Obesity, innate immunity and gut hormones

Donal O’SheaSt Columcilles & St Vincents University Hospitals, National Childrens Research Center & University

College Dublin, Ireland

July 12th 2013

donal.oshea@hse.ie

Outline of talkBackground

Obesity and the immune system

Gastrointestinal hormones and immunity

Childhood obesity work

Obesity: like no previous epidemic• Diabetes • Cancer• Dementia• Cardiovascular Disease• Asthma• Arthritis

Causes 4000 – 6000 Deaths per year in Ireland (Pop 5 million)

8 times the number from suicide 486 (2011) and road traffic accidents 112 (2012) combined

World Economic Forum 2011

• 2009 World Health Spend was $5 trillion ($4.4 trillion spent in high income countries).

• Cumulative loss of output from NCD 2010 to 2030 will be $47trillion (70% World GDP 2010)

• Currently high income countries bear most cost but this will change to middle income/developing areas

Sturm and Hattori, Int J Obes 2012

Percentage increase in BMI categories since 1986

Body Mass Index 40 & 50

BMI 40 BMI 52

Body Mass Index 40 & 50

BMI 40Guess 32

BMI 52Guess 41

Case

• 45YO male

Case

• 45YO male• Referred for left knee

pain

Case

• 45YO male• Referred for left knee

pain• Osteoarthritis diagnosed

Case

• 45YO male• Referred for left knee

pain• Osteoarthritis diagnosed• On examination

Wt 235kgs (BMI 78)BP 110/70Glucose 5.3Cholesterol 4.6

Case

• May need knee replacement

• Ideally should loose weight first

Intervention

• Dietician• Physiotherapist• Psychologist

• Monthly for 10 months

Result

Wt 233.5kgs (-1.5kgs)BMI 78

BP 118/76Glucose 5.6Cholesterol 4.6

Extreme obesity must be prevented

Extreme obesity must be prevented

because it is practically irreversible

Outcomes for Service in SVUH/SCH

Gained Weight ( > 2%)

9%

Lost Weight (> 2%)63%

Weight Stable

(+ or - 2%)28%

Societal influencesIndividual psychology

Biology

Activity environment

Individual activityFood

ConsumptionFood Production

TOXIC ENVIRONMENT

How much insulin would you advise?

They tell you what they do..

Nutrition in pregnancy vital

Albert Einstein (1879 - 1955)

I fear the day when the technology overlaps with our humanity.

Albert Einstein (1879 - 1955)

I fear the day when the technology overlaps with our humanity. The world will only have a generation of idiots.

Times and play have

changed….

Sedentary Time

Now 4th leading preventable cause of death

“Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it.”

Sedentary Time

Now 4th leading preventable cause of death

“Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it.” - Plato

American Diabetes Association

Childhood Obesity in Ireland (and Europe)

• 25% 3 year olds overweight/obese• 25% 9 years olds overweight/obese

• low self image, concept and self esteem

Growing up in Ireland 2009

Median BMI for each 5-year rise in age of onset of overweight

O’Connell et al JPHN 2011

• Study cohort - 6328 subjects (2961 male) – mean age 11.4 ± 4.0 years at baseline – mean length of follow-up 23.1 ± 3.3 years

• 5554 subjects normal weight as children– 812 (15%) were obese as adults

• 774 subjects overweight or obese as children– 500 (65%) were obese as adults

• 147 subjects obese as children– 121 (82%) were obese as adults

Juonala et al, NEJM 2011

This

Becomes this

BMI 51 BMI 52

Becomes this (82% chance)

BMI 51 BMI 52

Consumption of free sugar has soared

Sports Drinks• Growing Up Today Study II• Large Prospective Study• 5995 girls/4906 boys• 9-16 years old • Consumption of sports

drinks strongly associated with weight gain(Field et al, Consumption of Sports Drinks Prospectively Associated with Greater Weight Gain among Adolescents, Obesity Society Meeting 2012)

Consumption of sweet beverages and type 2 diabetes incidence in European adults: results from EPIC-InterAct. Diabetologia. 2013 Apr 26th

“This study corroberates the evidence between incidence of type 2 diabetes and high consumption of sugar sweetened drinks”

Consumption of sweet beverages and type 2 diabetes incidence in European adults: results from EPIC-InterAct. Diabetologia. 2013 Apr 26th

“This study corroberates the evidence between incidence of type 2 diabetes and high consumption of sugar sweetened drinks”

GSK decision to sell Ribena and Lucozade.

