Adipocinas e Inflamacion TILG (1)

The incidence of obesity and its associated disorders is increasing markedly worldwide. Obesity predis-poses individuals to an increased risk of developing many diseases, including atherosclerosis, diabetes, non-alcoholic fatty liver disease, certain cancers and some immune-mediated disorders, such as asthma1–3. In addi-tion to these associations between obesity and disease, research in the past few years has identified important pathways that link metabolism with the immune system and vice versa. Many of these interactions between the metabolic and immune systems seem to be orchestrated by a complex network of soluble mediators derived from immune cells and adipocytes (fat cells)1.

In mammals, adipose tissue occurs in two forms: white adipose tissue and brown adipose tissue. Most adipose tissue in mammals is white adipose tissue and this is thought to be the site of energy storage. By con-trast, brown adipose tissue is found mainly in human neonates and is important for the regulation of body temperature through non-shivering thermogenesis. In addition to adipocytes, which are the most abundant cell type in white adipose tissue, adipose tissue also contains pre-adipocytes (which are adipocytes that have not yet been loaded with lipids), endothelial cells, fibroblasts, leukocytes and, most importantly, macrophages (FIG. 1). These macrophages are bone-marrow derived and the number of these cells present in white adipose tissue correlates directly with obesity.

Adipose tissue is no longer considered to be an inert tissue functioning solely as an energy store, but is emerg-ing as an important factor in the regulation of many pathological processes. Various products of adipose tissue have been characterized, and some of the soluble factors produced by this tissue are known as adipocy-tokines. The term adipocytokine is used to describe certain cytokines that are mainly produced by adipose tissue, although it is important to note that they are not all exclusively derived from this organ. Adiponectin, leptin, resistin and visfatin are adipocytokines and are thought to provide an important link between obesity, insulin resistance and related inflammatory disorders1–6. Adiponectin and leptin are the most abundant adipocy-tokines produced by adipocytes. Various other products of adipose tissue that have been characterized include: certain cytokines, such as tumour-necrosis factor (TNF), interleukin-6 (IL-6), IL-1 and CC-chemokine ligand 2 (CCL2; also known as MCP1); mediators of the clotting process, such as plasminogen-activator inhibitor type 1; and certain complement factors1,2 (FIG. 1). These products have well-known roles in the immune system, and although some of them are also produced by adipocytes, they are not normally considered to be adipocytokines; nonetheless, they have important roles at the interface between the immune and metabolic systems.

Obesity is associated with a chronic inflammatory response, which is characterized by abnormal cytokine

Christian Doppler Research Laboratory for Gut Inflammation and Department of Medicine, Innsbruck Medical University, Anichstrasse 35, 6020 Innsbruck, Austria.Correspondence to H.T. e-mail: [email protected]:10.1038/nri1937Published online 22 September 2006

AtherosclerosisA chronic disorder of the arterial wall characterized by endothelial damage that gradually induces deposits of cholesterol, cellular debris, calcium and other substances. These deposits finally lead to plaque formation and arterial stiffness.

Adipocytokines: mediators linking adipose tissue, inflammation and immunityHerbert Tilg and Alexander R. Moschen

Abstract | There has been much effort recently to define the role of adipocytokines, which are soluble mediators derived mainly from adipocytes (fat cells), in the interaction between adipose tissue, inflammation and immunity. The adipocytokines adiponectin and leptin have emerged as the most abundant adipocyte products, thereby redefining adipose tissue as a key component not only of the endocrine system, but also of the immune system. Indeed, as we discuss here, several adipocytokines have a central role in the regulation of insulin resistance, as well as many aspects of inflammation and immunity. Other adipocytokines, such as visfatin, have only recently been identified. Understanding this rapidly growing family of mainly adipocyte-derived mediators might be of importance in the development of new therapies for obesity-associated diseases.

