Inflammatory Mechanisms in Obesity

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Inammatory Mechanisms in Obesity

Margaret F. Gregor and Gokhan S. Hotamisligil
Departments of Genetics and Complex Diseases and Nutrition, Harvard School of Public Health, Boston, Massachusetts 02115; email: [email protected]
Annu. Rev. Immunol. 2011.29:415-445. Downloaded from www.annualreviews.org by Universidade Federal de Juiz de Fora on 08/22/11. For personal use only.
Annu. Rev. Immunol. 2011. 29:41545 First published online as a Review in Advance on January 3, 2011 The Annual Review of Immunology is online at immunol.annualreviews.org This articles doi: 10.1146/annurev-immunol-031210-101322 Copyright c 2011 by Annual Reviews. All rights reserved 0732-0582/11/0423-0415$20.00
Keywords
adiposity, metaammation, insulin resistance, inammatory signaling, organelle stress, nutrient signals
Abstract
The modern rise in obesity and its strong association with insulin resistance and type 2 diabetes have elicited interest in the underlying mechanisms of these pathologies. The discovery that obesity itself results in an inammatory state in metabolic tissues ushered in a research eld that examines the inammatory mechanisms in obesity. Here, we summarize the unique features of this metabolic inammatory state, termed metaammation and dened as low-grade, chronic inammation orchestrated by metabolic cells in response to excess nutrients and energy. We explore the effects of such inammation in metabolic tissues including adipose, liver, muscle, pancreas, and brain and its contribution to insulin resistance and metabolic dysfunction. Another area in which many unknowns still exist is the origin or mechanism of initiation of inammatory signaling in obesity. We discuss signals or triggers to the inammatory response, including the possibility of endoplasmic reticulum stress as an important contributor to metaammation. Finally, we examine anti-inammatory therapies for their potential in the treatment of obesity-related insulin resistance and glucose intolerance.
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MODERN THREAT OF METABOLIC DISEASE: THE RISE AND CONSEQUENCES OF HUMAN OBESITY
In the past 50 years, the occurrence of human obesity has risen tremendously across the globe. In the United States, obesity (dened as a body mass index greater than 30) is now prevalent in more than 30% of the adult population (1). High-income countries are not the only ones affected by obesity, as the condition is on an alarming rise in the developing world as well (2). The World Health Organization reports that at least one billion adults are overweight and 300 million are obese, and these numbers are expected to rise in the future without intervention (3). Importantly, the obesity epidemic is now also affecting children, as the prevalence of childhood obesity has tripled in the past 30 years, leading to health problems in this susceptible population (4). Interestingly, carrying a large percentage of fat is not necessarily detrimental to an animals health. Although obesity is rare in the wild, there are naturally obese animals, such as Svalbard reindeer, seals, and polar bears. Moreover, in these cases the high degree of adiposity does not preclude but actually contributes to their tness, equipping them to survive in often harsh environments (5). Yet naturally occurring obesity is in contrast to the obesity found in modern humans, which is accompanied by inammation and often by disease and disability. Although there is no clear and identiable advantage to being obese in modern humans, it is worth noting that human obesity does not always result in disease, and therefore, the threshold for tolerable fat differs among individuals and may be determined by environmental and genetic variables. The recent rise in human obesity is caused by increased energy intake and decreased energy expenditure that results in a massive increase in adipose tissue that is generally harmful to health. Indeed, the rise in human obesity is closely associated with an increase in diseases such as type 2 diabetes (T2D),
cardiovascular disease, hepatic steatosis, airway disease, neurodegeneration, biliary disease, and certain cancers (6). These obesity-associated maladies are subsequently linked to reduced life expectancy and premature death. In fact, most of the worlds population today lives in countries where individuals are more likely to die from the consequences of being overweight than underweight (3). In light of these facts and the massive burden of obesity-associated care on health-care systems, obesity and its related disease cluster are now leading global public health problems. Hence, understanding the biological basis of obesity-related pathologies and discovering medical therapies to restore metabolic function is an urgent need for the biomedical community. Therefore, the scientic question of paramount importance is: What is the biology behind the transition from metabolic tness to illness?
HISTORICAL EVIDENCE FOR METABOLIC AND IMMUNE INTERFACE

A turning point in the study of the biology of T2D was the recognition and statement by H.P. Himsworth in 1936 that there were, in fact, two different types of diabetics: those who were insulin sensitive but simply lacked insulin and therefore presented with disease, and those who did not lack insulin but were insensitive to its effects (7). This delineation of sensitive versus insensitive diabetics paved the way for the study of insulin resistance, but it was not until 1960 and the development of the insulin radioimmunoassay by Berson & Yalow (8) that direct measurement of insulin levels was possible. This advance allowed for the discovery that the insulin-resistant state exhibited hyperinsulinemia. Berson & Yalow themselves went on to demonstrate that the obese diabetic had increased levels of insulin compared with lean controls (9). The ability to measure insulin led to vigorous study of glucose homeostasis in diverse conditions. Importantly, the association between insulin resistance and immune responses was recognized with the identication
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of insulin resistance in infectious states, beginning with studies in sepsis (10, 11). It is now appreciated that many diseases with active inammatory responses display insulin resistance as a feature, such as hepatitis C, HIV, and rheumatoid arthritis (1214). In addition, early clinical reports that connected the antiinammatory drug salicylate with improvements in insulin sensitivity [as summarized elegantly by Shoelson and colleagues (15)] also hinted at potential inammatory underpinnings to diabetes. Meanwhile, developing almost in parallel with the concept of insulin resistance was that of insulin antagonists. Scientists used the term insulin antagonist to refer to substances that interfered with the action of insulin, and their studies focused on the characterization of known antagonists such as antibodies produced against insulin, growth hormone, and adrenal steroid hormones; insulin-degrading enzymes; and the identication of unknown molecules (16, 17). In one case study, a diabetic patient who acquired gangrene in the foot developed severe insulin resistance. When this patients serum was used in mice, it provided protection from insulin-induced hypoglycemia, suggesting that the serum contained an insulin antagonist (18). This interesting case again raised the association of infection and its resulting soluble products with insulin resistance and added to it the idea of an insulin antagonist as a mediator of this pathological response. The search at that point did not include inammatory mediators as possibilities for insulin antagonists but did allow for the existence of unidentied antagonists. As Berson & Yalow (16) stated in an editorial, The possibility that one or another of the nonantibody antagonists is involved in the causation of diabetes has been suggested on occasion, but remains unproved. Thirty-ve years later, a candidate inammatory mediator from obese adipose tissue, tumor necrosis factor- (TNF-), emerged as one such antagonist inhibiting signaling by the insulin receptor (as discussed below). In the interim period, the evidence continued to mount that T2D patients (those most
closely associated with obesity) may be under a unique inammatory state. Epidemiological studies showed a rise in acute-phase response proteins in serum of T2D patients compared with controls (19, 20). During infections, patients exhibited a state of metabolic demise, including insulin resistance (2123). However, a specic link between inammatory and metabolic responses was not yet forged. This connection was later made with the discovery that, compared with lean tissue, obese adipose tissue secretes inammatory cytokines and that these inammatory cytokines themselves can inhibit insulin signaling (2426). These studies rst demonstrated the uniting of immune and metabolic pathways and the detrimental effects this relationship can have on cellular and systemic metabolism. The denitive proof of such a connection between inammatory mediators and insulin resistance in obesity and T2D came from genetic studies that interfered with inammatory mediators and demonstrated benecial effects of this interference on insulin action, opening up a new eld of study in metabolic diseases (27). We now turn to a more in-depth description of this unique obesity-induced inammation.
TNF-: tumor necrosis factor-
HALLMARKS OF OBESITY-INDUCED INFLAMMATION

