aberration
by restoring normal GIP sensitivity and reducing GIP secretion. Unlike GIP, GLP-1 has been shown
to significantly improve or even restore normal glucose-induced insulin secretion in diabetic patients
[87]. Although the changes in GLP-1 levels did not reach statistical significance in the Rubino et al.
study [83], the authors do not exclude a role of GLP-1 in restoring glucose homeostastis.
In diabetic obese patients one week after BPD, we have observed a significant decrease in
fasting- and glucose-stimulated GIP secretion during standard oral glucose loads and an increase
in fasting- and glucose-stimulated GLP-1 secretion [Guidone et al., unpublished data]. As previously
observed, insulin secretion decreases and β-cell sensitivity to glucose is improved [60]. All of the
above-mentioned reports in patients after RYGB or BPD and evidence from two elegant animal
studies [88,89] suggest that bypass of the duodenum and jejunum, which is performed in RYGB
and BPD, can ameliorate T2DM independently of weight loss through mechanisms that remain
unclear. In rats, transposition of the ileum [88], a procedure where an isolated segment of the ileum
is transposed to the jejunum, results in an intestinal tract of normal length but an alteration in the
normal distribution of the endocrine cells along the gut. The procedure is associated with a net
increase in insulin sensitivity without any significant decrease in adiponectin levels, a rise of
glucose-stimulated GLP-1, and significant lowering of plasma leptin.
The restoration of normal insulin sensitivity with subsequent improvement of β-cell sensitivity
is not predicted by the measured variables. In Goto–Kakizaki rats (a spontaneous, non-obese model
of T2DM), the effects of RYGB related to the exclusion of duodenum and proximal jejunum are
distinct from those related to gastric restriction and bypass. The stomach is left unperturbed, but
food is diverted from the pyloric area to the proximal jejunum with a gastrojejunal anastomosis.
Experimental animals display food intake and body weight similar to sham-operated controls,
indicating that foregut bypass alone is not sufficient to cause weight loss. Noteworthy is that the
rats show significant improvement in glucose tolerance compared with sham-operated controls,
despite equivalent body weights [89].
Consistent with these observations, our working hypothesis is that the exclusion of the entire
jejunum, which is characteristic of BPD, might be responsible for the inhibited secretion of an
unknown hormone that strongly affects insulin sensitivity. The reduction in food ingestion and
absorption suppresses the release of GIP and GLP-1, thereby contributing to the fall in insulin
secretion.
RESOLUTION OF HYPERTENSION
Even a modest weight loss can lower blood pressure significantly. It is commonly assumed that a
decrease of 1% in body weight reduces systolic blood pressure by 1 mmHg and diastolic blood
pressure by 2 mmHg [90–92]. The reduction of blood pressure seems to be independent of the type
of surgery [15]. A recent meta-analysis by Buchwald et al. [15] found that hypertension significantly
improves in morbidly obese subjects after bariatric surgery. The improvement is independent of the
type of surgery. The percentage of patients in the total population whose hypertension fully resolved
was 61.8%, and this figure rose to 78% when resolution and development were both considered.
RESOLUTION OF DYSLIPIDEMIA
Hypercholesterolemia and hypertriglyceridemia are significantly improved after bariatric surgery
independently of the technique used. The lipid profile improves in at least 70% of the patients. A
major improvement is obtained in patients after BPD, duodenal switch, or gastric bypass [15]. Total
cholesterol may be decreased by a mean value of 33%, low-density lipoprotein (LDL) by 29.34%,
and triglycerides by 79.65%. Surprisingly, high-density lipoprotein (HDL) cholesterol is improved
after gastric banding (by 4.63%) or gastroplasty (by 5.02%). Also, after BPD, we have observed a
significant increase in HDL levels and the reduction of cardiovascular risk [93]. In the late 1990s,
two studies suggested that bariatric surgery could be a therapeutic option for severe dislipidemia
[5,6]. Two sisters affected by a familial deficit of lipoprotein lipase and T2DM underwent bilio-
pancreatic diversion. Because their BMIs were within the normal range, the rationale for surgery
was to reduce the absorption of lipids to achieve normal glucose homeostasis [5].
POLYCYSTIC OVARY SYNDROME AND

ENDOCRINE-RELATED DISEASES
The etiology of PCOS is still largely unknown. The primary defect consists of increased androgen
synthesis and secretion by ovarian thecal cells [94,95], worsened by hyperinsulinism and insulin
resistance [96]. Obesity is commonly associated with PCOS and hyperandrogenism [97]. Compared
with non-hyperandrogenic women with morbid obesity, PCOS and hyperandrogenic patients with
regular menstrual cycles present with similarly increased total and free testosterone levels, but
insulin resistance is present only in the PCOS group. In contrast, the prevalence of PCOS is increased
six- to sevenfold in women with morbid obesity compared with unselected healthy controls [98].
Diet-induced weight loss ameliorates the clinical signs and symptoms of PCOS, including hyper-
androgenism and insulin resistance [99], menstrual dysfunction [100], and oligoovulation [101].
We and others [102,103] have recently showed that massive weight loss due to surgery is also able
to ameliorate or resolve signs and symptoms of hyperandrogenism. Moreover, the sustained and
marked weight loss achieved either after RYGB or BPD leads to the almost complete resolution of
PCOS [15]. PCOS patients recover regular ovulatory menstrual cycles after weight loss in parallel
with a marked improvement in the indices of insulin resistance.
RESOLUTION OF NONALCOHOLIC STEATOHEPATITIS

Nonalcoholic fatty liver disease (NAFLD) is a common condition that may progress to end-stage
liver disease. NAFLD ranges from fat depots in the liver, known as simple steatosis or nonalcoholic
steatohepatitis (NASH), to steatohepatitis or fat with inflammation and fibrosis, to advanced fibrosis
and cirrhosis, when fat may no longer be present. NAFLD is closely associated with obesity and
insulin resistance. NALFD is estimated to occur in 30 to 100% of obese adults. The majority of
obese patients have ultrasonographic evidence of fatty liver; 30% have histologically proven NASH.
Up to 25% of obese patients with NASH may progress to cirrhosis [104]. The exact mechanisms
leading to NAFLD or fibrosis are incompletely understood. Hyperinsulinemia and insulin resistance
are clearly important, as they act to increase the influx of free fatty acids into the liver and drive
hepatic triglyceride production. They promote de novo lipogenesis by upregulating lipogenic tran-
scription factors such as the sterol regulatory element-binding protein 1c (SREBP-1c) and the
carbohydrate response element-binding protein [105,106]. Furthermore, insulin-mediated activation
of SREBP-1c increases malonyl-CoA which inhibits free fatty acid oxidation, thereby favoring
hepatic triglyceride accumulation [107].
Lipid export from the liver may be impaired because of defective incorporation of triglycerides
into apolipoprotein B (apoB) or reduced apoB synthesis or excretion [108,109]. Hepatic triglyc-
eride accumulation subsequently leads to hepatic insulin resistance by interfering with tyrosine
phosphorylation of insulin receptor substrates 1 and 2 [110,111]. Hepatic lipid accumulation does
not universally result in hepatocellular injury, indicating that additional secondary insults are
important [112]. Day et al. [111] initially proposed a “two-hit” model to explain the progression
of NAFLD. The first hit constitutes the deposition of triglycerides into the hepatocyte cytoplasm.
The disease does not progress unless additional cellular events occur (the second hit), thus promoting
inflammation, cell death, and fibrosis. To date, surgical solutions for morbid obesity have proven
to be effective in the treatment of NAFLD, although some of these studies were confounded by
the unexplained progression of disease occurring after surgery in a few patients [113,114].
Recently, Mattar et al. [114] demonstrated significant and widespread improvement up to the
resolution of NAFLD and NASH after laparoscopic weight-loss procedures, which included gastric
bypass, sleeve gastrectomy, and laparoscopic banding in 70 obese patients. More than one third of
the patients had postoperative liver biopsies that showed resolution of steatosis and inflammation,
and 20% of the patients had at least some reversal of fibrosis. No patient experienced a progression
of abnormal liver morphology or a deterioration of hepatic function, as indicated by persistently
normal liver enzymes. The beneficial effects of weight loss are believed to be mediated primarily
via improved insulin sensitivity. After surgery, circulating levels of glucose, insulin, and leptin are
decreased, contributing to the decrease in fatty liver infiltration and inflammation [115]. However,
it cannot be ruled out that rapid weight loss may aggravate liver function and histology as a result
of increased free fatty acid levels derived from extensive fat mobilization or that additional factors,
such as toxins from bacterial overgrowth or nutritional challenge, may represent a second hit in
susceptible livers. Luyckx et al [113] confirmed this observation in patients after RYGB. Initially,
steatosis improved and inflammation transiently worsened, then liver inflammation improved over
time in accordance with resolution of other metabolic abnormalities [114].
Dixon et al. [112] demonstrated major improvement in liver disease in patients who achieved
significant weight loss with gastric banding. After BPD, a remarkable reversal of fibrosis and
macroscopic liver appearance was found in 60% of cirrhotic patients; in nearly 40%, fibrosis
increased, and de novo cirrhosis developed in a few cases [115].
CONCLUSION
Both RYGB and BPD are effective in the resolution of metabolic comorbidities of severe obesity.
Diabetes, hypertension, dislipidemia, nonalcoholic fatty liver disease, and polycystic ovary syn-
drome are improved or completely resolved. It must be pointed out, however, that (1) the mecha-
nisms by which bariatric surgery acts to ameliorate metabolic comorbidities are still unclear; (2)
severe morbidity is resolved by inducing a different pathological status, which requires a close
follow-up and continuous medication; and (3) no consensus has been reached on the treatment and
follow-up of these patients, despite the widespread diffusion of surgery as a therapeutic option for
severe obesity and metabolic comorbidities. Long-term complications of bariatric surgery must
therefore be carefully weighed against the beneficial effects, and surgery must represent the last
therapeutic option following the failure of any other feasible treatment.
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Index
A adipocytokines, 48, 54, 110, 143, 144, 160, 386,
abdominal obesity, 5, 10, 22, 43, 45, 124, 126, 388, 391
141, 142, 143, 220, 240, 366, 388, adipogenesis, 37, 38, 108, 116, 157, 159, 180,
464, 465, 466, 468, 482, 519; see also 181, 328, 386, 387, 388, 389, 390
visceral fat adipokines, 144, 156–157, 178, 179, 269, 328,
acanthosis nigricans, 117 386, 389–390, 392, 393, 487
acarbose, 283, 284, 293, 429 leptin, 93–100; see also leptin
acetaldehyde, 363, 366 adipokinomes, 156–157
acetaminophen, 166, 168 adiponectin, 45, 47, 53, 57, 142, 143, 145, 147,
acetate levels, serum, 284 156, 179–180, 257, 388, 391, 535, 537
acetic acid, 436 as risk factor for type 2 diabetes, 257
acetone, 363, 366 fragment, recombinant, 180
acetylated glucosamine, 414 small-molecule mimetics, 180
acetylation, 53 adiponectinemia, 385
acetyl-CoA, 355, 445 adipoQ, 47, 179
acetyl-CoA carboxylase, 329, 535 adipose drug targets, 177–189
N-acetylcysteine, 132, 160 adipose tissue, 44, 46, 49, 50, 51, 52, 87, 93, 96,
N-acetyl-hexosaminidase (NAH), 170 97, 98, 99, 105, 108, 144, 155, 156,
actin, 160 158, 159, 161, 177–178, 181, 182,
activational effects, of sex hormones, 34 183, 184, 221, 234, 235, 269, 281,
acute insulin response (AIR), 257, 535 328, 356, 379, 384, 387, 388, 389,
acyl CoA, 535 391, 403, 404, 459, 464, 465, 481
diacylglycerol acyltransferase 1 (DGAT1), adrenoreceptors in, 74
183–184 as endocrine organ, 487
monoacylglycerol acyltransferase, 310 branched-chain amino acids, and, 482
acylation, 107 brown (BAT), 90, 180, 185, 390, 404, 464,
adenosine monophosphate (AMP), 364 465, 467, 468, 472
adenosine triphosphate (ATP), 201, 364, 366, interscapular, 465
465 human vs. rodents, 185
adhesion molecules, 98 hydrogen peroxide, and, 48
adipocyte-complement-related protein leptin, and, 116
(adipoQ), 47, 179 macrophages, and, 51
adipocytes, 35, 47, 49, 50, 52, 54, 57, 87, 90, NADPH oxidase expression, 488
96, 143, 144–145, 156, 161, 178, 179, ob gene in, 83
181, 249, 250, 307, 308, 327, 328, omental, 328
366, 386, 387, 388–389, 390, 405, remodeling, 185–188
464, 470 superoxide anion exposure, and, 51
apoptosis of, 479, 483, 488 UCP2 expression, 478
brown-like, 185–188 white (WAT), 49, 97, 105, 156–157, 180,
calcium, and, 478 183, 185, 187, 206, 328, 386, 387,
estrogen and, 36–37 390, 391, 465, 467, 468–469, 470,
hyperplasia, 36, 37 472, 482
insulin-induced glucose uptake in, 37 caloric restriction, and, 269
post-mitotic, 36 adiposity, milk effects on, 485
545
adiposity, central, 45; see also abdominal anandamide, 79