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© 2006 Nature Publishing Group

Macrophage

Adipocyte

Lean adipose tissue Obese adipose tissue

Weight gain

Apoptoticadipocyte

Bloodvessel

Resistin (human)IL-1β

Macrophage-derived factors••

TNFIL-6CCL2

Pro-inflammatory cytokines and chemokines•••

Crosstalk

AdiponectinLeptinResistin

Adipocytokines•••

Complement factorsComplement factors are components of the complement system. Activation of these factors, which involves proteolytic cleavage of serum and cell-surface glycoproteins, leads to the formation of a terminal cell-lytic complex inside the cell membrane of a target cell. Complement fragments such as C3a and C5a have important pro-inflammatory properties, such as vasodilation, chemotaxis and opsonization.

production, increased synthesis of acute-phase reactants, such as C-reactive protein (CRP), and the activation of pro-inflammatory signalling pathways1. Although there is no doubt that pro-inflammatory pathways are activated in the adipose tissue itself in cases of obes-ity, the relative contribution of adipocytes as a source of the circulating and systemically active cytokines, adipo-cytokines and chemokines remains unclear. The adipose tissue of obese individuals also contains a large number of macrophages, which are an additional source of solu-ble mediators in the adipose tissue7,8 (FIG. 1). However, although macrophages in adipose tissue seem to be the main source of TNF, adipocytes contribute almost one third of the IL-6 concentration in the circulation of patients who are obese9. CCL2, produced by adipocytes, has recently been identified as a potential factor contrib-uting to macrophage infiltration into adipose tissue10. Once macrophages are present and active in the adipose tissue, they, together with adipocytes and other cell types present in the adipose tissue, might perpetuate a vicious cycle of macrophage recruitment and production of pro-inflammatory cytokines.

In humans, adipocytokines function as hormones to influence energy homeostasis and to regulate neuro-endocrine function. As cytokines, they affect immune functions and inflammatory processes throughout the body. The field of adipocytokines has attracted tremendous interest recently and the knowledge that has accumulated might lead to the development of new therapeutics. Here, we provide an overview of recent advances in our view of the role of adipocytokines in inflammation and immunity.

Insulin resistance: an inflammatory diseaseSystemic chronic inflammation has been proposed to have an important role in the pathogenesis of obesity-related insulin resistance1,11. Biomarkers of inflamma-tion, such as TNF, IL-6 and CRP, are present at increased concentrations in individuals who are insulin resistant and obese, and these biomarkers predict the develop-ment of type 2 diabetes mellitus and cardiovascular diseases (BOX 1).

The first link between obesity, an increase in expres-sion of the pro-inflammatory cytokine TNF, and insulin action was reported by Hotamisligil and colleagues11. Their findings in rodents showed that adipocytes directly express TNF and led to the concept of a role for inflammation in obesity. These observations were paralleled by human studies showing increased TNF expression in the adipose tissue of individuals who were obese, and decreased TNF expression after weight loss12. Evidence supporting a key role for TNF in obesity-related insulin resistance came from studies showing that ob/ob mice (leptin-deficient mice with evidence of insulin resistance) that were also deficient for TNF or TNF receptors (TNFRs) had improved insulin sensi-tivity in diet-induced obesity compared with TNF- and TNFR-sufficient ob/ob mice13.

In searching for the mechanisms involved in inflamma tion-induced insulin resistance, Yuan and co-workers identified the inhibitor of nuclear factor-κB (NF-κB) kinase-β (IKKβ) pathway of NF-κB activation as a mediator of TNF-induced insulin resistance14. They showed that overexpression of IKKβ in a human embry-onic kidney cell line (the HEK293 cell line) attenuated insulin signalling, and that ob/ob mice expressing only one copy of the gene encoding IKKβ (Ikbkb) were pro-tected against the development of insulin resistance14. The JUN N-terminal kinase (JNK) family of serine/threonine protein kinases, which are activated by many inflammatory stimuli — including TNF and ligation of Toll-like receptors (TLRs) — are also important regula-tors of insulin resistance in mouse models of obesity15. In both genetic and dietary animal models of obesity, JNK activity is increased in the liver, muscle and adipose tissue, and loss of JNK1 prevents insulin resistance15. Another important mechanism involved in insulin resistance is endoplasmic-reticulum (ER) stress16. ER stress leads to suppression of signalling through the insulin receptor in a rat hepatocyte cell line through activation of JNKs and the subsequent serine phosphorylation of insulin receptor substrate 1 (IRS1), which is one of the main mediators of insulin signalling and thereby controls