Investigators have appreciated for some time now that the inammatory state induced by metabolic surplus is distinctive and outside the paradigm of classical inammation as dened by the cardinal signs of redness, swelling, heat, and pain (reviewed in 6, 28). In addition, this classic response is uniformly associated with increased basal metabolic rate and represents the focused and rapid response of the immune system to a site of injury or infection. Normally, such an insult is removed or neutralized, and the inammation is resolved. However, the inammatory response found in the obese state is of a different nature (6). First, the inammatory trigger in obesity is metabolic and caused by the excess
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JNK: c-jun N-terminal kinase IKK: inhibitor of kinase PKR: protein kinase R TLR: Toll-like receptor HFD: high-fat diet
consumption of nutrients (for example, weight loss reverses the inammation). Not only is the trigger metabolic, but also the specialized metabolic cells (such as adipocytes) are the cells that sustain the insult and whose response begins the inammatory program, thus mediating the interface between metabolic input and inammatory output. In other words, metabolic signals emerging from metabolic cells start the inammatory responses and damage metabolic homeostasis. The rst discovery of inammation in obese tissues in the mouse revealed increased levels of the cytokine TNF- in adipose tissue (and in adipocytes themselves) of obese mice compared with lean controls (25). This report was soon followed by a wealth of studies describing the inammatory differences between obese and lean animals as well as humans. It is now appreciated that not only TNF- but an array of inammatory cytokines are increased in obese tissues, including interleukin (IL)-6, IL-1, CCL2, and others (15, 29). In addition, while predominant, adipose tissue is not the only site of such cytokine expression in obesity; we now know that liver (30), pancreas (31), brain (32), and possibly muscle (33) all experience an increase in inammatory exposure in the obese state. In certain cases, modest increases have been reported in systemic levels of cytokines or acute-phase reactants in obese animals and humans compared with lean controls (15, 34). Of note, the hallmark of such inammatory cytokine expression in obese tissues is that it is signicant but often modest or local when compared with that of an infection, trauma, or acute immune response. Investigations upstream of inammatory cytokine expression identied the kinases c-jun N-terminal kinase ( JNK), inhibitor of kinase (IKK), and more recently protein kinase R (PKR) as major intracellular contributors to the induction of inammation in metabolic tissues (35, 36). Compared with lean controls, obese tissues such as adipose and liver display markedly increased activation of these kinases and their downstream signaling cascades. Animal studies utilizing genetic deletion of these
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kinases also point to their important role in mediating the inammation found in obesity (30, 36, 37). In addition, the immune sensor known as the inammasome and the Toll-like receptors (TLRs) of the innate immune system are also activated in obese tissues compared with lean controls (3840). In sum, multiple signaling pathways in the metabolic cells may be activated upon nutrient excess to stimulate an inammatory response. An additional feature of the inammatory state of obesity is increased inltration of immune cells into the metabolic tissues. For example, the macrophage population is increased in the adipose tissue of obese mice or mice fed a high-fat diet (HFD) compared with lean mice fed normal chow, and these cells also contribute to the increased tissue cytokine expression (41, 42). Although the factors attracting and/or activating immune cells in obese tissues are not yet fully understood, it has been reported that isolated bone marrow cells migrated toward culture medium conditioned by adipose explants from obese animals (43), displaying the strong connection between obese tissues and immune cell inltration. Interestingly, the picture of immune cells has been uncovered to reveal more complexity than simple macrophage inltration. In adipose tissue, for example, the state of activation of the macrophage population, be it proinammatory or anti-inammatory (referred to as M1 or M2 activation, respectively), is important and inuenced by metabolic factors. Obese mouse tissues are reported to display an increase in the proinammatory M1 population of macrophages, which in turn has been shown to negatively affect insulin sensitivity (44). Not only macrophages, but also mast cells and natural killer T (NKT) cells are known to increase in obese adipose tissue compared with lean tissue and may contribute to the inammatory milieu and metabolic pathophysiology (45, 46). In addition, recent publications reported changes in the adipose tissue T cell populations in obesity (4749). The ratio of CD8+ to CD4+ T cells increased as animals became obese, and the immunosuppressive T regulatory cells
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(Tregs) decreased, creating an environment favorable to immune activation. Although the picture is far from clear, these data show that multiple types of immune cells are involved in the response to the metabolic overload of obesity, particularly in adipose tissue. Future studies will help to elucidate the orchestration of these cell types during obesity, the metabolic signals that engage these effectors, and their contribution to pathological outcomes. Another hallmark of the metabolic inammation found in obesity is its chronicity. The occurrences of inammatory cytokine expression and immune cell inltration appear to happen gradually and to remain unresolved over time. Again, this is in contrast to the acute inammatory response normally ascribed to discussions of inammation where rapid alert, response, and resolution occur at the site of injury. The timing of obesity-induced inammation in mice needs more careful and exhaustive analysis, although a few studies have begun to investigate the process by observing the inammatory state of adipose tissue at different time points during the onset of obesity and insulin resistance. Xu and colleagues (41) showed that increases in expression of macrophage-related genes in adipose tissue occurred early after HFD feeding (3 weeks), with a more dramatic increase at 16 and 26 weeks on diet, the latter increase coinciding with the onset of detectable systemic insulin resistance. Their conclusion was that as the fat mass increased, so did the inammatory gene expression, and the development of insulin resistance intensied this increase. A second study reported a rise in macrophage-specic gene expression from 8 weeks of HFD that increased until the end of the time points studied (weeks 16 and 20) (50). These authors correlated the macrophage inltration with an increase in adipocyte cell death and hypothesized that the macrophages may be responsible for the removal of the dead cells and remodeling of the adipose tissue. The issue of resolution or tissue remodeling in obesity is an intriguing but underexplored area. It would seem that the inammatory state induced by metabolic
overload may not be dramatic enough to stimulate a full resolution program, and therefore the low-grade signals coming from the metabolic tissues are maintained in a chronic state. Or it could be that a type of resolution unique to metabolic inammation occurs that includes the turnover of adipocytes or other unknown events. Finally, the metabolic origin of this inammation may preclude the mounting of a resolution response. This deciency of resolution may be due to an obesity-induced defect or lack of evolutionary selection to develop such a response to metabolic signals. There is also evidence that inammatory responses may be acutely evoked by nutrients. For example, administration of lipids into mice for a few hours results in inammatory responses such as activation of JNK in skeletal muscle and liver tissues (51). Studies in humans also indicate that nutrients may invoke a more rapid inammatory response. Work by Aljada and colleagues (52) showed that within hours after ingestion of a high-fat, high-carbohydrate meal, the circulating blood polymorphonuclear and mononuclear leukocytes exhibited signs of reactive oxygen species (ROS) and NF-B activation. The issue of the timing and progression of the obese inammatory response still requires careful time course studies, but one hypothesis is that the inammatory signals occur at both early and later stages. For example, small signals that occur in response to nutrient overload (or even certain inammatory nutrients) may build up over time to result in more major changes such as immune cell activation and inltration. This question of the timing of metabolic-induced inammation is intriguing, as it now points to the possibility of identifying specic nutrient-induced immune responses. This is addressed further below. Importantly, the inammation discovered in obese tissues in the mouse has also been reported in humans. First, several studies describe inammatory cytokine induction, increased kinase activity, and even macrophage inltration in the adipose tissue of obese humans when compared with their lean cohorts (25, 5355). Second, serum levels of inammatory
IRS-1: insulin receptor substrate 1
mediators such as C-reactive protein (CRP), plasminogen activator inhibitor-1 (PAI-1), and even white blood cell count in humans are associated with an increased risk for development of T2D (5658). Third, recent large-scale genetic analyses have revealed signicant systemic links between obesity and metabolic syndrome phenotypes and inammatory gene networks (59, 60). In summary, the hallmarks of obesityinduced inammation are that it (a) is metabolica nutrient-induced inammatory response orchestrated by metabolic cells; (b) is moderatelow-grade and local expression of inammatory mediators induced by stress sensors such as IKK and JNK; (c) creates a modied milieualtered composition of immune cells favoring a proinammatory tissue environment; and (d ) is maintainedchronic maintenance of the inammatory state without apparent resolution (Figure 1). Finally, unlike the classic paradigm, this inammatory state is associated with a reduced metabolic rate. Therefore, given the features discussed above, we may venture to name this unique state of inammation in order to distinguish it from the classical denition. We propose metaammation to clarify the inammatory state in question in obesity.
WHAT IS THE EFFECT OF METAFLAMMATION IN OBESITY?

After describing the inammation that occurs during the nutrient and energy overload of obesity, the natural next question to ask is what its effects are on tissue and organismal metabolism. There is strong evidence to conclude that activation of the inammatory pathways interferes with normal metabolism and disrupts proper insulin signaling. We describe these alterations in each of the major metabolic tissues specically.
Adipose Tissue
We begin in the adipose tissue, the site where inammatory alterations were rst described and are most studied in obesity. Inammatory
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mediators in adipose tissue can cause insulin resistance in adipocytes. For example, TNF-treated adipocytes display decreased insulin signaling and subsequently decreased glucose uptake (6163). This discovery led to or paralleled work in cells identifying the major intracellular pathways responsible for the blockade of insulin signaling. The identied pathways involve the inammatory kinases discussed above. In response to nutrient or inammatory signals, JNK and/or IKK are activated and can target insulin receptor substrate 1 (IRS-1) for serine phosphorylation, which inhibits the insulin receptor signaling cascade. An interesting area of future research is the identication of other cellular substrates targeted by these kinases as it relates to metabolic regulation. Not only JNK and IKK, but also other kinases such as PKR, S6K, protein kinase C (PKC), extracellular signalregulated protein kinase (ERK), and mammalian target of rapamycin (mTOR) can also target IRS-1 for inhibitory phosphorylation (64), implying that activation of diverse cellular networks can antagonize insulin signaling. The consequence of such diversity is that when a tissue is exposed to excess nutrients, multiple signaling networks are activated and may contribute to inammatory signaling. Therefore, one single kinase, one signal target, or a linear pathway will not be the sole response to the nutrient or the only conductor of the inammatory response, and a perspective of a network would be instrumental in our explanations of nutrient-induced insulin resistance or other metabolic adversities. The inammatory kinases not only inhibit insulin action through targeting insulin signaling molecules, but they also regulate downstream transcriptional programs through the transcription factors activator protein-1 (AP-1), NF-B, and interferon regulatory factor (IRF), resulting in increased expression of proinammatory cytokines (Figure 2). These cytokines then feed into the inammatory response and exacerbate the inhibitory signaling of metabolic pathways. As a stress kinase, PKR can also affect general translation within the cell by inhibiting the translation initiation
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Metabolic
Nutrients
Originates from and orchestrated by the metabolic cell Adipocyte