Outline of talkBackground

Obesity and the immune system

Gastrointestinal hormones and immunity

Childhood obesity work

Obesity causes and worsens outcome in……

• Diabetes • Cancer• Dementia• Sleep Apnoea• Asthma • Everything

• Suggests a common mechanistic fault• Focussed our research on the circulating immune

system

• Natural Killer cells

• Invariant Natural Killer T cells

• Dendritic cells

• Macrophages

• All cell types characterised by different cell surface markers

Studied four cell types to date

Flow cytometry

6B11

CD

3

Various cell types – with different surface markers

6B11

CD

3

Flow cytometry

Flow cytometry

Various cell types – with different markers

6B11

CD

3

• Key cell in attacking viruses and cancer cells

• Involved in a range of autoimmune conditions

Natural Killer Cell - foot soldier of the immune system

NK

cel

ls (

% t

otal

lym

ph

ocyt

es)

0

2.5

5

7.5

10

12.5

15

17.5

20

22.5

25

27.5

obese lean

*

n = 110, p = 0.006

Decrease in circulating natural killer cells in obesity

Smoking machine

Invariant Natural Killer T (iNKT) cell

A key cell in the innate immune system

Represents 0.2% - 1.2% of circulating T cells

Interacts with other immune cells to determine the downstream immune response:

Pro-inflammatoryAnti-inflammatoryCytotoxic

Cytokine

Cytotoxicity

NK cells

DCs

B cells

Macrophages

Chemokines

T cells

Invariant Natural Killer Cell – Swiss army knife of immune system

iNKT cells & Obesity

The invariant natural killer T cell is significantly depleted in severe obesity

***

iNKT

(% T

cel

ls)

0.0

0.15

0.30

0.45

0.60

0.75

0.90

Obese Lean

NKT

cel

ls (%

T c

ells

)

Lean Obese

Cross-sectional

Lynch et al, Immunity 2012

iNKT cells in obesity

RYGB restores iNKT cell number in humans

Longitudinal

010203040506070

iNKT

**

pre-op post-oppre-op post-op

BMI

0.0

0.1

0.2

0.3

0.4

0.5

0.6

**

NKT

cel

ls (%

T c

ells

)

Body

Mas

s In

dex

Gastric Bypass restores iNKT cell population in humans

What happens if you get rid of iNKT cells?

• Mouse model

• 0-12 weeks High Fat Diet (60% of kcals from fat) in wild type or iNKT knockout mouse

• Look at weight, metabolic status and inflammation

What happens if you get rid of iNKT cells in mice?

Ja18

Lean

mas

s (g

)

WT0

5

10

15

20

0

1

2

3 *

**

SFD WT Ja18

Wei

ght (

g)

Fat padsFat pads

WTJa18KO

0 1 2 3 4 5 6 7 8 920

25

30

35

40

**

***

****

*

***

***

***

weeks

Wei

ght (

g)W

eig

ht

(g)

0

2

4

6

8

10

12 *

HO

MA-

IR

WT Ja18KO WT HFD Ja18KO HFD

Liver

85

90

95

100

105

Adip

ocyt

e di

amet

er

m)

WT Ja18

*

iNKT cell KO mice get fatter & more severe metabolic disease on HFD

iNKT

obese Ja18KO mouse

iNKTiNKT continue on HFD for 4 days

PBS T NKT-2

-1

0

1

Wei

ght c

hang

e (g

) ***

PBS T NKT85

95

105

115

125

135***

**

*

Dia

met

er

m

SFDPBS T NKT0

1

2

3

Fat (

g)

*** **

100140180220260300340380420460500540580

PBS

NKTT cells

SFD

0 15 30 45 60 90

IL-4 & IL-10 dependent mechanismAlso re polarization of ATMReduction in serum inflammation

Adoptive transfer of iNKT cells but not T cells improves metabolism &weight

Conclusion

• Weight dysregulates the immune system

• Immune sytem regulates weight

IL-4 & IL 10 drive macrophages to switch on thermogenesis (UCP-1)

• Factors that affect IL-4 & IL-10 production will impact on thermogenesis and weight

IL-4 Producing iNKT cells

T3Control

iNKT cells

Stimulation +CSE

IL-4

pg/

ml

Looked at thyroid hormone and cigarette smoke

iNKT cells

Stimulation +Cortisol

iNKT cells +Stimulation

+Olanzapene

D.

Looked at cortisol and antipsycotic medication

Outline of talkBackground

Obesity and the immune system

Gastrointestinal hormones and immunity

Childhood obesity work

Gave GLP-1 to a diabetes patient with psoriasis

• Itch went within days and slept through for first time in 46 years

GLP-1 and the incretin effect

McIntyre et al. Lancet.1964

- 10’ 30’ 90’ - 90’ GLP-1

- - - - 30’ 30’ LPS

IB: pCREB

IB: CREB

IB: β-Actin

Time

Was it a consistent effect?Before After

PASI reduced by average of 38% (p - 0.008) DLQI reduced by average of 46% (p - 0.014)

Ahern et al, n=10 JEADV 2012

What about other inflammatory conditions?

0

1

2

3

4

5

6

7

8

1 2 3

Timepoints

DA

S28

0 6/52 12/52

All lost mean 4kg, HBa1C ↓

GLP-1 as a immunomodulator

• Looked at 12 T2DM starting GLP-1:

Circulating cytokines

Soluble CD163 (shed by macrophages)

iNKT levels

POST THERAPY

PBMCLPS

+-

++

+-

++

PRE THERAPY

GLP-1 regulates cytokine production and capacity for production

Pre Post

GLP-1 regulates adipokine production

LPS 0 10 30 90 0 10 30 90

Pre GLP-1

IB: pCREB

IB: p-p65

Post GLP-1

IB: p65

IB: CREB

IB: β-Actin

GLP-1 therapy restores p65 signalling pathway in human PBMC’s

Soluble CD163 in T2DM

GLP-1 therapy and soluble CD163

Is it just weight loss and glycaemia?