Figure 1 | Adipose tissue: cellular components and molecules synthesized. Expansion of the adipose tissue during weight gain leads to the recruitment of macrophages through various signals, which might include chemokines synthesized by adipocytes, such as CC-chemokine ligand 2 (CCL2). These macrophages are found mainly around apoptotic adipocytes. Various mediators synthesized by adipocytes and resident macrophages might contribute to local and systemic inflammation. The overall ‘adipocytokine–cytokine cocktail’ might favour a pro-inflammatory milieu. IL, interleukin; TNF, tumour-necrosis factor.

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Type 2 diabetes mellitusA disorder of glucose homeostasis that is characterized by inappropriately increased blood-glucose levels and resistance of tissues to the action of insulin. Recent studies indicate that inflammation in adipose tissue, liver and muscle contributes to the insulin-resistant state that is characteristic of type 2 diabetes mellitus, and that the anti-diabetic actions of peroxisome-proliferator-activated receptor-γ (PPARγ) agonists result, in part, from their anti-inflammatory effects in these tissues.

ob/ob miceMice with a spontaneous mutation in the gene encoding leptin (chromosome 6) that leads to decreased leptin production. These mice are severely obese and develop noninsulin-dependent diabetes mellitus.

Endoplasmic-reticulum stress(ER stress). A response by the ER that results in the disruption of protein folding and in the accumulation of unfolded proteins in the ER.

sensitivity to insulin. Furthermore, mice expressing only a single copy of the gene encoding X-box-binding pro-tein 1 (XBP1), which is a transcription factor that regu-lates a large number of genes in the ER-stress response, develop insulin resistance16. Other factors involved in the regulation of insulin resistance are IL-6 and various suppressor of cytokine signalling (SOCS) proteins17,18. Therefore, several pro-inflammatory cytokines, SOCS proteins, ER stress, the IKKβ pathway of NF-κB acti-vation and JNK signalling pathways are all associated with the development of insulin resistance, indicating that various pro-inflammatory mediators released by adipocytes, in addition to the initially described pro-inflammatory cytokine TNF, link the immune system with obesity-related insulin resistance.

By studying mice with conditional deletion of Ikbkb in either hepatocytes or myeloid cells, Michael Karin’s laboratory showed that mice lacking IKKβ in hepato cytes retain insulin responsiveness in the liver but develop insulin resistance in muscle and fat in response to a high-fat diet, obesity or aging19. By con-trast, mice lacking IKKβ in myeloid cells retain global insulin sensitivity and are protected from insulin resist-ance19. Therefore, this study indicates that myeloid cells, probably macrophages, regulate systemic insulin sensitivity and are involved in inflammation-associated insulin resistance, whereas hepatic IKKβ expression is required for insulin resistance in the liver. Selective activation of NF-κB, causing continuous low-level expression of IKKβ, in hepatocytes from a transgenic mouse model leads to moderate systemic insulin resist-ance20. In this study, insulin resistance was decreased by systemic neutralization of IL-6, which also resulted in decreased expression of SOCS1, SOCS2 and SOCS3 in the liver. Therefore, not only is a complex network of mediators involved in the regulation of insulin resistance,

but various cell types in addition to adipocytes are also involved, including hepatocytes, macrophages and muscle cells.