TNF- IL-1 CCL2
Moderate
JNK IKK PKR
Metabolic signals engage inflammatory pathways that mediate a modest, low-level induction of inflammatory cytokines
Modified milieu
JNK IKK PKR
TNF- IL-1 CCL2
Reconstruction of the metabolic tissue milieu including immune cell infiltration results in proinflammatory changes in the tissue environment
Macrophage T cell
Mast cell
Maintained
JNK IKK PKR
TNF- IL-1 CCL2
Inflammatory state is chronic and unresolved
Figure 1 Hallmarks of metaammation. The rst feature of obese inammation is that the initiation is metabolicit originates from metabolic signals and within metabolic cells such as the adipocyte. Second, the metabolic signals trigger inammatory intracellular signaling pathways that mediate the downstream inammatory response such as the JNK, IKK, or PKR pathways. The activation of these mediators induces inammation in metabolic tissues that is moderatea low-level induction of cytokines such as TNF-, CCL2, or IL-1 occurs in response to the excess nutrients. Over time, this low-grade inammation may induce the recruitment and activation of many professional immune cells, driving the metabolic tissue toward a modied milieuincreases in macrophages, mast cells, and various T cell populations result in a stronger proinammatory response and drive inhibition of metabolic cell function. The inammation induced by nutrient excess is maintainedno apparent resolution of inammation is observed, and the inammatory pathways continue to reinforce each other, from metabolic cell signals of distress to immune cell responses. Finally, unlike the classic inammatory paradigm, metaammation is associated with reduced metabolic rate. (Abbreviations: IKK, inhibitor of kinase; JNK, c-jun N-terminal kinase; PKR, protein kinase R; TNF-, tumor necrosis factor-.)
factor eIF2 (eukaryotic translation initiation factor 2), further complicating the action of anabolic pathways. Other mechanisms that contribute to the inammatory origin of insulin
resistance are under investigation and may involve SOCS (suppressor of cytokine signaling) proteins involved in the degradation of IRS-1 (65), as well as organelle dysfunction (66).
Insulin signaling
Nutrients Metabolites
Other sensors
Insulin receptor
Nutrient transporters
Phospho tyrosine
IRS-1 Cytokine/ TLR receptor

CYTOSOL Phospho serine
Other mechanisms IRS-1
Translational control PKR elF2 elF2 General translation IKK JNK Nutrient chaperones (FABPs, RBP4, etc.)
ER
IRF
NF- B
AP-1 Inflammatory mediators
ER
Mitochondria
NUCLEUS
Inflammatory response
Nuclear receptors
Figure 2 Inammatory disruption of metabolic functions. Obese or high-fat diet conditions lead to the induction of inammatory signaling pathways in metabolic cells through several paths. Nutrients or other metabolites may result in the activation of cytokine or Toll-like receptor (TLR) pathways and have access to cellular targets directly or via chaperoning molecules. Three prominent kinases downstream of these receptors are JNK, IKK, and PKR, which play important roles in relaying stress signals throughout the cell and engaging metabolic responses. All three of these kinases can inhibit insulin signaling via serine phosphorylation of IRS-1. This phosphorylation leads to the ubiquitination and degradation of IRS-1, thus blocking insulin action downstream of receptor activation. In addition, PKR can negatively regulate the translation initiation factor eIF2, leading to inhibition of general translation, and inuence ER function. This property of PKR suggests that inammatory signaling cascades, ER function, and insulin action may be regulated through metaammation complexes or metaammasomes containing these kinases. These three kinases can induce an inammatory response through activation of the transcription factors AP-1, NF-B, and IRF, which upregulate inammatory mediator gene expression. The increase in inammatory cytokines can then lead to exacerbated receptor activation as the cytokine signals combine with excess nutrients and establish a positive feedback loop of inammation. (Abbreviations: AP-1, activator protein-1; eIF2, eukaryotic translation initiation factor 2; ER, endoplasmic reticulum; FABP, fatty acidbinding protein; IKK, inhibitor of kinase; IRF, interferon regulatory factor; IRS-1, insulin receptor substrate 1; JNK, c-jun N-terminal kinase; PKR, protein kinase R; RBP, retinol-binding protein.)
The functional link between inammatory signaling and insulin resistance has also been demonstrated in vivo. Indeed, genetic loss-offunction mouse models for TNF-, TNFR1/2,
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JNK, TLR2, IKK, and others have all demonstrated benecial metabolic effects from lack of their respective inammatory mediators when the animals are challenged with obesity or
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HFDs (27, 37, 6769). For example, TNF/ mice undergoing diet-induced obesity display decreased blood glucose and insulin levels compared with control mice, along with improved glucose and insulin sensitivity (27). Importantly, these models have also shown a preservation of local insulin signaling and sensitivity in adipose tissue when the inammatory mediators are absent, indicating that protection of insulin signaling in the specialized metabolic tissues leads to systemic improvements. The effects of inammation in adipose tissue are not limited to insulin signaling alone. For instance, treatment of adipocytes in vitro with inammatory cytokines such as TNF- can induce lipolysis, itself a feature of obese adipose tissue pathology (70). In addition, inammatory signaling in the adipocyte can also downregulate the activity of the nuclear receptor peroxisome proliferator-activated receptor (PPAR), which is essential to adipogenesis and to maintenance of adipocyte gene expression and function (71). In support of this nding, TNF- treatment blocks the differentiation of preadipocytes in vitro (72). Indeed, without PPAR the adipocytes ability to make and store lipids and to maintain insulin sensitivity is compromised (71). One important consequence of inammation-induced PPAR downregulation is reduced adiponectin expression, a cytokine specic to adipocytes that is also involved in regulating systemic insulin sensitivity (73). Relief of inammation restores the adipocytes capacity for lipogenesis and adiponectin expression (74). Therefore, collectively we observe that the effects of inammation on adipose tissue are multifaceted but seem to have one goal in common: shutting down normal adipocyte processes in favor of stress responses. Without the proper functioning and endocrine action of adipose tissue, the bodys nutrient deposition is disrupted, and systemic glucose homeostasis is thrown into imbalance.
Immune Cell Contribution