obesity; visceral fat anesthesia, 166
adipostat, 178, 534 Angelman syndrome, 118
adjustable gastric banding (AGB), 533 angina pectoris, 54
adolescents, obesity among, 11–14, 115, 142, angiogenesis, 156, 157, 158, 160, 161, 211
219–220, 233, 250, 423 inhibitors, 158
adrenal insufficiency, 116 oxidants as inducers of, 159–160
β3-adrenergic receptor (β3-AR), 185–188, 373, redox control of, 159–160
379, 464 -targeted redox-based therapeutics,
adrenergic receptors, 116, 187, 241–242 155–161
adrenoceptors, 74 angiogenic factors, oxidants as inducers of,
adrenocorticotropic hormone (ACTH), 76, 78 159–160
adrenocorticotropin, 89, 116 angiopoietin-1, 159, 160
adult respiratory distress syndrome (ARDS), angiostatin, 158
47, 56 angiotensin-converting enzyme (ACE), 130,
advanced arteriosclerotic vascular disease 481, 488
(ASCVD), 204 angiotensin II, 53, 97, 159, 481
Advantra Z™, 379 angiotensin receptor blockers (ARBs), 130
adventitia, 96 animal models of obesity, 166
aerobic exercise, 129, 222 anorexia nervosa, 63, 64, 65, 66, 67, 86, 205,
for children, 518, 519 206
afferent signals, 105 anthocyanidins, 325
Africa, obesity in, 10 anthocyanins, 148, 323, 325, 328
age, obesity and, 27 berry, 160, 161
aglycones, 323 anti-aging caloric restriction, 265–274
agouti, 478, 482, 483 antiangiogenic therapeutics, 158–159, 160, 161
Agouti-related peptide/protein (AGRP), 44, 77, antibiotics, aminoglycoside, 170
78, 86, 89, 90, 108, 166 antihyperglycemia therapy, 130
L-alanine, 428 antiinflammatory
alginate, 438 adinopectin, 45, 53, 147, 388
alkaloids, ephedrine, 495–503 arachidonic acid, 454
allyl sulfides, 56 fucoxanthin, 470
alpha-amylase, 281, 282, 286 ghrelin, 53
alpha-amylase inhibition, 423–429 phytochemicals, 53, 56
alpha-amylase inhibitors, 280, 281, 282, 283, antioxidant supplementation, 131–132
284, 285, 288, 293 antioxidants, 54, 55, 56, 160, 161, 271, 311,
non-kidney-bean, 287–288 322, 331, 384, 392
alpha-glucosidase inhibitors, 280, 283, 293 dietary, 124, 127, 130, 160–161
alpha-methyl-para-tyrosine (AMPT), 201 enzyme, 128, 132
Amadori reactions, 125 exercise, and, 129
American Diabetes Association (ADA), 258 herbs, 326
American Heart Association diet, 256 hypertension, and, 53
γ-aminobutyric acid (GABA), 75 metabolic syndrome, and, 127–128
aminoglycoside antibiotics, 170 polyphenols, 323
aminorex fumarate, 202 small-molecule, 127
AMP-activated protein kinase (AMPK), 94, 96 tea, 235
amphetamine, 74, 201, 203, 204, 497 vitamins, 127
amphetamine derivatives, 203, 205 antisauvagine-30, 77
amylin, 208 antisense oligonucleotides (ASOs), 182, 184
anabolism, 249 apnea, 141, 142, 220, 322, 423, 521, 531
anaerobic bacteria, 282 apochromodulin, 341
Index 547
apolipoprotein B (apoB), 438, 538 benzo(a)pyrene, 45

apolipoprotein E (apoE), 160 benzoic acid, 498
apomorphine, 74 benzphetamine, 203, 204
appetite, 105–112 β-blockers, 130
control, 329 β-cells, 48, 49, 142, 143, 145, 146, 207, 208,
defined, 105 535, 536, 537
low-glycemic-load diet, and, 245–260 bile acids
regulation, 45 chitosan and, 414
stimulants, 108, 109, 427 glucomannan, and, 438
neuropeptide Y, 46 biliopancreatic diversion (BPD), 531–539
suppressants, 155, 202, 252, 331, 356, 365, binge eating disorder, 64–65, 66, 67, 209
366, 443 birth weight, 142
chitosan, 414 bisflavanols, 403
nicotine, 44 bisphenol A (BPA), 37, 38
apples, 322 bitter orange extract, 371–381, 439, 499; see
arachidonic acid, 392, 454 also Citrus aurantium
2-arachidonoylglycerol (2-AG), 79 chemistry, 372–373
arcuate nucleus (ARC), 73, 75, 77, 78, 84, 86, bitter principles, 444
87, 90, 95, 96, 110 blood–brain barrier, 85, 86, 87, 94, 110, 207,
arginine, 87 282, 373
L-arginine, 428 blood pressure
aromatase, 38 adipokines, and, 156
aromatic compounds, 55 adipokinomes, and, 157
aromatic L-amino acid decarboxylase, 72, 73 antioxidants, and, 131
arrhythmias, ephedra, and, 499, 500 bariatric surgery, and, 537
ascorbate, 415 caloric restriction, and, 270, 272
astragulus root, 210 Caralluma fimbriata, and, 446
atherogenesis, 45, 53–54, 56, 100, 391 dairy, and, 485
atherosclerosis, 47, 48, 49, 52, 54, 55, 57, 93, diastolic, 270
98, 99, 126, 128, 143, 144, 145, 148, Citrus aurantium, and, 375, 377, 379
159, 182, 339, 385, 386, 413, 487 ephedrine, and, 497
cholesterol, and, 455 white bean extract, and, 428
atherosclerotic lesions, 54, 98 diethylpropion, and, 204
Atkins diet, 246, 315–320 ephedrine, and, 497
metabolic advantage, 316, 317, 318 glycemic load, and, 256, 258, 259
atorvastain, 131 HCA, and, 361
Australia, childhood obesity in, 14 Lean Source™, and, 376
autonomic nervous system, 404 leptin and, 95–96
autoxidation, 51, 125 lipid peroxidation, and, 125
Ayurveda, 350, 366 physical activity, and, 129
potassium, and, 364
B sibutramine, and, 521
babassu oil, 457 synephrine, and, 373
bacteria, antibiotic-resistant, 458 systolic, 227, 270
Bardet–Biedel syndrome, 116 chitosan, and, 418
bariatric surgery, 146, 226–227, 240, 246, Citrus aurantium, and, 379
531–539 ephedrine, and, 497, 498
nutritional requirements of, 510 glucomannan, and, 438
basic fibroblast growth factor (bFGF), 54, 156 white bean extract, and, 428
Behavioral Risk Factor Surveillance System TheraSlim™, and, 292
(BRFSS), 8, 142 vitamin C, and, 131
blood vessel wall, composition of, 96 body weight, and, 483–484

Blount’s disease, 117 dairy vs. nondairy, 484–487
body mass index (BMI), 4, 5, 9, 10, 12, 13, intake, in children, 487
21–22, 23, 26, 43, 45, 85, 86, 88, 96, oxidative stress, and, 487–488
110, 112, 115, 125, 126, 129, 140, calcium carbonate, 481, 533
141, 142, 144, 208, 220, 223, 245, calcium channel blocker, 130, 227
251, 253, 257, 272, 292, 299, calcium hydroxycitrate, 352
300–301, 304, 306, 308, 309, 310, Calorex, 285
322, 343, 363, 364, 366, 367, 391, caloric restriction, 129, 265–274, 424
408, 409, 423, 428 causes and effects of, 268–269
bariatric surgery, and, 531 effect on blood pressure, 270, 272
Caralluma fimbriata, and, 446 in humans, 271–273
defined, 219 life span, and, 265–268
dietary calcium, and, 484, 487 mimetic drugs, 273–274
fiber, and, 434 cAMP response element-binding protein
orlistat, and, 521 (CREB), 467
television viewing, and, 516 cancer, 49, 157, 160, 161, 166, 182, 233, 258,
trends in, 141 259, 266, 322, 330, 331, 332, 341,
vitamin E, and, 127 350, 390, 423, 464, 470
whole-grain intake, and, 520 conjugated linoleic acid, and, 385
body weight regulation, 82–83, 105 cannabinoid-1 (CB1), 147
botanicals, 235–236 receptor, 206
branched-chain amino acids (BCAAs), 482, cannabinoids, 79
488 Cannabis sativa, 79
Brazil, obesity in, 10 capric acid, 458
breakfast, high-protein vs. high-carbohydrate, capsaicin, 329, 464, 477
308 Caralluma fimbriata, 443–448
breast cancer, 258 carbohydrate
Brewer’s yeast, 339, 340 digestion inhibitors, 279–294
BRFSS, see Behavioral Risk Factor mechanism of action, 282–283
Surveillance System safety of, 293
brown adipose tissue (BAT), 90, 180, 185, 390, metabolism, in small intestine, 327
404, 464, 465, 467, 468, 472 oxidation, 250, 362, 363, 464, 479
interscapular, 465 red pepper and, 330
bulimia nervosa, 63, 64, 65, 66, 67, 68, 86, 205, carbohydrates, 65, 66, 146, 307, 309
206 Atkins diet, and, 315–320
bupropion, 206 body fat levels, and, 241
butter, 283 complex, 280, 281, 287, 291, 294, 424
butyric acid, 436 depression, and, 66
diabetes management, and, 258
C digestion of, 281
caffeine, 203, 325, 329, 331, 372, 375, 377, forms of, 281
378, 379, 380, 381, 402, 403, 404, galanin, and, 76
405, 407, 408, 424, 439, 464, 477, glycemic index, and, 246, 247, 252
498, 499, 500, 502 glycemic load, and, 249, 253
habitual intake of, 408–409 ketosis, and, 317
HCA, and, 361 malabsorption of, 283, 426
calcineurin, 388 neuropeptide Y receptors, and, 75
calcium, 364–365, 367, 477–488 refined, 255, 315, 316, 319, 320, 350, 520
ACE inhibitor, and, 481, 488 simple/complex vs. glycemic load, 255
anti-obesity mechanisms of, 478–482 testing for malabsorption, 283–284
Index 549
Carbolite, 284–285 childhood obesity, 11–14, 25, 43, 66, 127, 142,
carboxypeptidase, 166 165, 219–220, 224–226, 349, 423,
cardiovascular disease, 3, 5, 50, 52–55, 97, 124, 515–523
126, 128, 142, 143, 146, 178, 179, glycemic load, and, 251, 252
180, 189, 204, 220, 233, 245, 246, China, obesity in, 10, 14
255–256, 259, 310, 315, 316, 320, Chinese medicine, 210, 496
329, 330, 331, 350, 372, 383, 384, chitin, 414
386, 388, 393, 463, 464, 518, 522 chitosan, 413–419, 424, 438
caloric restriction, and, 269–271 mechanism of action, 414
ephedrine, and, 500 toxicology of, 414
phytochemicals, and, 56 chlorogenic acid, 323, 325, 326, 402
potassium, and, 364 cholecystectomy, 258
risk markers for, 255–256 cholecystokine, 57
cardiovascular incidents, Citrus aurantium and, cholecystokinin, 44, 46, 82, 235, 308, 309, 318,
372, 373, 374, 377, 380 436
Caribbean, obesity in, 10 food intake, and, 46
carnitine, 377, 438 cholesterol, 292, 306, 330, 355, 356, 452, 455;
β-carotene, 127, 129 see also low-density lipoprotein
carotenoids, 127, 129, 331, 467–469, 470, 472 (LDL), high-density lipoprotein
in tea, 402 (HDL)
casein, 482 absorption, 329
caspase-3, 389 chromium (III), and, 339
catalase, 128, 271 fiber, and, 414
CATCH, 519 Phaseolus vulgaris, and, 426
catechin derivatives, 160 total, 254, 256, 292, 330, 340, 343, 360,
catechins, 161, 235, 323, 326, 328, 329, 470 361, 363, 364, 366, 385, 418, 438,
tea, 160, 402, 403, 404, 405, 407, 408, 409 446, 538
catecholamines, 36, 55, 71, 73–74, 75, 185, coconut oil, and, 460
241, 401, 404, 405, 464, 500 cholesteryl esters, 356
catechol-O-methyl transferase (COMT), 404 chromium, 148, 377, 438
cayenne pepper, 329, 424 chromium (III), 339–345
CCAAT/enhancer-binding protein (C/EBP), bioavailability of, 341
36, 388, 390 deficiency, 339
C/EBPα, 36 dietary sources of, 340
cell adhesion molecules, 53, 56 metabolic syndrome, and, 341–344
cell-surface receptors, 178, 180 safety of, 344–345
cellulose, 415 chromium chloride, 344, 345
Centers for Disease Control and Prevention chromium nicotinate, 360
(CDC), 8, 23, 115, 140, 226, 233 chromium picolinate, 341, 343, 344, 345, 376,
centile crossing, 35 497
central nervous system, 44, 46, 72, 73, 74, 75, chromium polynicotinate, 361
79, 81, 83, 87, 179, 202, 203, 204, 207, chromodulin, 341
210, 211, 234, 350, 372, 373 chromosome 15q11–q13 region, 118
ephedra, and, 497, 500 chronic obstructive pulmonary disease
leptin transport into, 85–86 (COPD), 47, 56
cereal starches, 281 chylomicron, 464
cerebrospinal fluid, 85, 86 cigarette smoke, components of, 45
chemical toxicities, 165–171 cigarette smoking, 310
chemokines, 47, 98, 100 appetite, and, 44–45
Child and Adolescent Trial for Cardiovascular Citrus aurantium supplements, and, 377
Health (CATCH), 519 energy expenditure, and, 44–45
cigarette smoking (cont.) corticotropin-releasing hormone (CRH), 76