GLP-1 therapy restores depleted circulating iNKT cell populations in

patients with T2DM

GLP-1 summary

• Anti-inflammatory

• Restores innate immune population and function

• Immune effects at least part independent of weight and glycaemic actions

PYY receptor expression and intracellular signalling in iNKT cells

IB: p-IκBα

IB: IκBα

IB: β-Actin

PYY (time) - 10’ 30’ 90’iNKT cells + + + +

IB: pCREB

IB: CREB

IB: β-Actin

PYY (time) - 10’ 30’ 90’iNKT cells + + + +

b. c.a.

iNKT cellsC1R cellsαGalCerNative PYY

++--

+++

0ug

+++

ug

iNKT cellsC1R cellsαGalCerNative PYY

++--

+++

0ug

+++

ug

e.d.

iNKT cellsC1R cellsNative PYY

++-

++

ug

++

ug

++

ug

f.

PYY: cytokine production and tumour killing capacity of iNKT cells

PYY: restores killing capacity of NK from obese individuals

Y59 – longacting PYY analogue: cytokine production by iNKT cells

iNKT cellsC1R cellsY-59

+--

++-

++

100ngc. d.

Y-59

Y59 – Tumour growth and tumour killing by iNKT cells

Con

PYY summary

• System-wide regulation of innate immunity

• Different effects to GLP-1

• Looks more anti-tumour potential than anti-inflammatory

Outline of talkBackground

Obesity and the immune system

Gastrointestinal hormones and immunity

Childhood obesity work

Childrens Baseline Data

Lean Obese

Age 12.6 yrs old 11.9 yrs old

Number 20 30

Weight 52kgs 90kgs

Glucose 4.9 5.1

Insulin

Childrens Baseline Data

Lean Obese

Age 12.6 yrs old 11.9 yrs old

Number 20 30

Weight 52kgs 90kgs

Glucose 4.9 5.1

Insulin 21 149

Reduction in iNKT cells number and NK function already present in obese children.

Gene expression for diabetes and heart disease

Gene expression for Cancer defencemiR 34a – Tumour Suppressor

KICKBUSCH DUBLIN 2013

We have been here before

SanitaryRevolution HIAP

Revolution

What we have chosen to forget• 19th century:

• Sanitary surveys proved that a relationship exists between communicable disease and filth in the environment, and it was said that safeguarding public health is the province of the engineer rather than of the physician.

• The Poor Law Commission argues in 1838,

• “The expenditures necessary to the adoption and maintenance of measures of prevention would ultimately amount to less than the cost of the disease now constantly engendered.”

KICKBUSCH DUBLIN 2013

Conclusion

• Weight regulates immune system

• Immune system regulates weight

• Gut hormones differentially regulate both

• Obesity in childhood must be prevented

GLP-1 and the incretin effect

McIntyre et al. Lancet.1964

Most recently focussed on Dendritic Cell

Key cell in the response to viral illnessCytokine

Cytotoxicity

NK cells

DCs

B cells

Macrophages

Chemokines

T cells

CD11c

HLA

-DR

obese non obesea.

Circulating DCs are depleted in obesity

obese non obese

The Obese Dendritic Cell

• Loss of CD83

• Loss of IL-12 secretion

• Increase in IL-10 secretion

• Increase in anti-inflammatory transcription factor activation – CREB

• Drive Th2 response from healthy T cells

O’Shea et al IJO 2013

Myeloid DC don’t upregulate CD83 in response to viral or bacterial stimuli

Obese NT LPS

Non obeseNT LPS

CD

83

% M

FI

CD

83

% M

FI

Non obeseNT Poly I:C

Obese NT Poly I:C

Myeloid DC don’t upregulate CD83 in response to viral or bacterial stimuli

Obese NT LPS

Non obeseNT LPS

CD

83

% M

FI

CD

83

% M

FI

Non obeseNT Poly I:C

Obese NT Poly I:C

CD86 is upregulated

Obese NT LPS

Non obeseNT LPS

CD

86

% M

FI

As is CD54, HLA-DR, CCR7

Obese DCs produce significantly less IL-12

Obese NT LPS

Non obeseNT LPS

Non obeseNT Poly I:C

Obese NT Poly I:C

Obese DC produce significantly higher levels of IL-10 in the

absence or presence of stimulus

Obese NT LPS

Non obeseNT LPS

Non obeseNT Poly I:C

Obese NT Poly I:C

Obese DCs have increased CREB phosphorylation

pCREB

CREB

Obese Non Obese

LPS - + - + Obese NT LPS

Non obeseNT LPS

k.

Obese DC skew naïve T cells to Th2 phenotype

Lean DCObese DCLPST cells

+-++

-+++

Side effects of anti-inflammatories

• Steroids

Weight gain

Hypertension

High glucose

Immune suppression

?Cancer

• GLP-1

Weight loss

Lower blood pressure

Lower glucose

Immune “restorative”

?Cancer