The work described above focuses on isolated adipocytes or germ-line genetic models
involving inammatory mediators where deletion occurs in every tissue. Given that immune cell inltration is one of the hallmarks of obese inammation, many researchers have focused on immune cell studies, primarily of macrophages, to determine the effects of the immune cells on adipose tissue function. Deletion of macrophage-specic genes of various inammatory signaling components has revealed the contribution of macrophage functions in obesity-induced insulin resistance. For example, deletion of the chemoattractant receptor CCR2 in HFD-fed mice resulted in decreased macrophage inltration into adipose tissue, a decrease in adipose inammatory gene expression, and also improved insulin sensitivity compared with control animals (75). Conversely, overexpression of the chemoattractant CCL2 specically in adipose tissue causes increased macrophage inltration and results in systemic insulin resistance and hepatosteatosis (76, 77). Again, in these studies the animals were carrying germ-line deletions; therefore, macrophage-specic effects were not distinguishable. To answer the question about macrophage-specic effects, several studies have utilized macrophage-specic deletion or bone marrow transplant models to pinpoint macrophage/myeloid contribution in the obese inammatory phenotype. Deletion of IKK in the myeloid lineage protected mice on HFDs from glucose intolerance (78). Additional studies investigating Cbl-associated protein (Cap), CCR2, fatty acidbinding protein 4 (FABP4/ap2), and TLR4 loss of function in macrophages also revealed decreases in obesity-induced inammation and insulin resistance of varying degrees (43, 7981). Interestingly, myeloid-specic deletion of JNK was not associated with a benecial metabolic phenotype, supporting the conclusion that activity of inammatory pathways in cells such as adipocytes is sufcient for obesity-induced insulin resistance and metabolic deterioration (82, 83). The only studies reporting advantageous molecules in the macrophages were done with PPAR and PPAR. Loss of PPAR or PPAR in macrophages actually worsens
the metabolic phenotype of the mouse, and this has been attributed to a failure of the M2 alternate activation of the macrophages and a subsequent switch to a proinammatory state (84, 85). Therefore, a general conclusion drawn from these studies is that interference with the proinammatory action of the macrophage is benecial for the adipose tissue environment and organismal glucose homeostasis. What about removing entire cell types? Taking these investigations one step further, many groups have used techniques that deplete entire cell types in the immune population. For instance, one study depleted mice of CD11c+ immune cells, which include macrophages, dendritic cells, and neutrophils, among other immune cells, and showed that insulin sensitivity was improved in these obese animals (86). Studies involving T cell populations also demonstrated that depletion of CD8+ T cells or transfer/enhancement of CD4+ T cells or Tregs improved the insulin sensitivity of diet-induced obese mice (4749). Finally, studies in mast cells and NKT cells also showed that depletion of these cell types leads to decreased inammation in the adipose tissue and improvements in glucose homeostasis (45, 46). Again, the data seem to point to the inammatory actions of the immune system as important contributors to the disruption of metabolic function, and when these are removed it is benecial for the anabolic insulin pathways. This benet can occur whether you are manipulating the system to act in an antiinammatory manner (for example, adoptive transfer of Tregs) or inhibiting its proinammatory actions (i.e., through gene deletion of chemoattractants). In sum, in the adipose tissue we see the outcropping of inammation leading to inhibition of insulin signaling and other adipocyte anabolic functions through complex interactions between adipocytes and a series of immune effectors. Taken together, large amounts of data point to a causal role of adipose inammation in the manifestation of obesity-induced insulin resistance.
Liver
The liver represents another major metabolic organ in its ability to control not only gluconeogenesis and glycogen storage, but also massive amounts of lipogenesis and cholesterol synthesis and secretion. In contrast to adipose tissue, the liver does not experience an inltration of macrophages during the onset of obesity but instead undergoes an activation of inammation within cells of the liver, including the resident macrophage-like Kupffer cells (87). In animal models of obesity, inammatory cytokine expression is increased in the liver compared with lean controls (30). Indeed, obesity is associated with fatty liver (or hepatosteatosis) that often leads to the more advanced inammatory state of steatohepatitis. What effects does this inammation have on liver metabolic functions? First, as described in adipose tissue, inammatory mediators have the ability to inhibit insulin signaling, and these same inhibitory pathways have been shown to be active in the obese liver (88). Specically, activation of the NF-B pathway appears to be critical in inammation-induced insulin resistance. Mice with liver-specic activation of IKK display decreased glucose tolerance and insulin sensitivity and decreased insulin signaling in the liver itself (30). Conversely, a loss of IKK in hepatocytes decreased the HFD induction of inammatory cytokines in the liver and rendered the mice more insulin sensitive (78). This reduction in insulin sensitivity and signaling affects other aspects of liver metabolism, most notably gluconeogenesis. Normally, gluconeogenesis is suppressed by insulin signaling, but in obese conditions this regulation is lost, and hepatic glucose production subsequently contributes to hyperglycemia. Again, upon inhibition of inammatory signaling, gluconeogenesis is properly suppressed by insulin (78). JNK kinase is also activated in the liver during obesity, and loss-of-function models have revealed decreased inammatory markers and increased insulin sensitivity in the liver of HFD-fed JNK1/ mice (37). Interestingly, unlike whole liver inhibition of JNK, hepatocyte-specic
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deletion of the JNK1 isoform resulted in glucose intolerance and increased glucose and lipid production in the liver of lean mice (89). In this setting, neither the impact of the remaining JNK isoforms ( JNK2 or 3) nor the effects of obesity have been addressed. A possible explanation for the discrepancy of liver JNK action is that JNK activation may operate on multiple cell types in the liver (such as hepatocytes, Kupffer cells, and others) and that this collective action is detrimental for metabolism. This hypothesis is supported by the inhibitor studies using small molecules, dominant-negative JNK, and RNAi-mediated blockade of JNK activity, all of which affected multiple cell types in the liver and resulted in increased insulin sensitivity and improved systemic metabolism (9093). Lipogenic effects of inammation are an important but understudied area. Early studies have shown that in vivo administration of TNF- or IL-6 can induce hepatic lipogenesis and increase hepatic triglyceride production (94, 95). This augmented production leads to an increase in very-low-density lipoprotein (VLDL) (and particularly apoB100) secretion from the liver and an overall increase in serum triglyceride levels. Although it seems that inammatory cytokines can induce lipogenesis pathways in the liver, mechanistically this process is not well understood and necessitates further study. Another effect of inammation in the obese liver is the activation of a secretory response involving inammatory mediators and acute-phase reactants. For example, serum levels of cytokines such as CRP, PAI-1, serum amyloid A, and IL-6 produced by the liver are increased in obese animals and humans compared with lean controls (15, 34). Some of these cytokines have been shown to have adverse metabolic effects on peripheral organs. One study found that liver IKK activation leads to an increase in systemic IL-6 that negatively inuences muscle insulin sensitivity (30). Therefore, the secretory prole of the liver in obesity may be a strong contributor to the malfunction of peripheral tissues under such nutrient excess. If the inammation in the liver escalates, cell death may occur, resulting in the
recruitment of immune cells and the pathological state known as steatohepatitis. The stress kinase JNK has been shown to be required for saturated free fatty acidinduced apoptosis in hepatocytes, providing a possible link between the excess lipids of obesity and the resulting inammation-induced cell death (96). Thus, the liver remains an important site where metabolic and immune cell signals converge to limit the tissues response to nutrients.
Muscle
The muscle is a key site of glucose uptake and energy consumption in the body and in this capacity is an important contributor to glucose homeostasis. Consensus has not been reached regarding the data on muscle inammation in obesity, and many of the following points may be debated. Thus far, obesity does not appear necessarily or uniformly to induce inammation in muscle tissue, but inammatory mediators from other sites such as liver and adipose can inuence muscle metabolism (30, 97). For example, morphologically, macrophage inltration is not observed in muscle bers per se in obese animals, but the adjacent adipose tissue displays increased inltration compared with lean tissues (42). Also, unlike adipose or liver tissues, muscle does not express or release signicant amounts TNF- or IL-6 in T2D patients compared with controls and therefore is not likely to be a source for the rise in inammatory mediators (98, 99). However, data contrary to this also exist, as local increases in TNF- expression in muscle tissue of obese humans reportedly correlate strongly with impaired insulin sensitivity (33). Mechanistic studies in mice activating the IKK/NF-B pathway in muscle reveal a muscle wasting phenotype but no induction of inammatory cytokines (100). Inhibition of the NF-B pathway through muscle-specic repression of NF-B or deletion of IKK2 also revealed no effect on muscle insulin sensitivity or systemic glucose homeostasis, leading to the conclusion that at least this major inammatory pathway does not appear to regulate muscle metabolic
dysfunction during obesity (100, 101). Musclespecic deletion of JNK1 also presents with complex results, displaying increased insulin sensitivity in the muscle but impaired liver and adipose tissue metabolism and, as a result, no systemic benet (102). Although the muscle cell does not seem to be an origin of inammatory signals in obesity or to regulate metabolism through inammatory kinase action, the inuence of peripheral inammation on muscle function is well established. For example, inammatory cytokines are able to induce insulin resistance in muscle cells in culture (103, 104) and in vivo by infusion into humans, resulting in decreased glucose uptake and glycogen synthesis (105). It has been proposed that TNF-, IL-6, CCL2, and/or retinol-binding protein-4 are inammatory mediators from sources such as adipose and liver tissue that can act on the muscle (30, 97, 103). Indeed, the TNFR/ mouse is resistant to the decrease in muscle glucose uptake and insulin resistance in response to TNF- administration (106), and treatment with antibodies to TNF- can increase muscle insulin sensitivity (107). In addition, liver-specic activation of IKK in mice results in increases in systemic IL-6 levels. The muscle displays increased IL-6 signaling and decreased insulin sensitivity and glucose uptake. When antibodies to IL-6 are administered, muscle IL-6 signaling is decreased and glucose homeostasis improves (30). The role of IL-6 in muscle insulin sensitivity is controversial and complex, however. Several studies report no effect or insulin-sensitizing effects of IL-6, as in the context of exercise-induced IL-6 release from muscle (reviewed in 108). Given that muscle is a tissue of paramount importance for glucose uptake and glycogen synthesis, further studies are necessary to elucidate the connections between muscle metabolism and inammatory pathways during obesity.
Brain
Although not usually classied as a metabolic organ per se, the brain is the site of central
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regulation of appetite control and energy expenditure. The brain, and specically the hypothalamus, responds to metabolic endocrine signals, including nutrients themselves, insulin released from the pancreas, and leptin secreted from the adipose tissue. Insulin and leptin both have important appetite-suppressant effects mediated through hypothalamic signaling. Interestingly, in obesity the hypothalamus itself exhibits both insulin and leptin resistance, leading to a loss of this control of appetite and feeding behavior, exacerbating the already excessive body weight gain (reviewed in 109). In addition to inuencing appetite, the central nervous system can also inuence peripheral organ response to nutrients, as seen in hypothalamic control of hepatic glucose production (110). Intriguingly, more recent studies have revealed that inammatory pathways in the hypothalamus are also activated during obesity. De Souza et al. (32) reported an increase in expression of TNF-, IL-1, and IL-6, among other immune-related molecules, in HFD-fed rats compared with lean controls. In addition, HFD-fed rats display evidence of increased apoptosis in the hypothalamus (111). What are the effects of such inammation in the brain and subsequently on metabolic homeostasis? Again, the few studies available on this subject point to a relationship not only with insulin resistance but also with leptin resistance and the resulting feeding behavior and energy expenditure. For example, in HFD-fed mice, brain-specic activation of the inammatory kinase IKK resulted in an increase in food intake and body weight along with signicant hypothalamic insulin and leptin resistance (112). Conversely, inhibition of IKK signaling in the brain restored insulin and leptin sensitivity and protected mice from HFD-induced weight gain, resulting in overall improved glucose homeostasis. Further evidence to support the idea that brain inammation may play a causal role in obesityinduced insulin resistance comes from studies done upstream of IKK signaling, namely in the TLR pathway. The TLR pathway of the innate immune system is involved in sensing
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pathogens and eliciting a proper immune response. It is thought that under HFD conditions, saturated fatty acids themselves may activate TLR signaling. Infusion of a TLR4 antibody via intracerebroventricular canulation protected rats from the inammatory response elicited by saturated fatty acids and concomitantly decreased food intake and body weight gain (113). In addition, brain-specic deletion of MyD88, a downstream adaptor molecule for TLR signaling, enhanced leptin signaling in HFD-fed mice compared with control littermates (114). This recovery of leptin signaling was accompanied by a decrease in food intake and weight gain and improvements in glucose homeostasis. The role of the JNK kinase in central regulation of metabolism is substantial, yet complex. Studies utilizing brain-specic deletion of JNK1 under HFD conditions demonstrated protection against insulin resistance, hyperinsulinemia, and glucose intolerance in the mice lacking JNK1 compared with controls (115, 116), implicating the brain as a key site of JNK action. However, mice that have undergone JNK1 brain deletion are smaller than their wild-type counterparts and exhibit increased thyroid hormone signaling and thermogenesis. Therefore, further study is needed to distinguish the effects on general body growth from those on energy metabolism and adiposity. Nonetheless, the advances described above reveal that inammatory pathways in the brain during obesity may be major players in the imbalance of systemic metabolic homeostasis by contributing to inhibition of insulin and leptin signaling and thereby impeding regulation of food intake, body mass, and systemic metabolism.
Pancreas
The pancreas is at the heart of glucose homeostasis, given its role as the source of insulin and glucagon production. Failure of this organ to produce sufcient insulin in response to rising systemic glucose levels is at the center of diabetic disease. Although the immune origin of type 1 diabetes has long been appreciated,
given the autoimmune mechanism that destroys the insulin-producing cells, evidence is now accumulating to implicate inammation in the dysfunction of the T2D pancreas. During the course of obesity, peripheral insulin resistance requires ever increasing amounts of insulin to remove glucose from the circulation. This increased production results in stress on the cell, eventually leading to its hyperproliferation and surrender to apoptosis. Indeed, recent data have shown that during the time course of a HFD, inammatory cytokine expression in the pancreas increases and macrophage inltration occurs, in parallel with the onset of glucose intolerance (31). Inammatory activity in the pancreas has long been known to disturb insulin production and cell survival, two of the main mediators being IL-1 and IFN-. IL-1 activates the NF-B pathway in pancreatic islets, and the effects of this activation have been studied in the pancreas using a nondegradable inhibitor of NF-B signaling known as IB. Overexpression of this inhibitor in human islets in vitro protects cells from IL-1-induced nitric oxide (NO) production and apoptosis (117). A transgenic mouse expressing this same inhibitor specically in cells also resulted in decreased NO production and apoptosis in response to inammatory cytokines and signicant in vivo protection from streptozotocin (STZ)-induced diabetes, a disease model characterized by selective cell loss (118). JNK signaling has also been implicated in pancreatic protection from apoptosis: JNK1/ mice are resistant to STZ-induced diabetes (119), and expression of a dominant-negative JNK in transplanted islets elevated insulin levels and decreased blood glucose in STZ-treated mice (120). In cultured cells, JNK inhibition protects from loss of insulin gene expression and secretion induced by oxidative or cytokine stress (120, 121). Thus, these two kinases at the core of inammatory signaling can affect major cell functions such as insulin production and survival. However, what is really needed to understand these processes are studies in the context of obesity. The work described above
investigates inammatory molecules in isolated cells or in pancreas-destroying models of diabetes. Obesity differs from these models in its distinct features of lipid overload, peripheral insulin resistance, and slowly progressing time course of pathology. Studies in pancreasspecic genetic models performed during the development of obesity and T2D will be useful to investigate the role of inammatory mediators on pancreatic cell function. For example, it has been hypothesized that low-level inammation in the pancreas (namely IL-1 expression) may promote cell proliferation and that only exacerbated inammation results in apoptosis (122). Given that one of the characteristics of obesity-induced inammation is a low level of cytokine expression, this may drive islet hyperproliferation and be needed for adaptation to peripheral insulin resistance. However, this adaptive hyperinsulinemia itself can also be a driver of metabolic complications. As a result, it is favorable to inhibit inammation as conditions worsen to preserve cell survival and function for the organism.
Inammatory Mechanisms in the Gastrointestinal Tract