energy homeostasis, and, 45–46 cortisol, 250, 254, 482, 484
obesity and, 43–57 cortisone, 482
oxidative stress, and, 47–51 cottonseed oil, 455
synephrine, and, 378 p-coumaric acid, 323, 326
ciliary neurotrophic factor, 386 coumarins, 148, 323
cirrhosis, 166, 538 coumarylquinic acid, 402
citric acid, 351 coumestans, 330
Citrus aurantium, 371–381, 424; see also bitter coumestrol, 330
orange extract C-peptide, 284, 286, 287, 344, 425, 426
adverse events, 379–380 cravings, 65, 66, 67, 345, 366
as substitue for ephedra, 373 C-reactive protein (CRP), 50, 53, 55, 56, 96, 97,
LD50 for, 374 99, 144, 179, 255, 256, 391, 392
CLA-mediated lipoatrophic syndrome, 385 creatine phosphate, 364
cocaine- and amphetamine-regulated transcript creatinine monohydrate, 499
(CART), 86, 89, 108, 112 Crete, childhood obesity in, 12
cocoa, 325 critical periods, 34, 35, 37
coconut, 456–458 Crohn’s disease, 416
coconut oil, 452–460 cryptorchidism, bilateral, 117
as antimicrobial agent, 458 curcumin, 56, 161
heart disease, and, 455 cyanidin, 323, 328
coenzyme A, 131 cyanidin-3-glucoside, 328
coenzyme Q, 271 cyclic adenosine 3′,5′-monophosphate (cAMP),
coenzyme Q10, 127, 131 404
coffee, 325, 340 cyclin D, 391
cold sensitivity, 186 cyclooxygenase, 467
colecistectomy, 532 cyclooxygenase-2 (COX-2), 392
Colombo curing, 350 cytochrome c, 389
complementary and alternative medicine cytochrome P450s, 51, 159, 168, 170, 171, 380
(CAM), 439 cytokines, 47, 49, 50, 51, 54, 55, 56, 83, 84, 93,
Comprehensive Assessment of the Long-Term 99, 144, 145, 159, 178, 257, 386, 390
Effects of Reducing Intake of Energy adipose-derived inflammatory, 157
(CALERIE), 273 inflammatory, 49, 51, 53
conjugated linoleic acid, 235, 376, 383–393, proinflammatory, 391, 392
424, 464, 477
c9t11-CLA, 384–385, 387–388, 390, 392 D
chemical properties of, 384–385 daidzein, 323, 330
pharmacology/dosage, 385 dairy foods, 384, 477–488
safety, 385–386 damiana, 331
t10c12-CLA, 384–385, 387–388, 390, 392, db gene, 84, 85, 87
464 death rate, effect of obesity on, 165
conjugated linolein acid, 359 delphinidin, 323
coronary artery disease, 53, 142, 143, 144, 321, 2-deoxy-D-glucose (2-DG), 273
386, 520 depression, 67, 68
coronary heart disease, 66, 97, 131, 205, 255, carbohydrates and, 66
377, 423 depsides, 402
among cigarette smokers, 48 dexamethasone, 388
corticosteroids, 82 dexfenfluramine, 202
corticotropin-releasing factor (CRF), 71, dextrins, 281
76–77, 80 dextroamphetamine, 201
receptos, 76, 77 diabesity, 139
Index 551
diabetes, 5, 14, 15, 16, 22, 43, 49, 50, 54, 55, 57, disposition index, 257
82, 84, 93, 117, 124, 128, 139–149, of insulin, 535, 536
159, 165, 166, 189, 200, 205, 207, diuretics, 130, 201, 424
208, 220, 227, 246, 254, 255, 257, DNA methylation, 115–118
258, 273, 280, 293, 315, 316, 317, docosahexaenoic acid (DHA), 306, 454,
320, 321, 322, 327, 328, 330, 331, 464–465, 467
332, 372, 383, 384, 385, 386, 387, dopamine, 71, 73–74, 82, 203, 206, 318, 323
391, 423, 464, 465, 531, 539 receptors, 73, 74
chromium (III), and, 339, 340 dorsomedial nucleus of the hypothalamus
diagnostic criteria for, 141 (DMH), 85, 86, 95
medical costs of, 423 dosing adjustment, for obese patients, 170
reversal of after bariatric surgery, 536 drug toxicities, 165–171
white bean extract, and, 425 dual oxidase, 49
diacylglycerol, 235, 464 duodenal switch, 532, 538
diacylglycerol acyltransferase 1 (DGAT1), DUOX, 49
183–184, 189 dynorphin, 77
diacylglycerol kinase, 132 dyslipidemia, 66, 123, 124, 130–131, 132, 143,
diacylglycerols, 235 145, 178, 179, 180, 182, 188, 189,
diadzin, 323 207, 386, 391, 463, 531
diastolic blood pressure, see blood pressure:
diastolic E
Dietary Intervention Study in Children (DISC), eating disorders, 63–69
519 health effects of, 66–68
dietary supplements, 132, 235–236, 322, 326, leptin, and, 86
350, 351, 373, 374, 377, 378, 379, medication for, 68–69
384, 385, 386, 405, 418, 429, 439, prevalence of, 66
440, 507–511 eating disorders not otherwise specified, 64–65,
carbohydrate digestion inhibitors, 279–294 67
ephedra, 495–503 effector mechanisms, 105
diethylpropion, 203, 204 eicosanoids, 99, 389, 467
diethylstilbestrol (DES), 37 eicosapentaenoic acid, 306, 454, 464–465, 467
diet-induced thermogenesis (DIT), 534 8-epi-prostaglandin-F2α (8-iso), 125, 126, 129,
dieting, 129 130, 131
as a risk factor for binge eating, 66 electrospray ionization (ESI), 353
children and, 516, 522 elephant yam, 435
differentiation, 34, 35, 36–37, 38, 47, 52, 53, endocannabinoids, 71, 79, 80
156, 180, 181, 187, 328, 387, endocrine disruptors, obesity and, 33–38
388–389, 390, 391, 470 endogenous glucose output (EGO), 144
digitalis, 201 endoplasmic reticulum (ER), 51
diglycerides, 356 endorphins, 89, 116
dihydrocapsaicin, 329 endostatin, 158
dihydroxyphenylalanine (DOPA), 73 endothelial adhesion molecules, 125
1,25-dihydroxyvitamin D, 478, 479, 482, 484, endothelial cells, 98, 100, 156, 159, 160, 161
487–488 endothelial dysfunction, 49, 50, 52, 96, 97, 98,
dinicotinic acid, 340 144, 391
dinitrophenol, 200–201 hypertension, and, 53
dipeptidyl peptidase 4 (DPP-4), 207 endothelial injury, 51, 52, 53, 54, 55, 98
disaccharides, 280, 281, 293, 424 endothelial nitric oxide synthase (eNOS), 49,
disintegrin, 387 50, 52, 53
dislipidemia, 206, 539 endothelin-1, 97
bariatric surgery, and, 538 endothelin-A (ETA), 97
endothelium-derived relaxing factor (EDRF), 49 epicatechin, 323, 325, 329, 403

endothelium, oxidative stress, and, 52 epicatechin gallate, 402, 403, 408
energetic efficiency, 477 epigallocatechin, 326, 327, 402, 403
energy balance, 45, 47, 65, 74, 76, 78, 81, 82, epigallocatechin gallate, 326, 327, 328, 329,
83, 85, 87, 88, 90, 105–112, 157, 223, 402, 403, 404, 405, 407, 408, 409, 464
233 epigallocatechin-3-gallate (EGCG), 160
energy density, 234 epigenetic modifications, of DNA, 34, 35, 37
energy expenditure, 44–47, 71, 82, 83, 94, 105, epinephrine, 73, 241, 242, 250, 251, 328, 330,
155, 178, 179, 183, 200, 220, 233, 377, 401, 403, 404
240, 241, 256, 307, 310, 328, 332, epitheaflavic acids, 403
364, 376, 387, 390, 401, 403, 404, ergocalciferol, 533
405, 406, 408, 409, 463, 468, 499, essential fatty acids, 454, 467
517, 534 estradiol, 33, 34, 35, 36, 37, 38, 330, 390
fatty acids, and, 459 cholecystokinin, and, 44
green tea extract, and, 464 estrogens, 161, 390
hydroxycitrate, and, 357, 359, 362 adipose tissue, and, 36–37
medium-chain triacylglycerols, and, 458 obesity, and, 33–38
resting, 45, 241, 253, 377, 380, 407, 534 removal of, 35
total, 241, 534 estrogen receptor, 390–391
uncoupling proteins, and, 465 estrogen receptor alpha (ERα), 35, 37
energy homeostasis, 82, 88, 93, 95, 109, 110, estrogen receptor beta (ERβ), 37
111 estrogen-related receptor α (ERRα), 188
cigarette smoking and, 45–46 estrogen-related receptor γ (ERRγ), 188
ghrelin, and, 47 ethanol, 160, 169
leptin, and, 46 ethnicity, obesity and, 8–10, 13, 515
energy intake, 44–47, 234 ethylamine, 403
energy metabolism, 252 Europe, obesity in, 6–8, 11–12, 23
energy storage, 44–47 exenatide, 147, 207
enflurane, 166 exendin-4, 207
enteroglucagon, 207 exercise, 129, 219–229
environmental estrogens, 33–38 aerobic, 129, 222
enzymes, antioxidant, 128, 132 for children, 518, 519
ephedra, 203, 246, 372, 373, 495–503 gender differences in, 241–242
adverse events options, 222–223
factors affecting, 502–503 prescription, 221–222
reports for, 500–503 weight maintenance, and, 221
alkaloid content variation in, 496–497, 502 extracellular matrix, 53, 54
caffeine, and, 499, 502 extracellular signal-regulated kinase (ERK),
case reports for, 499–501 117
overuse, 502
pharmacokinetics of, 498 F
pharmacological action of, 497 FABP aP2 (FABP4), 52
sensitivity to, 502 FABPs, see fatty-acid-binding proteins
Ephedra sinica, 495, 496, 500 Famoxin, 180
ephedrine, 203, 350, 371, 372, 373, 375, 424, fasting, 65, 85, 110, 132, 240, 256, 257, 258,
495–503 270, 340, 362, 425, 535
botanical vs. synthetic, 498 ghrelin levels, and, 90
caffeine, and, 499 fasting plasma glucose (FPG), 141
half-life of, 498 fat, 44, 246, 306, 307, 309–310
label claims, 502 absorption, 413, 415–417, 436
pharmacokinetics of, 498 as energy source, 240
Index 553
Atkins diet, and, 315–320 omega-3, see omega-3 fatty acids