One exciting new area of discovery is the inuence of gut microbiota upon obesity and metabolism. The interactions between microbes of the intestine and host responses can affect weight gain, insulin sensitivity, and the inammatory state, not only of the gut but of peripheral organs as well. A rst critical observation in this area came with the discovery that populations of gut microbiota are signicantly different between lean and obese animals (123). Specically, at the division level genetically obese (ob/ob) mice display decreased levels of Bacteroidetes with an increase in Firmicutes bacteria compared with lean controls. A similar population change was also shown to be present in obese versus lean humans (124), and changing the diet to promote weight loss was able to change the microbiota prole toward a lean phenotype. Intriguingly, this altered ora has a potential
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activity of its own, as transfer of obese gut microbiota to lean mice caused them to gain more weight when compared with mice receiving wild-type microbiota (125). The mechanism behind this difference is thought to be increased energy harvest in the obese intestine due to its specic microbiota makeup, although further study is needed to fully understand the process behind this phenomenon. The picture becomes more complex when the inammatory status of the intestine is considered. The idea that inammation of the gut could play a role in determining body weight was supported by the fact that transfer of microbiota from normal or conventionalized mice into germ-free mouse donors caused a signicant weight gain accompanied by increased insulin resistance (126). In addition, germ-free mice were protected from body weight gain, insulin resistance, and glucose intolerance induced by HFD compared with conventionalized mice (127). More specically, studies investigating the bacterial cell wall component lipopolysaccharide (LPS), which activates the hosts innate immune system through TLR4, reveal a relationship between HFD and increased levels of LPS exposure (128). In addition, a study in rats reported that those animals with a propensity for obesity displayed altered gut microbiota and increased TLR4 activation (129). Treatment of obese mice with antibiotics decreased levels of LPS and TNF- expression in the intestine and led to a decrease in body weight and serum insulin and improvements in glucose tolerance (130, 131). Finally, one intriguing study provides evidence that host inammatory mediators can actually inuence intestinal microbiota and whole body metabolism. Vijay-Kumar et al. (132) report that Tlr5/ mice develop obesity along with features of metabolic syndrome including glucose intolerance, fatty liver, insulin resistance, and islet hyperplasia. Of note, transfer of gut microbiota from Tlr5/ cecum to wild-type recipients recapitulated some aspects of the metabolic syndrome phenotype in the wild-type animals. The
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metabolic phenotype in these animals is mild, however, and not likely to account for the extent of pathology observed in the obese, type 2 diabetic state. The transferred Tlr5/ microbiota also resulted in increased TNF- and IL-1 in the colon of recipient animals, pointing to enhanced inammation as a possible factor in the regulation of the metabolic phenotype. In sum, these observations support the concept that bacterial and host interactions within the gastrointestinal tract may inuence systemic metabolic homeostasis and point to inammatory molecules as potential mediators of these effects. This is an important area to explore, as our understanding of the communication of the various microbes to the complex array of host tissues and cell types is limited; research into this area will uncover these interactions and their inuence on whole body metabolism.
HOW DOES METABOLIC INFLAMMATION OCCUR?

We now come to the question of how the inammatory response occurs in obesity in the rst place. Starting signals for a traditional inammatory response are usually described in terms of pathogensa molecule from a microbe, parasite, foreign body, or injured tissuethat will engage a cell signaling pathway (either in the host cell or sentinel immune cell) to initiate an immune response. With overfeeding or HFDs, however, the starting signal is unclear and remains a critical area of future research. Although the initiating factor is not fully known, it is thought that the insult-tosignaling pathway originates within the specialized metabolic cell, e.g., in the adipocyte, hepatocyte, or myocyte. As even nonimmune cells possess their own defensive mechanisms, these metabolic cells are fully capable of engaging inammatory signaling and communicating in response to danger signals. For example, the adipocyte can execute many of the downstream inammatory signaling events such as inammasome and TLR activation, JNK and NF-B signaling, and production of inammatory cy-
tokines in response to metabolic stress signals that are normally viewed as the territory of professional immune cells. One theory to explain the origin of the inammatory response in obesity is that nutrients themselves are naturally inammatory. That is to say, there is a normal physiological response from metabolic cells encountering nutrients that results in a low level of inammation. The idea is that food or nutrients are not self and therefore elicit a slight immune response as they are encountered and metabolized. Indeed, digestion of food and its metabolic trafcking is a daily yet intense experience as cells encounter the ood of energy and nutrients in a short period of time (i.e., lunch), and such a stimulus may be anticipated to induce a brief episode of stress signaling in the target cells. If this is the case, then there may be mechanisms to mitigate this physiological nutrient response in metabolic cells and tissues. One study supporting this hypothesis demonstrated that the six-transmembrane protein STAMP2 may play just such a role in metabolic tissues encountering nutrients (133). STAMP2 expression was increased in adipose tissue during feeding and displayed anti-inammatory properties in response to nutrient stimulation in adipocytes. When cultured adipocytes lack STAMP2, they produce an uncontrolled inammatory output when exposed to nutrients. Indeed, Stamp2/ mice exhibited increased adipose tissue inammation when fed a regular diet and systemic metabolic dysfunction such as insulin resistance and glucose intolerance. These results suggest that STAMP2 may function as an immune suppressor in metabolic and immune cells as they respond to nutrients. Under obese conditions, the upregulation of STAMP2 expression during feeding is lost, correlating with increased inammatory conditions. While the STAMP2 molecule possesses a metalloreductase/oxidoreductase activity, the exact substrates to which it responds or the molecular mechanisms by which it prepares the cells for incoming nutrients and prevents inammatory responses remain important areas of future research.
A second hypothesis is that feeding naturally couples the nutrients with inammatory molecules. For example, there is increased permeability of the intestine after feeding, probably to ensure maximal nutrient uptake. Interestingly, studies in mice and humans revealed that serum LPS was increased after feeding, suggesting the hypothesis that intestinal permeability releases inammatory molecules into the circulation, coupling nutrient entry with inammatory signals (128, 134). Therefore, the metabolic cells would adapt to coping with both. In lean animals postfeeding or during fasting, levels of nutrients and LPS are low, indicating the system has effectively handled the nutrient load. However, in obese animals the intestine is constantly more permeable than in lean animals, and serum levels of LPS are higher, indicating that the system no longer functions efciently and there may
Obese inflammatory response
Degree of inflammatory response
Recruitment of professional immune cells
Lean inflammatory response
Fasting/feeding cycles over time

Figure 3 Pulsatile inammatory response during feeding: normal versus obese reactions over time. Fasting/feeding cycles induce low-level inammatory responses in metabolic cells of lean, healthy animals that are easily resolved. During the high-fat diet or excess feeding of obesity, responses to food become more intense and frequent, and resolution of the inammatory response becomes less efcient, raising the baseline of inammation in metabolic tissues. Once the level of inammatory response reaches a certain threshold in the metabolic cells, professional immune cells such as macrophages, mast cells, and T cells are recruited and activated. Their participation in the inammatory response alters the tissue environment toward a proinammatory milieu and exacerbates the inammation even further.
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be a constant source of inammatory signal present. Higher LPS levels in obesity could also be explained in that increased nutrient/LPS exposures heighten the baseline inammatory response of metabolic tissues. Hence, a general hypothesis may be drawn from the two examples given above, as follows: During the feeding/fasting cycle, a pulsatile inammatory response occurs in the metabolic cells (Figure 3). Under normal conditions, the low-level inammation peaks with feeding and resolves after the nutrients are metabolized. With overfeeding or obese conditions, however, a constant stimulus from nutrient intake results in a more consistently active inammatory response. These low-level signals accumulate over time, amplify with each nutrient exposure, begin to impair normal metabolic pathways, and may reach a level where the professional immune cells are alerted and called to duty. Once the immune cells are activated and participate in the response to inammation, the severity of the response increases, and disruption of metabolic cell function becomes more complete. Another theory to explain the origin of the inammation found in obesity is that the nutrients themselves are not naturally inammatory but in excess can engage the classical pathogensensing or immune-response pathways. This is almost a mistaken identity theorythe system is tricked into thinking that these abundant nutrients are pathological. This mistaken identity may be due to a dose-dependent loss of specicity that exploits the ability of pathogen sensors to recognize similar structural entities, such as lipids. We focus on two examples from the literature that may support this hypothesis. The rst is in the study of TLRs, the pathogen-sensing receptors of the innate immune system. Again, as the specialized metabolic cells possess their own defense system, they express various TLRs. Adipocytes, for example, express functional TLR4 and TLR2. Studies in mice have revealed that adipose TLR4 can be activated by infusion of saturated fatty acids and that this activation contributes to the resulting insulin resistance (39). Also,
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increasing the level of fatty acids in the system via HFD feeding causes an increase in TLR4 expression, and genetic loss of TLR4 in these conditions may ameliorate insulin resistance (81, 135). A second example is the pathogen-sensing kinase PKR, known to sense double-stranded RNA, which is indicative of viral invasion of the cell, and to initiate an inammatory response (136). Recently, our group has shown that PKR is activated (in the absence of virus) during obesity or lipid infusion in mice (36). Interestingly, PKR itself can orchestrate the activity of JNK and downregulate insulin signaling in metabolic cells, all from signals received via a HFD. Thus, the model derived from these examples is that nutrient overload induces pathogen sensors (Figure 4). The ability of PKR to interact with JNK and IKK as well as insulin signaling components and translational control through eIF2 also leads us to postulate that such complexes may represent metaammasomes and may in fact be the recognition mechanisms for metabolic signals that trigger inammation. Under regular conditions, the
Nutrient input
level of nutrients pouring into the system is low enough that only normal metabolic pathways are engaged and delity is ensured. However, upon overfeeding, the organism is exposed to high nutrient levels, which begin to directly activate pathogen-sensing molecules or pathways within the cells. This spillover of signals may even reach a third level as immune cells are activated and coordinate a multilayer response within the tissue, effectively blocking nutrientinduced anabolic activity.
Signals to Inammatory Pathways

Evidence for the direct engagement of nutrients with pathogen or immune sensors is still lacking, but this remains one of the most fascinating areas of obesity research. An important future area in this respect is the systematic characterization of nutrients for their ability to directly engage innate immune responses through pathogen sensors or other mechanisms. Such platforms could give rise to groundbreaking insights regarding the health effects and underlying mechanistic actions of
Excess nutrient intake Prolonged excess nutrient intake
Healthy nutrient intake

Immuneresponse pathways Pathogensensing pathways
Metabolic pat ays pathways
Drain
Figure 4 Overload of nutrient signals spills from metabolic pathways to immune-response pathways. Nutrient input under normal or healthy conditions should engage metabolic pathways within the cells, leaving immune-response pathways inactive. With increased nutrient intake, the levels of nutrients ooding the system may rise enough that the overow stimulates pathogen-sensing pathways. Because these pathways recognize biological molecules (such as specic fatty acids), nutrient moieties in excess may also be able to activate such sensors. Once the immune sensors are activated, they may be antagonistic to the metabolic pathways, in effect blocking the drain of nutrient metabolism. If the nutrient excess persists to an extreme state, immune-response pathways of the professional immune cells may also be activated. The involvement of these pathways will intensify the inhibition of metabolic pathways and contribute to the backlog of nutrients in the system.
UPR: unfolded protein response
nutrients. For example, is there a nutrient that engages the TLR system? If so, at what concentration does the interaction take place? As mentioned above, the biological targets and actions of the overwhelming majority of nutrients, exogenous or endogenous, remain unknown. The concept of a nutrient-induced immune response provides an opportunity to approach a small but tractable portion of this vast question. To date, studies in cultured cells have identied several candidates for inducers of metabolic inammation. As implicated above, free fatty acids and especially saturated free fatty acids can activate inammatory signaling in various cell types (137, 138). In addition, high glucose, hypoxia, and cell damage and death have all been proposed as initiators of inammation during obesity (139, 140), often in combination. For example, one scenario may be that as the obese adipocyte expands, it reaches a mechanical limit to its storage capacity. The tissue may be less vascularized due to expansion, and the cells stress response and perhaps even death response occur, releasing cytokines and excess fatty acids. These in turn are sensed by inammatory kinases (such as JNK, PKR or IKK), the inammasome, or TLRs, and an inammatory cascade begins. There may also be specialized signaling complexes, metaammasomes, that are organized by sensing molecules such as PKR and that coordinate the responses based on the nature and level of nutrient exposure. Such PKR complexes could also be integrating organelle function with metabolic and inammatory outcomes (see below), and exploring these intriguing possibilities requires further work.
Organelle Stress
A key contributor to metabolic deterioration and the inammatory response that deserves discussion is organelle dysfunction of the metabolic cells. Before we arrive at a single cytokine or free fatty acid inducer, we should consider that, in response to nutrient excess, the cell experiences functional stress that then generates an inammatory response. For instance, we know that, compared with lean tissues, obese
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liver and adipose display increased levels of endoplasmic reticulum (ER) stress (141). As the ER is the primary site of protein folding in the cell, ER stress is measured by the activation of the unfolded protein response (UPR), which is driven by three main transmembrane sensors that reside on the ER, namely PERK (PKR-like eukaryotic initiation factor 2 kinase), IRE-1 (inositol-requiring enzyme 1), and ATF-6 (activating transcription factor 6) (reviewed in 142). Briey, PERK, which possesses a kinase domain, inhibits general protein translation through phosphorylation of eIF2, leading to alternative translation of ATF-4 and its downstream targets. IRE-1, a transmembrane protein that has kinase and endoribonuclease activities, cleaves the mRNA of the transcription factor XBP1 (X-box-binding protein 1), resulting in translation of an activated form of XBP1 responsible for upregulation of many chaperone genes. Finally, ATF-6 is a transcription factor that resides on the ER membrane and is cleaved in response to ER stress, producing an active factor that translocates to the nucleus and upregulates transcription of chaperone genes. The goal of activating the three arms of the UPR is to restore ER homeostasis by halting protein synthesis, increasing degradation of proteins from the ER, and increasing the level of chaperone proteins to assist in protein folding. If proper ER function cannot be achieved or if the stress continues, the UPR may also initiate apoptotic pathways. For indepth discussion of this response and its effects on metabolism, we direct the reader to a recent review (66). Interestingly, there are many connections between the UPR and inammatory signaling pathways (Figure 5). First, chemical agents that target the UPR such as tunicamycin and thapsigargin lead to the induction of inammatory kinases and the production of an array of inammatory genes including Il6, CXCL8, CCL2, or Tnfa (143, 144). ER stress can also be a source of the production of oxidative stress or apoptosis, processes that themselves can lead to inammation (145). Investigations into the mechanism behind this effect revealed that
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Mitochondria
ER stress
ER
PERK IRE-1 Annu. Rev. Immunol. 2011.29:415-445. Downloaded from www.annualreviews.org by Universidade Federal de Juiz de Fora on 08/22/11. For personal use only.
ATF-6
TRAF2
PKR
IB
ATF-4
JNK XBP1
IKK
NF-B
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NF- B XBP1
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Inflammatory mediators Immune-response genes
Figure 5 Endoplasmic reticulum (ER) stress pathways leading to inammation. The three branches of the ERs unfolded protein response have all been implicated in the cellular inammatory response. IRE-1 utilizes its kinase domain in association with TRAF2 to activate the inammatory kinases JNK and IKK, leading to upregulation of inammatory mediators via the transcription factors AP-1 and NF-B, respectively. IRE-1 splicing of XBP1 mRNA also results in inammatory consequences, as XBP1 has been shown to regulate inammatory cytokine induction and immune responses in various cell types, especially macrophages. PERK activation leads to decreased translation of IB, an inhibitor of NF-B signaling, thereby augmenting NF-B transcriptional activity. In addition, PERK activation mediates ATF-4 translation, and ATF-4 was shown to regulate inammatory cytokine induction, although the mechanism remains unknown. PKR is also activated by ER stress and contributes to JNK and IKK activation. Finally, ATF-6 has also been shown to increase NF-B transcriptional activity. All of these pathways are linked to metabolic regulation, as discussed in the text. (Abbreviations: AP-1, activator protein-1; ATF-4/6, activating transcription factor 4/6; IKK, inhibitor of kinase; IRE-1, inositol-requiring enzyme 1; JNK, c-jun N-terminal kinase; PERK, PKR-like eukaryotic initiation factor 2 kinase; PKR, protein kinase R; TRAF2, TNF receptor-associated factor 2; XBP1, X-box-binding protein 1.)
IRE-1, through its kinase domain and interaction with TRAF2 (TNF receptor-associated factor 2), can activate both JNK and IKK, leading to increased expression of inammatory cytokines (144, 146). In addition, PERK
activation can also lead to enhanced NF-B signaling. PERK-mediated inhibition of protein translation leads to decreased translation of IB (a negative regulator of IKK and NF-B signaling) and results in greater activation of
NF-B and the expression of its proinammatory target genes Tnfa and Il6 (147149). ER stress can also activate PKR, itself an eIF2 kinase (36). Interestingly, PKR is required for full JNK activation in response to ER stress and also augments NF-B signaling during inammation, suggesting a central role for PKR in integrating organelle stress to inammatory responses (36, 150). The UPR transcription factor ATF-6 has also been shown to increase NF-B signaling (151), whereas ATF-4 and XBP1 have been implicated in the induction of inammatory cytokines during UPR activation in various cell types (143, 152, 153). XBP1 in particular is necessary for a proper host response to pathogens in the induction of inammatory cytokines, as evidenced by studies in Caenorhabditis elegans and in murine macrophages in vivo (153155), suggesting a conserved mechanism whereby the ER and its UPR are intimately connected with host-cell defense. Finally, many of the above listed triggers (saturated free fatty acids, hypoxia, high glucose) that can induce inammatory signaling also induce ER stress (145). How do we bring these relationships to bear in the context of obesity? Given that obese animals exhibit an increased UPR activation compared with lean controls, the various arms of the UPR may be sources of the inammatory response in the specialized metabolic cells. Of note, a mouse model bearing genetic haploinsufciency of XBP1 exhibited an aggravated UPR response compared with wildtype mice, and intriguingly, these mice also displayed increased body weight, insulin resistance, and glucose intolerance (141). We suggest that organelle dysfunction in response to nutrient overload causes a unique inammatory response in the metabolic cells that then leads to inhibition of insulin signaling, beginning the pathological process of insulin resistance and homeostatic dysfunction. This is a hypothesis, and as yet no denitive study exists that connects the UPR to inammation during the onset of obesity and its complications. Although activation of inammatory kinases such as JNK and IKK are clearly linked to ER stress, fu434 Gregor
ture study in this area will reveal the importance of the UPR as a mechanism of metabolic inammation.
ARE ANTI-INFLAMMATORY THERAPIES IMPORTANT TO OBESITY TREATMENT?