distribution, 45, 240 omega-6, see omega-6 fatty acids
function of, 453 omega-9, see omega-9 fatty acids
loss oxidation of, 387, 389, 459, 478
chitosan, and, 417–419 polyunsaturated, 454, 455
chromium (III) and, 343 saturated, 283, 310
mass, plasma leptin concentrations and, 46 short-chain, 282, 287, 424, 436
monounsaturated, 283, 306, 310 synthesis of, 356
neuropeptide Y, and, 88 trans, 451, 454, 459, 522
obesity, and, 65 transport of, 478
oxidation, see fat oxidation unsaturated, 455
partially hydrogenated, 455 volatile, 414
physical activity, and, 241 fatty liver, 145–146
polyunsaturated, 310 fecal fat excretion, 414, 415–417, 479–480
satiety, and, 234 fenfluramine, 72, 73, 202, 203, 210
saturated, 283, 310, 452, 453 fennel, 428
storage, 241 fermentation
stores, 46 by colonic bacteria, 436
regulation of, 44 of tea, 402
subcutaneous, 240, 241, 242, 408, 482 ferrulic acid, 160, 161
synthesis, 464 fertility, impaired, 116
table and cooking, 453 ferulic acid, 323
unsaturated, 310 fetal basis of adult disease, 35
utilization, gender differences in, 239–243 fetal growth, 35
visceral, 143, 144, 240, 241, 242, 258, 363, fetal levels of bisphenol A, 37
391, 409, 482, 488, 518 fiber, 234, 248, 257, 281, 306, 307, 309, 414,
fat oxidation, 250, 309, 362, 363, 366, 367, 401, 415, 424, 433, 440, 520; see also
405, 406, 407, 409, 534 glucomannan
calcium, and, 479, 483 diabetes, and, 257
green tea, and, 464 supplements, 434
in white adipose tissue, 472 weight reduction, and, 434
postprandial, 409 fibrosis, 538, 539
fatty-acid-binding proteins (FABPs), 52 fisetin, 160, 161, 328
fatty acid synthase, 478 fish oil, 464–465, 467; see also marine lipids
fatty acids, 82, 96, 180, 181, 182, 183, 188, 240, fish-eaters, 300
241, 271, 282, 287, 310, 327, 355, flavanoids, 327
362, 387, 389, 487; see also free fatty flavanols, 323, 326, 402, 403
acids flavanones, 323
categories of, 455 flavans, 402
circulating, 535 flavocytochrome, 49
essential, 454, 467 flavones, 323, 326
vs. non-essential, 454–455 flavonoids, 56, 148, 160, 161, 323, 325, 326,
fecal volatile, 416 328, 329, 330, 331, 374, 402, 406
long-chain, 455, 459 flavonols, 323
marine lipid, 464 fluoxetine, 72, 207, 423
medium-chain, 451, 454, 455, 457–458, fluvastatin, 131
459 foam cells, 56, 98
immune-enhancing properties of, atherosclerotic, 52
459–460 macrophage-derived, 54
milk fat, 385 food choices/preferences, 65–66
monounsaturated, 454 Food Guide Pyramid, 248, 315, 350, 519
food intake, 178, 179, 463 sibutramine, and, 74, 205

adipokines, and, 328 signaling pathways for the regulation of, 89
adrenoceptors, and, 74 thioperamide, and, 75
adrenocorticotropic hormone, and, 79 vs. energy intake, 307
amphetamine, and, 74 forkhead box protein C2 (FOXC2), 187
anorexia, and, 65, 66 formaldehyde, 363, 366
anti-obesity drugs, and, 74 formic acid, 436
black tea, and, 403 FOXC2, 187
cannabinoids, and, 79 free fatty acids, 55, 96, 143, 144, 145, 147, 201,
cholecystokinin, and, 46 240, 249, 250, 356, 409, 467, 538, 539
cigarette smoking, and, 44 glycemic load, and, 251
Citrus aurantium, and, 374 hydroxycitrate, and, 358
compensation effect of, 241 free radicals, 55, 57, 124, 125, 127, 130, 385
corticotropin-releasing factor, and, 76, 77 NOS, 49
cravings, and, 65 fructosamine, 254, 255, 438
dopamine, and, 73 fructose, 247
ephedrine, and, 499 fruit juice, 322
epigallocatechin gallate, and, 404 fruits, 56, 234
estrogen, and, 35 polyphenols from, 321–332
exendin-4, and, 207 fucoxanthin, 467–470, 472
fiber, and, 520 fucoxanthinol, 470
galanin, and, 76 fumagillin, 158
gallic acid, and, 211 functional foods, 68, 160, 235, 332, 393, 409,
gender differences in, 240–241 457
ghrelin, and, 47, 90, 108, 110, 111, 112 fundus, 536
glucagon-like peptide 1, and, 207 furosemide, 170
glucomannan, and, 435
glycemic index, and, 520 G
glycemic load, and, 250 galanin, 71, 76, 80
HCA, and, 357, 358, 359, 364 gallbladder disease, 66, 82, 220, 233, 322, 350
histamine, and, 74 gallic acid, 211, 326, 329, 403
histidine, and, 75 gallocatechin, 323, 402, 408
insulin, and, 46 gallocatechin gallate, 408
leptin, and, 78, 94, 95, 105, 110, 157, 179, 3-galloylquinic acid, 402
390 gamma-aminobutyric acid (GABA), 75
long-term regulation of, 463 Garcinia cambogia, 350–353, 358, 360, 361,
melanocortin, and, 73, 78, 89, 90 362, 366, 424, 427
melanocortin-4, and, 116 Garcinia indica, 360
α-melanocyte-stimulating hormone, and, gastric banding, 533, 536, 538, 539
76, 78 gastric bypass, 207, 510, 536, 537, 538, 539
neuropeptide Y, and, 75, 76, 88 gastric emptying, 331, 359, 360, 426, 435
niacin-bound chromium, and, 343 gastric inhibitory peptide, 309, 425, 426
orexins, and, 77 gastric inhibitory polypeptide, 282, 284, 286,
peptide signals, and, 234 287, 288
proopiomelanocortin (POMC), and, 76, 116 gastric motility, 282
regulation of, 234 gastric restriction, 532–534
regulation of body weight, and, 82 gastrin, 426
restriction, see caloric restriction gastrin-releasing peptide, 82
SCD1, and, 182 gastrointestinal fat absorption, 413, 415–417
sensory inputs, 82 gastroplasty, 108, 532, 536
serotonin, and, 72, 73, 366 gender differences, 239–243, 258, 377, 516, 517
Index 555
gene expression, caloric restriction, and, 271 homeostasis, 143, 184, 185, 327, 330, 538
gene regulation, by HCA-SX, 365–366 intolerance, 257, 341, 537
genes, estrogen-responsive, 33 metabolism, 45, 47, 178, 184, 535
genistein, 160, 161, 323, 327, 328, 330, 390 oxidation, 330, 405, 535
genistin, 323 Phase 2®, and, 288, 289
gentamicin, 170 phloridzin, and, 326–327
geriatric population, physical activity and, 226 postprandial levels of, 246, 247, 249–250,
GH-releasing hormone receptor (GHRH-R), 106 281, 286, 287, 288, 359–360, 425,
ghrelin, 45, 47, 53, 57, 82, 90, 105–112, 148, 426, 427, 446
209, 308, 309, 318, 536 psyllium, and, 434
appetite control, and, 108 sensitivity, 339
central vs. peripheral, 108, 111, 112 tolerance, see glucose tolerance
food intake, and, 47, 90, 108, 110, 111, 112 transport, 48
gut-derived, 110 transporter 4 (GLUT4), 37, 535
levels, regulation of, 109–110 transporters, 327
structure of, 106–107 uptake, 326–327
unacylated, 107, 111, 112 glucose-dependent insulinotropic polypeptide
ginger, 210, 375 (GIP), 536, 537
ginkgo, 375 glucose-dependent insulinotropic polypeptide
ginseng, 375 receptor (GIPR), 537
glipizide, 273 glucose-6-phosphatase, 327
globesity, 349, 350 glucose tolerance, 209, 257, 359, 518, 535, 537
glucagon, 36, 74, 82, 249, 250, 251, 284, 344, coronary artery bypass surgery, and, 256
362, 426 dairy, and, 485
upregulation of, 308 factor (GTF), 339, 340–341
glucagon-like peptide 1 (GLP-1), 147, 207, impaired, 126, 127, 142, 143, 147, 148,
283, 308, 309, 536, 537 208, 257, 521
glucoamylase, 281, 282 test, 254, 340, 359
glucocorticoids, 36 glucosides, 330
glucokinase, 327 glucosinolates, 56
glucomannan, 416, 424, 433–440 glucosuria, 326
case study, 438–439 glucuronidation, of acetaminophen, 168
dosage, 437 GLUT4, 37, 535
drug interactions, 437 glutamine, 87
mechanisms of action, 435–436 glutathione (GSH), 54, 127, 130, 132, 166, 171,
pharmacokinetics of, 436 340
safety of, 436–437 glutathione peroxidase (GSHPx), 54, 128, 130,
structure of, 435 271
Glucomannan+®, 438 glycation, 385
gluconeogenesis, 143, 188, 317, 327 glycemic control, 255, 258, 536
glucosamine, 414 glycemic index, 246–247, 248, 250, 252, 256,
glucose, 54, 74, 82, 90, 94, 96, 125, 128, 132, 257, 258, 259, 281, 294, 307, 309,
141, 205, 241, 258, 281, 309, 317, 318, 366, 393, 520, 522
340, 362, 424, 436 alpha-amylase inhibitors, and, 293
absorption, 327, 359 lowering of, 282
as energy source, 240 Phase 2®, and, 289
caloric restriction, and, 273 glycemic load, 245–260, 281, 309, 520
control, 520 defined, 248
2-deoxy-D-glucose (2-DG), 273 effect on hunger, 250–251
exercise and, 227 of American diet, 248–249
fasting, 207, 521 weight loss, and, 251–254
glycerides, 235 herbs, 325–326, 371–372, 497, 499, 501, 502,

glycerol, 96, 235, 240, 362, 453, 478 510
glycogen, 249, 250, 281, 327, 363, 424 as obesity drugs, 210–211
hydroxycitrate, and, 357 HgbA1c, 207
stores, depletion of, 317 high-carbohydrate vs. high-protein meals, 308
synthesis, 327 high-density lipoprotein (HDL), 128, 139, 143,
glycogenesis, 249 146, 147, 205, 206, 254, 256, 270,
glycogenogenesis, 207 280, 361, 363, 364, 366, 388, 418,
glycogenolysis, 143 426, 438, 446, 460
glycolipids, Undaria, 467–469 bariatric surgery, and, 538
glycolysis, 250, 273, 327, 366 niacin-bound chromium, and, 343
glycomacropeptide, 235 high-fructose corn syrup, 165, 315, 319
glycoproteins, 425 high-protein diet, 308
glycosides, 323, 326 high-sensitivity C-reactive protein (hs-CRP),
pregnane, 444 255
saponin, 444 hippuric acid, 498
glycoxidation, 385 Hispanics, glycemic index and, 520
gonadotropin-releasing hormone (GnRH), 111 histamine, 71, 74–75, 80
gp91phox, 49 receptors, 75
G-protein-coupled receptors, 75, 76, 77, 89, histidine, 74, 75
107, 159 L-histidine decarboxylase, 74
granulocyte-colony-stimulating factor, 84 histone proteins, 34
grapes, 323 homeostasis, 156
grapeseed extract, 328, 375 energy, 45–47, 82, 88, 93, 95, 109, 110, 111
green tea, see tea: green glucose, 143, 184, 185, 327, 330, 538
growth factors, 36, 49, 54, 156, 159, 160, 328 lipid, 47
growth hormone, 36, 47, 90, 106, 148, 250, 251, vascular wall, 96–97
308 homeostasis model assessment (HOMA), 251,
secretion, 107, 111 254, 257
growth hormone secretagogue receptor hordenine, 373, 377
(GHS-R), 108, 110, 111, 112 hormones, 44, 45, 46, 157, 178, 185, 234, 251
structure of, 106–107 adipogenic, 388
growth hormone secretagogues (GHSs), 106, adrenocorticotropic, 76, 78
108, 110 corticotropin-releasing hormone, 76
guar gum, 359, 414, 415, 424, 434, 438, 440 gastrointestinal, 426
guarana, 331, 376, 377, 407, 439, 497, 498, 499 gonadotropin-releasing, 111
gymnema, 438 growth, 36, 47, 90, 106, 107, 111, 148, 250,
Gymnema sylvestre, 343, 363, 364 251, 308
insulin-like, 161
H luteinizing, 111
halothane, 166 melanin-concentrating, 44, 77
haptoglobin, 156 melanocyte-stimulating, 76, 78, 79, 89, 90,
HCA-SX, 343, 351–355, 358, 359, 363, 364, 116
367 metabolism, and, 318
gene regulation by, 365–366 parathyroid, 478, 479
heart-valve abnormalities, 202, 204 sex, 34
hemoglobin, 254, 255, 258, 291, 378, 446 suppression of by calcium, 478
hepatic regeneration, 269 thyroid, 36, 44, 185, 200, 201, 467
hepatic steatosis, 166, 182, 183, 385 hormone-sensitive lipase (HSL), 467
hepatitis B vaccinatio, 392 human umbilical vein endothelial cells
hepatomegaly, 182 (HUVECs), 97, 157, 160
Index 557
hunger hypertension, 52, 53, 54, 55, 57, 66, 82, 93, 95,
caloric restriction, and, 272 115, 123, 124, 128, 130, 132, 141,
glycemic load effect on, 250–251 142, 143, 144, 146, 148, 166, 182,
insatiable, 117 200, 202, 204, 205, 206, 220, 227,
pains, 316 270, 316, 321, 341, 364, 378, 386,
hydrogen breath test (H2BT), 282, 283, 284, 391, 423, 463, 464, 498, 502, 531,
285, 286, 287, 288, 424, 425, 426 539; see also blood pressure
hydrogen peroxide, 47, 48, 49, 124, 159, 161 bariatric surgery, and, 537
hydrogenated vegetable oils, 384 calcium, and, 483
hydroxy-3-methyl glutaryl CoA (HMGCoA), 329 lipid peroxidation, and, 125–126
hydroxybenzoic acid, 323 hyperthyroidism, 204
hydroxycinnamic acid, 323 hypertriglyceridemia, 146, 356
hydroxycitrate, see (–)-hydroxycitric acid bariatric surgery, and, 538
(–)-hydroxycitric acid, 72, 349–367, 377, 427 hyperuricemia, 146
animal studies of, 355–360 hypoadiponectinemia, 142, 144
bioavailability of, 353 hypocaloric diets, 129
chemistry, 351–352 hypochlorous acid, 124
clinical studies, 360–364 hypoglycemia, 209, 249, 251, 293, 438
isolation techniques, 352 exercise-induced, 227
NOAEL, 355 hypophagia, 73, 77
pharmacognosy, 351 hypotension, 227
physicochemical properties, 352 hypothalamic–pituitary axis, 76
safety of, 354–355 hypothalamic–pituitary–adrenal axis, 94, 386
salts, 352–353 hypothalamus, 44, 45, 53, 72, 73, 74, 76, 77, 78,
hydroxyeicosatrienoic acid (HETE), 467 81, 83, 84, 86, 87, 88, 89, 90, 95, 99,
5-hydroxyindoleacetic acid, 72 105, 106, 107, 108, 110, 184, 201,
11β-hydroxysteroid dehydrogenase-1 206, 234, 390, 444
(11β-HSD-1), 482 hypothyroidism, 209
5-hydroxytryptamine (5-HT), 71, 72–73, 80, hypotonia, 117
205 hypovitaminosis D, 534
receptors, 72, 73 hypoxia, 157, 159, 160
5-hydroxytryptophan (5-HTP), 72 hypoxia-inducible factor 1 (HIF-1), 157
hyperactivity, 71, 74
hyperandrogenism, 538 I
hypercholesterolemia, 52, 128, 131, 418, 438 ideal body weights, 21
bariatric surgery, and, 538 I-kappaB kinase (IκBK), 51
hyperglycemia, 51, 123, 124, 126, 127, 130, ileal fluids, 283
132, 158, 209, 250, 327, 328, 385, 536 immunity, impaired, 116
antioxidant enzymes, and, 128 impaired glucose tolerance (IGT), see glucose
lipid peroxidation, and, 125 tolerance: impaired
Hypericum perforatum, 331, 375 imprinting, 118
hyperinsulinemia, 47, 72, 127, 143, 147, 249, incretin mimetics, 147
250, 251, 365, 385, 521, 538 indoles, 331
hyperleptinemia, 72, 86, 96, 97, 98, 99, 100, inducible nitric oxide synthase (iNOS), 49–50,
187, 365 392
hyperlipidemia, 51, 54, 93, 142, 144, 220, 316, inflammation, 145, 156–157, 161, 178, 386,
321, 330, 340, 356, 465, 509 390, 391–392, 393, 487, 539
hyperlipogenesis, 356 exercise and, 129
hyperphagia, 65, 66, 68, 72, 73, 75, 78, 85, 86, leptin and, 99
90, 117 obesity and, 43–57
hyperplasia, 54, 357 vascular, 148
inflammatory cytokines, adipose-derived, 157 insulin sensitivity, 96, 143, 144, 145, 157, 158,
inflammatory response, 49, 50, 51, 52, 389 178, 181, 183, 184, 208, 252, 254,
inosine, 364 257, 273, 308, 309, 327, 332, 339,
insulin, 36, 44, 45, 46, 48, 49, 82, 110, 132, 184, 340, 341, 388, 424, 518, 520, 521,
241, 283, 309, 326, 388, 425, 518 522, 535, 536, 537, 539
adipocytes, and, 47 BPD vs. RYGB, 535
bisphenol A, and, 37 dairy, and, 485
Brewer’s yeast, and, 340 t10c12-CLA, and, 385
caloric restriction, and, 273 insulin-like growth factor, 36, 273
cancer, and, 161 insulin-like growth factor 1 (IGF-1), 57, 308
cholecystokinin, and, 44 insulin-like hormones, 161
chromium (III), and, 340, 341 Interactive Multimedia for Promoting Physical
downregulation of, 308 Activity (IMPACT), 517
estradiol, and, 390 interleukin 1 (IL-1), 54, 56
fasting, 257, 258 interleukin 1β (IL-1β), 47, 156
food intake, and, 46 interleukin 2 (IL-2), 392
hypersecretion, 209 interleukin 6 (IL-6), 50, 52, 53, 84, 144, 145,
glycemic load, and, 251, 253 156, 388, 391, 392
leptin secretion, and, 365 interleukin 8 (IL-8), 56, 156
needs, exercise and, 227 interleukin 10 (IL-10), 156
postprandial levels of, 247, 249–250, 286, International Association for the Study of
287, 425, 436 Obesity (IASO), 16
receptor, 341, 535 International Obesity Task Force (IOTF), 7, 11,
receptor substrate 1 (IRS1), 184, 327, 390 12, 15, 16, 17
release of, 44 interscapular brown adipose tissue, 465
resistance, see insulin resistance intestinal malabsorption, 532–534
response, 282, 343 intima, 96
to glucose, 249–250, 254 intramyocellular lipid (IMCL), 518
secretion, see insulin secretion inulin, 427
sensitivity, see insulin sensitivity ischemia, 159, 270, 299, 310, 378, 499
insulin resistance, 37, 45, 47, 48, 50, 51, 52, 54, 3-isobutylmethylxanthine, 388
93, 100, 124, 125, 126, 127, 128, 139, isoflavones, 323, 330
141, 142, 143, 144–145, 146, 147, isoleucine, 482
148, 157, 161, 178, 179, 180, 181, isorhamnetin, 327
182, 183, 184, 185, 187, 188, 207, isovitexin, 326
220, 249, 250, 257, 269, 280, 310,
316, 317, 318, 319, 331, 341, 365, J
385, 386, 388, 389, 391, 393, 516, JAK/STAT pathway, 84, 88, 94, 96
520, 521, 522, 535, 538 Janus kinase (JAK), 51, 94, 95
antioxidants, and, 127 Janus kinase 2 (JAK2), 84, 184
calcium, and, 365 Japan, obesity in, 10
dairy intake, and, 487 jejunoileal bypass, 533
phytoestrogens, and, 330 c-Jun N-terminal kinase (JNK), 117, 390, 389
predictor of in children, 35
insulin secretion, 48, 57, 74, 96, 108, 143, 144, K
145, 207, 209, 254, 309, 328, 330, kaempferol, 160, 161, 323, 326
520, 522, 534, 535–536, 537 keratinocytes, 161
glucose-dependent insulinotropic ketones, 317
polypeptide receptor, and, 537 ketosis, 316, 317, 318
glycemic load, and, 251 kola nut, 497, 499
metabolic inflexibility, and, 534 extract, 378
Index 559
konjac, 435, 436 smooth muscle cells, and, 98