As described above, inammation causes adverse metabolic consequences in every tissue investigated thus far. This striking nding naturally leads to the question of therapeutic intervention by modulation of inammatory cascades. Will inhibition of obesity-induced inammation lead to benecial effects on organismal metabolism? If so, what are the optimal strategies to design such agents? Studies from the literature targeting actual inammatory molecules in metabolic disease are few in number. In one study, blocking TNF- in a small group of obese T2D patients decreased plasma levels of inammatory markers but did not alter systemic insulin sensitivity (156). However, treatment of insulin-resistant rheumatoid arthritic patients with TNF- antibody did improve insulin resistance (157), indicating that additional and more detailed studies with these agents in a larger number of subjects are required to form a conclusion. One promising very recent study also reported that treatment of obese T2D patients with etanercept, a TNF- antagonist, resulted in reduced blood glucose and increased high molecular weight adiponectin levels (158). Another important study using recombinant IL-1 receptor antagonist also yielded positive metabolic results such as improved glycemia and increased cell secretion of insulin (159). These studies are important as direct proof-of-principle that addressing the inammatory component of obesity results in improved insulin sensitivity in humans. However, whether blocking the action of a single cytokine is a feasible and sufciently potent intervention in obesity and T2D remains a subject of ongoing debate. Targets to reduce obesity-associated inammation may also include the kinases or pathogen-sensing pathways described above,
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and it is likely that such interventions may prove to be more effective. In obese mice, administration of either synthetic or peptide JNK inhibitors, interfering RNAs, or dominant-negative approaches led to signicant metabolic improvements, including increased glucose tolerance and recovery of insulin sensitivity (90, 92, 93, 160). The efcacy of the JNK-targeted molecules in humans remains to be evaluated. However, it appears that preventing activation of these upstream kinases (which inuence a program of mediators) would be far more effective than interfering with individual classic inammatory mediators known at this time. Support for such an idea also comes from the extensive studies performed with the anti-inammatory drug family of salicylates, hypothesized to decrease inammation through inhibition of IKK activity. Multiple independent studies have supported the nding that treatment of T2D patients with salsalate or aspirin lowers systemic inammation, improves glycemia, lowers blood lipid levels, and increases circulating adiponectin (161 163). Although the precise target of salsalates remains a subject of discussion, these agents clearly prevent inammation in a broad manner and diminish the pathological activation of multiple signaling networks that are critical in metabolic deterioration. Cell-based immunotherapy also presents itself as an option, achieved through manipulation of the immune cells themselves. As discussed above, elimination or inhibition of various cell types such as CD11c+ immune cells, various populations of T cells, and even mast cells in obese mouse models have yielded benecial metabolic effects (45, 4749, 86). This area is just beginning to develop and may hold promise in obesity-related disease. Again, in this context it will be important to understand the metabolic signals that give rise to activation of these immune effectors and prevent their action specically, rather than interfering with the entire immunological cell population. Finally, agents that target the original signals to inammation in obesity are also under investigation. For example, ameliorating
ER stress in the specialized metabolic cell may cut off the source of inammatory signals and restore insulin sensitivity. Indeed, obese mice treated with two different chemical chaperones exhibited reduced ER stress in metabolic tissues and substantial increases in glucose tolerance and insulin sensitivity, accompanied by a decrease in JNK activity (164). One of these molecules has also been tested in obese humans and in a small clinical trial demonstrated promising insulin-sensitizing activity (165). Thus, amelioration of ER stress carries strong potential for therapeutic intervention. Restoring natural or endogenous antiinammatory molecules to metabolic cells may also be benecial. The best example of this is PPAR activation in adipose tissue. PPAR is a transcription factor that controls adipogenesis and adipocyte-specic functions. The group of compounds known as thiazolidienes (TZDs) is a potent agonist of PPAR already in clinical use as insulin sensitizers (although their use is controversial). TZDs not only activate PPAR and restore lipogenic function to adipocytes, but also possess anti-inammatory properties (74, 166, 167). In addition, one PPAR target, adiponectin, is an adipokine that acts as an endogenous anti-inammatory molecule. Adiponectin can upregulate IL-10 expression in macrophages and leukocytes, resulting in potent anti-inammatory activity (168, 169). TZDs as a therapeutic agent increase adiponectin expression and possess anti-inammatory activities. Whether this is the primary mechanism of improving insulin sensitivity is not yet known. Adiponectin itself as a treatment for T2D has not been investigated in humans, although in mice delivery of recombinant protein reduces the production of inammatory cytokines such as TNF-, lowers blood glucose levels, relieves fatty liver, and may reduce atherosclerosis (170173). In obese humans, one recent study showed that blocking TNF- increased the level of biologically active, high molecular weight, adiponectin levels (158). A new area of promising research in therapeutic approaches against obesity
and metabolic disease is the use of antiinammatory nutrients provided through diet. The most studied example may be the omega-3 polyunsaturated fatty acids (n-3 PUFAs). This fatty acid in particular possesses anti-inammatory properties via its metabolites EPA and DHA and has already been shown to ameliorate inammatory diseases such as cardiovascular disease, atherosclerosis, and inammatory bowel disease (174). Mouse studies supplementing HFDs with n-3 PUFAs reveal decreased expression of inammatory cytokines and macrophage inltration in adipose tissue and increased insulin sensitivity in liver and muscle (175, 176). In humans, there are few data investigating the effects of n-3 PUFAs in obesity and T2D. In a study of T2D women, n-3 PUFA intake was associated with decreased risk of developing cardiovascular disease (177), and a second study reported decreased triglyceride levels in T2D patients supplemented with n-3 PUFAs (178). Additional studies in this area will be important to assess the benets or lack thereof of n-3 PUFAs on obese pathologies. Interestingly, our lab recently identied a lipokine from adipose tissue, C16:1n7-palmitoleate, that possesses potent insulin-sensitizing properties, including stimulation of glucose removal by muscle and inhibition of lipogenic pathways in the liver (179). This lipokine can also neutralize some of the detrimental and inammatory effects of saturated fatty acids and may contribute to regulation of metabolically triggered inammatory responses (179). As palmitoleate is a naturally occurring lipid, dietary supplement during metabolic disease is an attractive therapeutic option to be explored. In fact, recent studies have found signicant association between palmitoleate levels and SUMMARY POINTS
metabolic disease in humans, providing further support for such possibilities (180181). Thus, the difference between inammatory and antiinammatory nutrients remains a fascinating area of future work, including the identication of other nutrients with such anti-inammatory properties and the effects these may have on dysfunctional tissues. Discussion of anti-inammatory therapy raises the fundamental question of whether we should inhibit inammation in the rst place. Inammation is a host response to danger, usually in the form of a pathogen or injury, which is necessary for wound repair and survival. Removing this signal altogether before the threat is resolved may leave the system vulnerable to continuing damage or subsequent exposures. We assume that in obesity the inammation is caused by nutrient signals, and therefore inhibition of inammatory mediators will not remove the troublesome excess nutrients or the accompanying organelle dysfunction that is related to the metabolic signals. However, if inammation is regulating how the cells react to the excess nutrients and therefore exacerbating insulin resistance, inhibition may still be helpful. Ultimately, the most effective strategies should address the root causes as well the inammatory consequences of chronic metabolic disease. The strategies should focus on the right mechanistic bases or targets without compromising the immune response in general. In conclusion, we propose that in obesity immune and metabolic pathways unite to affect cell function. Therefore, anti-inammatory therapies are valuable in that they compromise the engagement of these two pathways and may effectually take out one of the eyes of the monster that is driving the insulin resistance of obesity and its related pathologies.
1. Obesity-induced inammation may be best described as metaammation: a chronic, low-grade inammatory response initiated by excess nutrients in metabolic cells. The inammatory signaling conducted by the metabolic cell eventually causes activation of specialized immune cells and leads to an unresolved inammatory response within the tissue.
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2. Metaammation in general has inhibitory effects on insulin action through the inammatory kinases JNK, IKK, and PKR in metabolic tissues and disrupts nutrient and energy metabolism through these or other mechanisms. 3. Obesity may induce metaammation when nutrient excess engages pathogen sensing either through physiological nutrient-induced stress taken to extremes or through a dose-dependent loss of specicity that activates immune-response pathways. 4. Therapeutic interventions to inhibit inammatory pathways in obesity are showing benecial effects on insulin sensitivity in mouse models and human trials.
FUTURE ISSUES 1. Is there such a thing as inammatory versus noninammatory nutrients? How can specic nutrients that trigger metaammation be identied? 2. Is there a metaammasome(s) where multiple endogenous and exogenous metabolic signals are received and conveyed into inammatory signaling complexes and networks? 3. Can metabolic health be preserved or recovered despite inammation by alternative interventions or is it mandatory to dampen metaammation? 4. Are there any benecial effects from the inammation associated with obesity?
DISCLOSURE STATEMENT
G.S.H. is on the scientic advisory board, is a shareholder in, and receives research support from Syndexa Pharmaceuticals. M.F.G. is not aware of any afliations, memberships, funding, or nancial holdings that might be perceived as affecting the objectivity of this review.
ACKNOWLEDGMENTS
We thank members of the Hotamisligil laboratory for helpful discussion and comments. LITERATURE CITED
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Annual Review of Immunology
Contents
Innate Antifungal Immunity: The Key Role of Phagocytes Gordon D. Brown p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 1
Volume 29, 2011
Stromal CellImmune Cell Interactions Ramon Roozendaal and Reina E. Mebius p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p23 Nonredundant Roles of Basophils in Immunity Hajime Karasuyama, Kaori Mukai, Kazushige Obata, Yusuke Tsujimura, and Takeshi Wada p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p45 Regulation and Functions of IL-10 Family of Cytokines in Inammation and Disease Wenjun Ouyang, Sascha Rutz, Natasha K. Crellin, Patricia A. Valdez, and Sarah G. Hymowitz p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p71 Prevention and Treatment of Papillomavirus-Related Cancers Through Immunization Ian H. Frazer, Graham R. Leggatt, and Stephen R. Mattarollo p p p p p p p p p p p p p p p p p p p p p p p p 111 HMGB1 Is a Therapeutic Target for Sterile Inammation and Infection Ulf Andersson and Kevin J. Tracey p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 139 Plasmacytoid Dendritic Cells: Recent Progress and Open Questions Boris Reizis, Anna Bunin, Hiyaa S. Ghosh, Kanako L. Lewis, and Vanja Sisirak p p p p p 163 Nucleic Acid Recognition by the Innate Immune System Roman Barbalat, Sarah E. Ewald, Maria L. Mouchess, and Gregory M. Barton p p p p p p 185 Trafcking of B Cell Antigen in Lymph Nodes Santiago F. Gonzalez, Sren E. Degn, Lisa A. Pitcher, Matthew Woodruff, Balthasar A. Heesters, and Michael C. Carroll p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 215 Natural Innate and Adaptive Immunity to Cancer Matthew D. Vesely, Michael H. Kershaw, Robert D. Schreiber, and Mark J. Smyth p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 235 Immunoglobulin Responses at the Mucosal Interface Andrea Cerutti, Kang Chen, and Alejo Chorny p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 273 HLA/KIR Restraint of HIV: Surviving the Fittest Arman A. Bashirova, Rasmi Thomas, and Mary Carrington p p p p p p p p p p p p p p p p p p p p p p p p p p p 295
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Mechanisms that Promote and Suppress Chromosomal Translocations in Lymphocytes Monica Gostissa, Frederick W. Alt, and Roberto Chiarle p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 319 Pathogenesis and Host Control of Gammaherpesviruses: Lessons from the Mouse Erik Barton, Pratyusha Mandal, and Samuel H. Speck p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 351 Genetic Defects in Severe Congenital Neutropenia: Emerging Insights into Life and Death of Human Neutrophil Granulocytes Christoph Klein p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 399 Inammatory Mechanisms in Obesity Margaret F. Gregor and G khan S. Hotamisligil p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 415 o Human TLRs and IL-1Rs in Host Defense: Natural Insights from Evolutionary, Epidemiological, and Clinical Genetics Jean-Laurent Casanova, Laurent Abel, and Lluis Quintana-Murci p p p p p p p p p p p p p p p p p p p p 447 Integration of Genetic and Immunological Insights into a Model of Celiac Disease Pathogenesis Val rie Abadie, Ludvig M. Sollid, Luis B. Barreiro, and Bana Jabri p p p p p p p p p p p p p p p p p p p 493 e Systems Biology in Immunology: A Computational Modeling Perspective Ronald N. Germain, Martin Meier-Schellersheim, Aleksandra Nita-Lazar, and Iain D.C. Fraser p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 527 Immune Response to Dengue Virus and Prospects for a Vaccine Brian R. Murphy and Stephen S. Whitehead p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 587 Follicular Helper CD4 T Cells (TFH ) Shane Crotty p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 621 SLAM Family Receptors and SAP Adaptors in Immunity Jennifer L. Cannons, Stuart G. Tangye, and Pamela L. Schwartzberg p p p p p p p p p p p p p p p p p 665 The Inammasome NLRs in Immunity, Inammation, and Associated Diseases Beckley K. Davis, Haitao Wen, and Jenny P.-Y. Ting p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 707 Indexes Cumulative Index of Contributing Authors, Volumes 1929 p p p p p p p p p p p p p p p p p p p p p p p p p p p 737 Cumulative Index of Chapter Titles, Volumes 1929 p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p p 744 Errata An online log of corrections to Annual Review of Immunology articles may be found at http://immunol.annualreviews.org/errata.shtml
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ANNUAL REVIEWS