Kreb’s cycle, 327 sympathoactivation of, 95
transport of into the CNS, 85–86
L leptin receptor (Ob-R), 84–85, 87, 94, 116, 157,
lactate, 362 179
lactic acid, 287 defects in, 87
lactone, HCA, 352 gene, 167
lacto-ovo vegetarians, 300, 306 gene, mutations in, 116
lactovegetarians, 304 long form of (Ob-Rb), 85, 86, 88, 89, 94,
lactulose, 283 96, 97, 98
Lamiaceae, 326 short form of (Ob-Ra), 85, 94
laparoscopic banding, 539 leptinemia, 385
LASIX®, 170 leucine, 482
lateral hypothalamus (LH), 85, 86 leukocyte inhibitory factor, 84
Latin America, obesity in, 10 leukotriene B4, 467
lauric acid, 451, 454, 455–457, 458, 459 life expectancy, decline in, 165
antimicrobial properties of, 458, 459 life span, caloric restriction, and, 265–268,
laxatives, 201 271–272, 273
Lean Source™, 376 lignans, 323, 330
Lean System 7™, 376 lignin, 309
left ventricular hypertrophy, 98 linoleic acid, 235, 376, 454
legumes, 281, 282 biohydrogenation of, 385
LEP gene, 46 conjugated, 383–393, 464
leptin, 44, 45, 46, 57, 78, 81, 82, 83–90, 105, high doses of, 509
112, 116, 145, 148, 155, 156, 157, linolenic acid, 385, 454
158, 160, 166, 178, 179, 184, 200, lipase, 328, 329, 464
253, 282, 307, 309, 318, 328, 343, inhibitors, 328, 521
359, 364, 365, 366, 367, 386, 388, lipid
390, 391, 404, 408, 535, 537 absorption, 328–329, 415–417
action in the brain, 86–87 homeostasis, 47
as a vasoactive adipokine, 93–100 malabsorption, 533, 535
blood pressure, and, 95–96 metabolism, 45, 52, 156, 157, 328–329,
central effects of, 94–96 388, 464, 479, 481, 535
-deficient mice, 46 regulation of by calcium, 478
eating disorders, and, 86 oxidation, 90, 358, 405, 478, 481, 535; see
food intake, and, 78, 94, 95, 105, 110, 157, also fat oxidation
179, 390 peroxidation, 48, 49, 53–54, 129, 359, 385
gene, mutations in, 116 biomarkers of, 125–126
ghrelin, and, 109–110 postprandial, 401
HCA, and, 363 peroxides, 55, 132
inflammation, and, 99 synthesis, 178, 189, 327, 355, 356, 464
peripheral effects of, 96–99 viruses, 458
plasma, 97 lipids, 51, 52, 54, 56, 76, 249, 256, 269, 271,
proatherogenic effects of, 98 341, 344, 389
protein, 83–84 dieting, and, 129
recombinant, 116, 179 glucomannan, and, 437, 438
resistance, 81, 85, 86, 95, 100, 179, 282, major classes of, 453–454
310 marine, 463–472
obesity, and, 87–88 metabolic inflexibility, and, 534
sensitivity, 183 psyllium, and, 434
signaling pathways, 88–90 Undaria, 467–469
Lipodex-2™, 360 M
lipodystrophy, 179 Ma huang, 331, 495, 496, 499
lipofuscin, 125 macrophage inflammatory protein 2, 47
lipogenesis, 35, 36, 96, 148, 249, 328, 355, 356, macrophages, 45, 46, 49, 50, 52, 53, 54, 55, 56,
357, 359, 389, 390, 424, 458, 481, 483 98, 178, 386, 392
α-lipoic acid, 127, 130 in adipose tissue, 51
lipolysis, 74, 96, 148, 188, 203, 211, 240, 242, malabsorption, of lipids, 533, 535
249, 250, 328, 330, 364, 371, 379, malondialdehyde (MDA), 53, 125, 129, 130,
387, 390, 403, 404, 405, 464, 467, 363, 366
478, 479, 481, 483 malonyl-CoA, 535, 538, 445
lipopolysaccharide (LPS), 50, 392 maltase, 281
lipoprotein, 464 maltose, 282, 424
lipoprotein lipase, 538 malvidin, 323
activity, 37 mammalian target of rapamycin (mTOR), 482
lipoprotein(a), 460 mannose, 436
liver, 184 marine lipids, 463–472
disease, 166 mast cells, 74
nonalcoholic fatty, 141, 145, 515, 531, mastocytes, 386
538–539 matrix metalloproteinase (MMP), 52, 158, 387
nonalcoholic steatohepatitis, 117, 142, mead acid, 454
166, 538–539 media, 96
fatty, 145–146 Mediterranean diet, 306
steatosis, 166, 182, 183, 385 Mediterranean islands, obesity rates in, 11
long-chain fatty acids, 455, 459 medium-chain fatty acids, 235, 451, 454, 455,
long-chain triacylglycerols, 458 457–458, 459
long-chain triglycerides, 235 immune-enhancing properties of, 459–460
loop diuretic furosemide (LASIX®), 170 medium-chain triacylglycerols, 458, 464
lorazepam, 166 medium-chain triglycerides, 235, 362, 477
lovastatin, 131 melanin-concentrating hormone (MCH), 44, 77
low-carbohydrate diet, 246, 281; see also melanin-concentrating hormone receptor-1
Atkins diet gene, 117
low-density lipoprotein (LDL), 22, 52, 53, 54, melanocortin, 71, 78–79, 80, 82, 89–90, 116,
55, 56, 128, 130, 131, 143, 158, 205, 148
254, 256, 270, 292, 329, 330, 385, receptors, 78, 89
418, 426, 438, 446, 460, 519 melanocortin-4
bariatric surgery, and, 538 gene mutations in, 116
chromium (III), and, 341 receptor (MC4R), 116, 166
exercise, and, 129 melanocyte-stimulating hormone (MSH), 116
HCA, and, 361, 363, 364, 366 α-MSH, 76, 78, 79, 89, 90
niacin-bound chromium, and, 343 β-MSH, 78, 89
oxidation, 126, 391, 408, 460 γ-MSH, 78, 89
receptor-related protein 2, 366 membrane-associated rapid response to steroid
low fat consumption, 309, 316, 319, 455 (MARRS), 478
low-glycemic-load diet, 245–260 menopause, 35
components of, 260 metabolic efficiency, 534
physiological effects of, 249–250 metabolic inflexibility, 534–535
luteinizing hormone (LH), 111 metabolic rate, 158, 178, 182, 184, 185, 187,
luteolin, 160, 161 188, 189, 221, 242, 307, 330, 343,
lycopene, 56–57, 129 344, 365, 366, 375, 376, 401, 406,
lypogenesis, 90 409, 424, 464, 465, 466
L-lysine, 428 basal, 241, 242
Index 561
dinitrophenol, and, 201 monoglycerides, 457, 458, 459

gender differences in, 240 monolaurin, 458, 459, 460
leptin, and, 179 antiviral action of, 458, 459
metabolic risk factors, pharmacotherapy for, monosaccharides, 280, 281, 424
146–147 monosaturated fat, 522
metabolic syndrome, 35, 48, 50, 54, 56, 93, monounsaturated fat, 283
123–132, 142, 143, 144, 147, 156, monounsaturated fatty acids, 182, 454, 455
157, 158, 182, 206, 220, 316, 321, morbid obesity, 165, 226, 240, 349, 532, 536,
322, 339, 341–344, 386, 388, 391, 537, 538, 539
393, 482, 509, 515 morbidity
adinopectin, and, 145 drug-related, 166
antioxidant defense mechanisms, and, obesity-related, 14, 25, 43, 51, 165, 168,
127–128 220, 488, 531
biomarkers of oxidative stress, and, 128–132 smoking-related, 48
pharmacotherapy of, 130–132 type 2 diabetes and, 142
prevalence of, 124 morin, 327
metabolism, 46–47, 93–100 morning anorexia, 68
metacresol, 208 mortality
metenkephalin, 106 drug-related, 166
metformin, 147, 208, 273, 293 obesity-related, 5, 14, 21, 25–26, 51, 165,
use by adolescents, 521 220
methamphetamine, 201 reductions in, 15
methoxyflurane, 166 smoking-related, 48
methylation, 115–118, 328 type 2 diabetes and, 142
methyl-binding protein 2 (MeCP2), 118 motilin, 106, 426
3,4-methylene dioxy methamphetamine motilin-related peptide (MTLRP), 106
(MDMA), 466 mouse models, 166
N-methylephedrine, 496 multimedia health promotion, 516
N-methylpseudoephedrine, 496 muraglitazar, 182
N-methyltyramine, 373, 377 mutations, in leptin receptor gene, 87
methylxanthine, 203, 375, 378, 402, 404, 405, myocardial infarction, 54, 377
409 myricetin, 323, 327
metronidazole, 282
Micronesia, obesity in, 10 N
microsomal ethanol-oxidizing system, 169 NAD(P)H oxidase, 49, 50, 53, 54
milk fat, 384 NADPH oxidase (NOX), 49, 159, 391, 488
mimetics, caloric restriction, 268, 273–274 naringenin, 327, 328
mitochondrial dysfunction, 389 National Center for Health Statistics (NCHS),
mitochondriogenesis, 181, 187, 188 25
mitogen-activated protein kinases (MAPKs), Native Americans, obesity and, 9, 13
117, 328 natural killer (NK), 99
mitogens, 156 neoplasms, 268
MONICA study, 23 neosynephrine, 379
monoacylglycerol acyltransferase (MGAT), 310 neovascularization, 98, 158, 160
monoamine oxidase inhibitor (MAOI), 204, nerve growth factor (NGF), 391
205, 206, 207, 378, 498, 502 neurobiology, of obesity, 81–90
monobutyrin, 156 neuroleptic malignant syndrome, 207
monocaprin, antiviral action of, 458 neuronal nitric oxide synthase (nNOS), 49
monocyte chemotactic protein 1 (MCP1), 47, neuropeptide Y, 44, 46, 57, 71, 73, 75–76, 78,
49, 98 80, 82, 86, 88, 90, 108, 148, 365, 367
monocytes, 53, 56, 98 receptors, 75–76, 77
neuropeptides, 75–79, 86, 89, 105, 108, 112, nuclear vitamin D receptor (nVDR), 478
116, 366, 404 nutrient partitioning, 155
orexigenic, 44, 45 nutrigenomics, 332
neuropilin-1, 158 nutrition transition, 3
neurotensin, 426 nutritional supplements, 509
neurotransmitters, 71–80, 82, 83, 86, 155, 318 nuts, 325–326
neurotrophins, 386, 391
neutrophils, 45, 49 O
New Zealand Obese mouse (NZO/HlLt), 148 ob gene, 81, 83, 84, 85, 157
niacin-bound chromium, 341, 343, 344, 345, obese mice, 48, 49, 50, 78, 81, 94, 95, 116, 117,
363 148, 184
nicotinamide adenine dinucleotide phosphate obesity
(NADP+), 364 adinopectin, and, 47
nicotine, 44, 45, 55 age, and, 27
food intake, and, 44 animal models of, 166
nicotinic acid, 340, 341, 345 carbohydrates, and, 65, 316
night eating syndrome, 64, 65, 68, 209 cardiovascular disease, and, 52–55
nitric oxide, 45, 50, 52, 96, 97, 98, 99, 100 central, 5, 10
nitric oxide synthase (NOS), 49–50, 51, 159 chemical toxicities, and, 165–171
nitrite, plasma, 50 cigarette smoking, and, 43–57
nitrogen-bound chromium, 364 comorbidities, 141
nitrolinoleic acid, 392 costs of, 5, 15, 115, 165, 200
nitrosative stress, 52–55 defined, 3, 12, 13, 140, 245, 386, 423
nitrotyrosine, 126 DNA methylation, and, 115–118
nonalcoholic fatty liver disease, 141, 145, 515, drug toxicities, and, 165–171
531, 538–539 drugs, safety of, 199–212
nonalcoholic steatohepatitis, 117, 142, 166, early-onset, 116
538–539 eating disorders, and, 63–69
nonesterified fatty acids (NEFAs), 404, 487 endocrine disruption, and, 33–38
non-exercise activity thermogenesis (NEAT), energy expenditure, and, 46–47
534 environmental estrogens, and, 33–38
non-insulin-dependent diabetes mellitus epidemiology of, 3–17, 21–27
(NIDDM), 5, 14; see also type 2 epigenetic mechanisms, and, 35
diabetes ethnicity, and, 8–10, 13
no-observed adverse effect level (NOAEL), factors contributing to, 233
355 genetic component of, 83
noradrenaline, 201, 202, 203, 205, 404, 464, 467 genetics vs. environment, 167
nordexfenfluramine, 202 health consequences of, 14
norephedrine, 496, 498 (–)-hydroxycitric acid, and, 349–367
norepinephrine, 46, 71, 73, 74, 75, 80, 82, 97, impact on type 2 diabetes, 142
201, 206, 241, 242, 330, 401, 403, -induced oxidative stress, 487–488
404, 405, 497 inflammation, and, 50–51
norfenfluramine, 73 initiatives to combat, 220–221
norpseudoephedrine, 496 iNOS, and, 49–50
NOX, 49, 159, 391, 488 leptin resistance, and, 87–88
NT, 210 lipid peroxidation, and, 125
nuclear factor kappa-B (NF-κB), 51, 161, 391, marine lipids, and, 463–472
392 melanocortin-4 receptor, and, 116
nuclear factor of activated T (NFAT), 388 metabolism, and, 46–47
nuclear receptors, 52 molecular genetics of, 116–117
nuclear transcription factor, 470 morbid, 165, 166
Index 563
neurobiology of, 81–90 oxedrine, 371

pharmacotherapy for, 146–147 oxidants, 159–160
phytochemicals, and, 55–57 cigarette-smoke-derived, 45
polyphenols, and, 321–332 oxidation
prevalence of, 3, 5–14, 21, 22–25, 115, carbohydrate, 250, 362, 363, 464, 479
140, 155, 219, 233, 239, 349, 423 red pepper and, 330
in children/adolescents, 11–14 fat, see fat oxidation
race, and, 8–10, 13 fatty acid, 387, 389, 478
regulation, by neurotransmitters, 71–80 glucose, 330, 405, 535
sex, and, 27 lipid, 90, 358, 405, 478, 481, 535
thrombotic events, and, 54–55 low-density lipoprotein, 126, 391, 408, 460
treatment, adipose drug targets for, 177–189 products, increases in, 125–126
type 2 diabetes, and, 139–149 protein, 131, 271, 464, 479
vegetarian diets, and, 299–311 oxidative damage, 270–271
visceral, 5 oxidative stress, 45, 46, 52–55, 56, 100,
obsessive–compulsive disorder, 67, 68 123–132, 159, 327, 331, 391–392
obstructive sleep apnea, 141; see also sleep biomarkers, changes in, 128–132
apnea cigarette smoking, and, 47–51
octopamine, 372, 373, 377, 378 dietary calcium, and, 487–488
octreotide, 209 exercise, and, 129
oil palm, 457 pharmacotherapy of, 130–132
oleic acid, 182, 454 oxidized low-density lipoproteins (ox-LDLs),
Olibra™, 235 52, 54, 56, 126
oligosaccharides, 281 oxygen radicals, 99
olive oil, 283
omega-3 fatty acids, 148, 249, 306, 310, 451, P
454 p22phox, 49, 50
omega-6 fatty acids, 149, 451, 454 palm kernel oil, 454, 455–458
omega-9 fatty acids, 454 palmitic acid, 454
omnivores, 300 pancreas, 282
oolong tea, see tea: oolong pancreatic β-cells, 48, 49
oolonghomobisflavans, 403 pancreatic islets, Ob-Rb in, 96
oolongtheanin, 403 paraoxonase (PON), 131
OptiBerry, 160–161 paraoxonase-1 (PON-1), 128
orexigens, 108, 110 parasympathetic nervous system, 44, 329
orexin, 71, 80, 82, 108 parathyroid hormone, 478, 479
organizational effects, of sex hormones, 34 paraventricular nucleus (PVN), 75, 76, 78, 85,
organogenesis, 35 86, 117
organotin compounds, 37–38 partially hydrogenated fat, 455
orlistat, 129, 146–147, 148, 200, 205–206, 211, partially purified white bean products,
328, 380, 416, 423, 480, 534 286–287, 289
use by adolescents, 521 pears, 322
Ornish, 316 pectin, 414, 416, 424
orocecal transit time, 283 pelargonidin, 323
osteoarthritis, 66, 227, 233, 245, 322 peonidin, 323
osteopontin, 117 peptide signals, 234
osteoporosis, 115, 330, 331, 365, 390 peptide YY, 426
overfed rat model, 166, 167–168, 169, 170 peptides, 155
overweight peripheral vascular disease, 53
defined, 12, 13, 21, 140, 423 smoking, and, 55
prevalence of, 515 peroxisome proliferation, 182
peroxisome proliferator-activated receptor picolinic acid, 345

(PPAR), 180–182, 188–189, 388, pioglitazone, 181, 182, 467
389–390, 464 piperine, 376
peroxisome proliferator-activated receptor α pituitary dysfunction, 116
(PPARα), 182, 188–189, 389–390 placental blood flow, restriction of, 35
peroxisome proliferator-activated receptor β placental growth factor (PGF), 392
(PPARβ), 389–390 Planet Health, 516
peroxisome proliferator-activated receptor δ plantago, 330, 434
(PPARδ), 181–182, 189, 389–390 plantain, 330
peroxisome proliferator-activated receptor γ plaques, 52, 53, 54–55, 98, 99, 339
(PPARγ), 36, 38, 47, 52, 145, plasminogen activator inhibitor, 255
180–181, 182, 187, 189, 328, 366, plasminogen activator inhibitor 1 (PAI-1), 156
387, 389–390, 392, 467, 470 platelet aggregation, smokers and, 55
coactivator-1α (PGC-1α), 187 platelet-derived endothelial cell growth factor,
peroxisome proliferator-activated receptor γ2 156
(PPARγ2), mutations in, 116 platelet-derived growth factor (PDGF), 54
peroxisomes, 389 plum juice, 145
peroxynitrite, 45, 53, 98, 124, 126 polycarbonate plastic, 37
petunidin, 323 polycystic ovary syndrome (PCOS), 117, 141,
PGC-1α, 187–188 144, 208, 515, 521, 531, 538, 539
phagocytes, 49 polymerase chain reaction (PCR), 118
Phase 2®, 288–293, 426–429 real-time, 159, 390
Phaseolamin 2250®, 285 polymerized polyphenols, 403, 407
Phaseolus vulgaris, 282 Polynesia, obesity in, 10
α-amylase inhibition, and, 423–429 polypeptide N, 118
phendimetrazine, 203, 204 polypeptides, 288
phenethylamine, 204 polyphenol oxidases, 401, 402
phenolic acids, 323, 325, 326, 329, 331 polyphenolic compounds, in tea, 402
phentermine, 74, 202, 203, 204–205 polyphenols, 160, 161, 273, 311, 321–332, 460
phenylephrine, 373, 379 mechanisms of action, 326–330
phenylethanolamine, 373 plant, 323–324
phenylethylamine, 371, 373, 374, 375, 376, 378 polysaccharides, 281, 324, 424
phenylpropanolamine, 202–203, 350, 373, 498 polyunsaturated fat, 522
phloretin, 327 polyunsaturated fatty acids, 56, 306, 310, 454,
phloridzin, 326–327 455, 464, 465, 467
phosphodiesterase, 404 polyvinylchloride (PVC), 37
phosphoinositide 3-kinase (PI3K), 327 potassium, 364–365, 367
phosphoinositol 3-kinase-dependent pathways, potatoes, 247, 252, 281, 285, 323
94 PPARγ coactivator-1α (PGC-1α), 389
phospholipids, 356, 453, 460, 464 Prader–Willi syndrome (PWS), 117–118, 209
phosphorylation, 467 pramlintide, 208
physical activity, 36, 219–229, 366, 463, 534 preadipocytes, 36, 37, 52, 156, 158, 327, 328,
IMPACT, and, 517 387, 388–389, 391
of children, 517–519, 522 pre-B-cell colony-enhancing factor (PBEF), 145
Physical Activity for Total Health (PATH), 519 Precose™, 293
physical education, 225–226, 516, 517 pregnane glycosides, 444
physical inactivity, obesity and, 27, 65, 220 preproghrelin, 106
phytoalexin, 160 preproorexin, 77
phytochemicals, 54, 55–57, 66, 68, 311 primary dermal irritation index (PDII), 354
phytoestrogens, 330, 390 primary pulmonary hypertension, 202, 204, 205
phytopharmaceuticals, 68, 350 proanthocyanidins, 324, 402, 403
Index 565
procyanidins, 324, 327 regulation, of body weight, 82–83

prohormone convertase 1, 116 repaglinide, 130
proopiomelanocortin (POMC), 76, 77, 78, 83, reserpine, 200, 211
86, 89, 108, 116, 166 resistance training, 225
propionic acid, 436 among children, 518–519
prostacyclin, 55 resistin, 45, 145, 392, 393
prostaglandin D synthase, 366 restenosis, 97, 98
prostaglandin E2 (PGE2), 392 resting energy expenditure (REE), 45, 241, 253,
prostaglandins, 454, 467 377, 380, 407, 534
protein, 246, 247, 271, 306, 307, 308; see also resveratrol, 160, 161, 273, 329
Atkins diet retina, of diabetics, 160
absorption, 436 retinoic acid receptor (RAR), 390–391, 467
conversion to glucose, 317 retinoic X receptor (RXR), 38, 180, 391, 467
metabolism, 482 retinoids, 467, 470
oxidation, 131, 271, 464, 479 rhamnetin, 327
pork vs. soy, 308 rhubarb, 210
satisfaction, and, 316 rimonabant, 79, 147, 200, 206
whey, 481 rosiglitazone, 181, 182, 273
protein kinase, 467 rosmarinic acid, 326
protein kinase C, 50, 132 Roux-En-Y gastric bypass (RYGB), 531–539
protein tyrosine phosphatase 1B (PTP1B), 95, rumenic acid, 384
179, 184–185, 189 rupture, 54–55, 99
pseudoephedrine, 496, 497, 498 rutin, 160, 161
psyllium, 414, 416, 424, 434, 438, 440, 520
Pu-Erh black tea, 403 S
purging, 64, 65 safety, of obesity drugs, 199–212
pyrrolidine dithiocarbamate, 160 salicylic acid, 323
pyruvate dehydrogenase kinase (PDK4), 535 Salix matsudana, 330
saponin glycosides, 444
Q satiation, 250, 366, 520
quantitative trait loci (QTL), 148, 187 Satietrol®, 235
quercetin, 160, 161, 323, 326, 327, 328, 329 satiety, 71, 73, 77, 82, 94, 147, 148, 205, 207,
quercetin glycosides, 326 234–235, 249, 250, 251, 259, 282,
307, 308, 309, 310, 322, 332, 363,
R 366, 390, 434, 435, 437, 440, 480, 520
race, obesity and, 8–10, 13, 515 index, 250
radioprotective effect, of Citrus aurantium, 374 leucine, and, 482
rainbow pills, 201 Satíse®, 235
rat models, 166, 167–168 saturated fat, 283, 452, 453, 522
reactive nitrogen species (RNS), 47 saturated fatty acids, 454, 455
reactive oxygen species (ROS), 45, 47, 48, 49, Scd1 gene, 182, 183
51, 53–54, 98, 159–160, 270–271, seaweed, 467–469
391, 487 sedentary lifestyles, 27
Recommended Dietary Allowances (RDA), seeds, 325–326
508, 510 selective estrogen receptor modulators
recruitment, 186 (SERMs), 33
red pepper, 329, 330 selective peroxisome proliferator-activated
red sage root, 210 receptor modulators (SPPARMs),
redox-based therapeutics, 155–161 181, 182
redox ratio, 127 selective serotonin reuptake inhibitors (SSRIs),
redox recycling, 45 68, 72, 205, 207
semivegetarians, 304 stearoyl-CoA desaturase 1 (SCD1), 182–183,

sennosides, 211 189
serotonin, 71, 72–73, 74, 82, 202, 205, 318, steatohepatitis, nonalcoholic, 117, 142, 166,
323, 343, 359, 363, 364, 365, 366, 367 538–539
serotonin receptor reuptake inhibitors (SRRIs), steatosis, 166, 182, 183, 385
365, 366 stem cells, 268–269
sertraline, 207 steroids, 453
serum amyloid A, 156 sterol regulatory element-binding protein
Seventh-Day Adventist vegetarians, 300, 308, (SREBP), 388, 390
309 1c (SREBP-1c), 96, 538
Seville orange juice, 378 sterols, 470
sex, obesity and, 27 stilbene, 323, 329
shear stress, 49, 52, 97, 159 stomach motility, 282
short-chain fatty acids, 282, 287, 424, 436 stool tests, for carbohydrate malabsorption, 284
sibutramine, 74, 146, 147, 200, 205, 206, 423, stress-response genes, 51
534 stroke, 53, 54, 66, 220, 258, 259, 321, 364, 378,
use by adolescents, 521 423, 499, 500
signal transducers and activators of subcutaneous tissue, 240, 241, 242, 408, 482
transcription (STATs), 94 sucrose, 247, 286
signal transduction, 389–390 sugar intake, among Latino children, 520
pathway, 85 sulfate iron, 533
signaling molecules, 46–47 sulfation, of acetaminophen, 168
simvastatin, 131 sulfonylurea, 208
single nucleotide polymorphisms (SNPs), 117 medications, glucomannan, and, 437
sleep apnea, 141, 142, 220, 322, 423, 521, 531 sulfonylureas, 293
sleep disturbances, 66 Super CitriMax®, 352, 358
sleeve gastrectomy, 539 superoxide anion, 45, 49, 50, 51, 159
Slimaluma™, 444 superoxide dismutase (SOD), 54, 128, 130, 271
small intestine, manipulation of, 536 suppressor of cytokine signaling 3 (SOCS-3),
small-molecule adiponectin mimetics, 180 88, 95
small-molecule antioxidants, 127 sympathetic nervous system, 44, 53, 74, 97,
sodium, 327 178, 185, 329, 401, 405, 467
sodium-dependant glucose transporters, 327 sympathoactivation, of leptin, 95
Solanaceae, 330 syncope, exercise-induced, 378
Solanum lycocarpum St. Hill, 330 syndrome X, 123, 144, 316, 364, 366, 386, 509
soluble thrombomodulin (sTM), 96 synephrine, 371, 372, 374, 376, 377, 378, 379,
somatostatin, 209 380, 499
soy, 323, 330 content in fruit, 372
isoflavone extract, 273 isomers of, 373
protein, 330 LD50 for, 372
SPARK, 517 systolic blood pressure, see blood pressure:
St. John’s wort, 68, 331, 375, 497 systolic
starch blockers, 279–294
starches, 281, 424 T
digestion of, 424, 425 tamarind, 350
malabsorption of, 283 tannic acid, 470
Starchex, 285 tannins, 323, 324, 325, 328, 330, 331
starvation, 63, 239 tar, in cigarette smoke, 45
statins, 131 tea, 235, 328, 329, 401–409, 439
stearic acid, 454 black, 401, 402, 403
∆9 stearoyl-CoA desaturase, 385, 388 L-theanine content of, 403
Index 567
composition of, 402–403 TNP-470, 158