Inammatory Mechanisms in Obesity

HISTORICAL EVIDENCE FOR METABOLIC AND IMMUNE INTERFACE

TNF-: tumor necrosis factor-

HALLMARKS OF OBESITY-INDUCED INFLAMMATION

IRS-1: insulin receptor substrate 1

WHAT IS THE EFFECT OF METAFLAMMATION IN OBESITY?

Originates from and orchestrated by the metabolic cell Adipocyte

JNK IKK PKR

JNK IKK PKR

TNF- IL-1 CCL2

JNK IKK PKR

TNF- IL-1 CCL2

Inflammatory state is chronic and unresolved

IRS-1 Cytokine/ TLR receptor

Other mechanisms IRS-1

AP-1 Inflammatory mediators

Immune Cell Contribution

Inammatory Mechanisms in the Gastrointestinal Tract

HOW DOES METABOLIC INFLAMMATION OCCUR?

Obese inflammatory response

Degree of inflammatory response

Recruitment of professional immune cells

Lean inflammatory response

Fasting/feeding cycles over time

Signals to Inammatory Pathways

Healthy nutrient intake

Metabolic pat ays pathways

UPR: unfolded protein response

Inflammatory mediators Immune-response genes

ARE ANTI-INFLAMMATORY THERAPIES IMPORTANT TO OBESITY TREATMENT?

www.annualreviews.org Inammatory Mechanisms in Obesity

Annual Review of Immunology

Volume 29, 2011

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