green, 56, 68, 160, 235, 326, 327, 329, 361, α-tocopherol, 53, 127, 129, 131, 271
375, 376, 377, 401, 402, 403, 405, α-tocopherol quinone, 53
406, 407, 408, 409, 464, 477 tocopherols, 129
catechins, 160, 464 tofu, 308
powder, 403, 404, 405 Tonga, obesity in, 11
oolong, 235, 328, 329, 401, 402, 403, 406, topiramate, 209–210
407, 408, 409 torula yeast, 340
catechins, 403 Traffic Light Diet, 519
television, obesity and, 220, 225, 516, 522 transcription factors, 49, 187
tendamistat, 287 transcriptome, 366
testosterone, 38 trans-fatty acids, 451, 454, 459, 522
tetrahydrobiopterin, 50 transferrin, 341
∆9-tetrahydrocannabinol (THC), 79, 206 transforming growth factor β (TGF-β), 54, 156
thalidomide, 158 triacylglycerol, 235, 283, 340, 358, 363, 409,
The Zone, 316 458, 464
theaflavins, 235, 403 accumulation, 37
L-theanine, 403 tea, and, 403
theanine, 329, 404 tributyltin, obesity and, 37–38
thearubigins, 235, 403 tricyclic antidepressants, 207
theasinensins, 403 triglycerides, 44, 45, 47, 54, 90, 139, 143, 144,
theobromine, 402 146, 147, 178, 182, 183, 189, 205,
theogallin, 402 206, 235, 240, 254, 255, 256, 270,
theophylline, 402, 404 280, 281, 282, 316, 341, 343, 356,
therapeutics, angiogenesis-targeted, redox- 357, 360, 361, 363, 364, 366, 385,
based, 155–161 387, 388, 390, 392, 407, 415, 416,
TheraSlim™, 292 417, 426, 428, 446, 478, 509, 518,
thermogenesis, 71, 74, 77, 83, 147, 157, 182, 519, 538, 539
185, 187, 205, 235, 308, 329, 364, medium-chain, 451–460
371, 372, 374, 377, 380, 401, 404, white bean extract, and, 428
405, 406, 409, 458, 465, 466, 467, trisaccharides, 293
472, 478, 483, 534 troglitazone, 130, 182
diet-induced, 407, 467 trypsin, 425
thiazide, 200 tryptophan, 72
diuretics, 130, 211 tryptophan hydroxylase, 72
thiazolidinediones (TZDs), 130, 181, 182, 521 tumor necrosis factor α (TNFα), 47, 50, 51, 52,
thiobarbituric acid reactive substances 53, 54, 55, 56, 144, 145, 156, 161, 387,
(TBARS), 125, 130, 131 388, 391, 392
thioperamide, 75 tunica adventitia, 96
thioredoxin reductase, 271 turmeric, 56, 161, 210
thioridazine, 207 type 2 diabetes, 10, 11, 21, 22, 35, 45, 47, 50,
3T3-L1 cells, 49, 327, 328, 387, 388, 389, 390, 54, 66, 97, 115, 117, 126, 130, 131,
405, 470, 37, 391 132, 139–149, 178, 179, 180, 182,
thrombosis, 55 184, 185, 188, 207, 208, 220, 233,
thrombotic events, 54–55 245, 246, 254, 269, 286, 331, 341,
thromboxane A2, 55 349, 350, 386, 438, 463, 472, 520,
thrombus formation, 99 522, 538
thyroid hormone, 36, 44, 185, 200, 201, 467 bariatric surgery, and, 535
thyroid hormone receptor β (TRβ), 185 diagnostic criteria for, 141
thyroxine, 200 glycemic load, and, 256–258
tissue regeneration, 268–269 impact of childhood obesity on, 142
type 2 diabetes (cont.) vascular smooth muscle cell (VSMC), 53, 54

impact of obesity on, 142 vascular tone, 97, 99
in children, 515, 521 vascular wall homeostasis, 96–97
metformin, and, 521 vascular wall remodeling, 97–99
prevalence of, 140, 141, 280 vascularization, 157, 158, 160, 161
prevention of with weight reduction, vasculature, 93–100
147–148 vasoconstriction, 50, 52, 55, 95
resistance training, and, 518 vasodilation, 50, 52, 97
the gut, and, 536–537 vasopressin, 55
trends in, 141 vegans, 299, 300, 304, 306, 308, 309, 310
tyramine, 323, 372, 373, 377, 378 vegetable diets, 299–311
tyrosine, 73, 84, 378 vs. non-vegetarian diets, 306
tyrosine hydroxylase, 73 vegetable oils, 465
tyrosine kinase, 144, 157, 327, 328, 341 vegetables, 234
tyrosine kinase inhibitors, 327 consumption of, 56
tyrosine phosphorylation, 84, 538 polyphenols from, 321–332
ventricular function, 270
U ventromedial nucleus of the hypothalamus
ubiquinol, 127 (VMH), 85, 86, 95
ubisemiquinone, 51 vertical banded gastroplasty, 531, 532
Ucn-I/II, 77 very-low-density lipoprotein (VLDL), 144, 460
uncoupling protein 1 (UCP1), 181, 185, 186–187, viruses, monolaurin, and, 459
464, 465–467, 468, 469, 472 visceral fat, 143, 144, 240, 241, 242, 258, 363,
uncoupling protein 2 (UCP2), 478, 479, 488, 391, 409, 482, 488, 518
535 resistance training, and, 518
uncoupling protein 3 (UCP3), 535 visceral obesity, 5, 43, 53, 141, 143, 144
uncoupling proteins, 389, 465–467, 535 visfatin, 145
Undaria pinnatifida, 467–470 vitamin C, 131, 160
United Kingdom, obesity rates in, 8, 11–12 vitamin D, 478
United States, obesity rates in, 8–10, 13 vitamin E, 53, 127, 130, 131–132, 148, 160, 206
unpurified white bean products, 284 vitamins, antioxidant, 127
upregulation vitexin, 326
of adhesion proteins, 47 vomiting, self-induced, 64
of mRNA expression of NADPH, 49
uric acid, 127 W
urine tests, for carbohydrate malabsorption, 284 waist circumference, 5, 10, 22, 43, 125, 126,
urocortin, 76 129, 141, 143, 147, 220, 252, 257,
291, 300, 301, 304, 306, 361, 406,
V 408, 427, 428, 446, 516
vaccenic acid, 385 waist-to-hip ratio, 22, 43, 96, 125, 141, 304,
vagal nerve, ghrelin and, 108 363
valine, 482 walking, 222
valvulopathy, 205 water content of foods, 234
vanadium, 509 weight cycling, 242
vanadyl sulfate, 509 weight loss
vascular cell adhesion molecule 1 (VCAM-1), approaches to, 350, 423–424
96 chromium (III), and, 341–344
vascular dysfunction, 55 dietary supplements, and, 507–511
vascular endothelial growth factor (VEGF), glucomannan, and, 433–440
156, 157, 158, 159, 160, 161 glycemic load, and, 251–254
vascular injury, 55 supplements, sale of, 434
Index 569
weight loss, benefits of, 14–15, 25, 146, 220 white bean extract, 425–429
weight management, 316, 318, 321–332, 350, white kidney bean, 282, 283, 284, 285, 286,
366, 423 288, 425
calcium, and, 477–488 wine, 273, 327, 329, 331, 340
Caralluma fimbriata, and, 443–448 World Health Organization (WHO), 3, 16, 21,
childhood, 515–516 23, 123, 140, 220, 247, 321, 331, 349,
chitosan, and, 419 413, 497, 515
Citrus aurantium, and, 371–381 standards of obesity, 4, 10, 21
dietary supplements, and, 507–511
energy ratios, and, 317
HCA-SX, and, 364–365 X
medium-chain triglycerides, and, 451–460 Xenadrine EFX™, 375, 378, 379
nutritional/dietary approaches to, 233–236 XENICAL®, 328, 380
physical activity, and, 219–229
tea, and, 401–409 Y
Weight Watchers, 316 yerba maté, 331, 375, 376
weight-to-height ratio, 4 YGD, 331
Western Samoa, 3
wheat-based amylase inhibitor (WAI), 287, 288
whey, 481, 482 Z
white adipose tissue (WAT), 49, 97, 105, Zhi shi, 371, 372
156–157, 180, 183, 185, 187, 206, Zone, The, 316
269, 328, 386, 387, 390, 391, 465, zonisamide, 210
467, 468–469, 470, 472, 482 Zucker rat model, 166, 167–168

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3802_C000.

fm Page i Tuesday, January 30, 2007 9:37 AM

CRC Series in Modern Nutrition Science

Phytopharmaceuticals in Cancer Chemoprevention

Handbook of Minerals as Nutritional Supplements

Intestinal Failure and Rehabilitation: A Clinical Guide

Nutrition and Wound Healing

A Clinical Guide for Management of Overweight

Obesity: Epidemiology, Pathophysiology, and Prevention

CRC Series in Modern Nutrition Science

Boca Raton London New York

CRC Press is an imprint of the

No claim to original U.S. Government works

International Standard Book Number-10: 0-8493-3802-6 (Hardcover)

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Visit the Taylor & Francis Web site at

Dedicated to my beloved father, the late Tarak Chandra Bagchi,

Dedicated to my teachers, especially the late Rachel B. Lott

2 Epidemiology of Obesity: A Global Burden for the New Millennium..............................21

PART II Pathophysiology of Obesity

4 Cigarette Smoking, Inﬂammation, and Obesity ..................................................................43

5 Disordered Eating as a Correlate in the Development of Obesity .....................................63

6 Role of Neurotransmitters in Obesity Regulation...............................................................71

7 Neurobiology of Obesity .....................................................................................................81

8 Leptin as a Vasoactive Adipokine: Link Between Metabolism and Vasculature ...............93

9 Overview of Ghrelin, Appetite, and Energy Balance........................................................105

10 Molecular Genetics of Obesity Syndrome: Role of DNA Methylation ...........................115

viii Obesity: Epidemiology, Pathophysiology, and Prevention

PART III Obesity and Degenerative Diseases

11 Oxidative Stress Status in Humans with Metabolic Syndrome ........................................123

12 Obesity and Type 2 Diabetes.............................................................................................139

13 Angiogenesis-Targeted Redox-Based Therapeutics ..........................................................155

PART IV Novel Concept in Obesity Drug Development

15 Adipose Drug Targets for Obesity Treatment ...................................................................177

PART V Safety of Obesity Drugs

16 Safety of Obesity Drugs ....................................................................................................199

PART VI Natural, Nutritional, and Physical

18 Nutritional and Dietary Approaches for Weight Management: An Overview .................233

19 Gender Differences in Body Fat Utilization

20 Appetite, Body Weight, Health Implications of a Low-Glycemic-Load Diet..................245

21 Beyond Obesity Prevention: The Anti-Aging Effects of Caloric Restriction...................265

22 Dietary Supplement Carbohydrate Digestion Inhibitors: A Review of the Literature .....279

23 Vegetarian Diets in the Prevention and Treatment of Obesity .........................................299

24 The Atkins Paradigm .........................................................................................................315

26 Chromium (III) in Promoting Weight Loss and Lean Body Mass...................................339

27 An Overview on (–)-Hydroxycitric Acid in Obesity Regulation......................................349

29 Conjugated Linoleic Acid and Weight Control:

30 The Role of Tea in Weight Management ..........................................................................401

31 Laboratory and Clinical Studies of Chitosan ....................................................................413

32 Phaseolus vulgaris and α-Amylase Inhibition..................................................................423

33 Glucomannan in Weight Loss: A Review of the Evidence...............................................433

34 Role of Caralluma ﬁmbriata in Weight Management ......................................................443

x Obesity: Epidemiology, Pathophysiology, and Prevention

35 Role of Medium-Chain Triglycerides in Weight Management.........................................451

36 Anti-Obesity by Marine Lipids .........................................................................................463

37 Dairy Foods, Calcium, and Weight Management .............................................................477