AdiponectinAlthough adiponectin is synthesized mainly by adipo-cytes, it is also expressed by skeletal muscle cells, car-diac myocytes and endothelial cells21–23 (FIG. 2a). It has sequence homology with a family of proteins that are characterized by an amino-terminal collagen-like region and a carboxy-terminal, complement factor C1q-like globular domain24–26. Adiponectin exists as a full-length protein, as well as a proteolytic cleavage fragment, consisting of the globular C-terminal domain (which is known as globular adiponectin). It is thought that a leukocyte elastase, secreted by activated monocytes and/or neutrophils, mediates this cleavage process and generates the globular fragment of adiponectin. Globular adiponection can trimerize after cleavage, but cannot oligomerize further27. Full-length adiponectin can exist as: a trimer (known as low-molecular-weight adipo nectin); a hexamer, which consists of two trimers linked by a disulphide bond (known as middle-molecular-weight adiponectin); and a high-molecular-weight 12- to 18-mer (FIG. 2a). Adiponectin circulates at high concentrations in human serum (5–10 mg per ml, compared with leptin, which circulates at a concen-tration of a few ng per ml) and it has a wide range of biological activities9. Serum levels of adiponectin are markedly decreased in individuals with visceral obesity and states of insulin resistance, such as non-alcoholic fatty liver disease, atherosclerosis and type 2 diabetes mellitus, and adiponectin levels correlate inversely with insulin resistance28. Both trimers and other oligomers of adiponectin are present in the circulation, whereas the presence of the globular fragment in the serum in humans has been questioned29,30. It has been suggested recently that the ratio, and not the absolute amounts, of high-molecular-weight and low-molecular-weight adi-ponectin in the serum might be crucial in determining insulin sensitivity31. In support of the importance of cir-culating high-molecular-weight adiponectin in protecting against insulin resistance, moderate weight loss leads to a relative increase in the ratio of high-molecular-weight to middle-molecular-weight adiponectin and a decrease in the amount of low-molecular-weight adiponectin in the serum32.

Two receptors for adiponectin have been identi-fied recently (ADIPOR1 and ADIPOR2). ADIPOR1 is expressed widely in mice, whereas ADIPOR2 is expressed mainly in the liver33. Whereas globular adiponectin seems to activate mainly ADIPOR1, ADIPOR2 engages mainly with the full-length variant of adiponectin33. In addition, T-cadherin, which is expressed by many cells including endothelial cells and smooth muscle cells, seems to func-tion as a receptor for middle-molecular-weight and high-molecular-weight adiponectin, but not for the trimeric (low-molecular-weight) and globular forms34.

TNF suppresses the transcription of adiponectin in an adipocyte cell line, which might explain the lower levels of serum adiponectin in individuals who are

Box 1 | Insulin resistance, obesity and inflammation

Insulin regulates the uptake, oxidation and storage of fuel in insulin-sensitive tissues, such as the liver, skeletal muscle and adipose tissue, and also macrophages. Obesity, in particular visceral obesity, which is the accumulation of adipose tissue inside the abdominal cavity, is associated with resistance to the effects of insulin (insulin resistance) on peripheral glucose and fatty-acid utilization, often leading to type 2 diabetes mellitus. With the recent trend for individuals to be more obese, a large increase in the prevalence of insulin resistance in westernized countries is expected. Insulin resistance, together with the associated hyperinsulinaemia and hyperglycaemia, and the presence of pro-inflammatory mediators might lead to a state of vascular endothelial dysfunction, an abnormal lipid profile, hypertension and vascular inflammation, all of which promote the development of atherosclerotic cardiovascular disease.

Subclinical, low-grade inflammation might have an important role in the pathogenesis of insulin resistance and type 2 diabetes mellitus. Population studies show a strong correlation between the levels of pro-inflammatory biomarkers, such as C-reactive protein, interleukin-6 and tumour-necrosis factor, and perturbations in glucose homeostasis, obesity and atherosclerosis. However, although epidemiological correlations have been established, the exact cellular and molecular mechanisms that link obesity and insulin resistance are unknown. Insulin resistance might be partly precipitated or accelerated by an acute-phase reaction as part of the innate immune response, in which large amounts of pro-inflammatory mediators and insufficient amounts of anti-inflammatory mediators, such as adiponectin, are released from adipose tissue.

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a

b

Endothelial cellSkeletal andcardiac myocytes

Low-molecular-weight adiponectin

Low-molecular-weight adiponectin

Globularadiponectin

Globularadiponectin

Middle-molecular-weight adiponectin

High-molecular-weight adiponectin

Adipocyte

IKKα IKKβIκB

p50

NF-κB

p65

IKKγAMPK

ADIPOR1

TNFR1

ADIPOR2

p50 p65

SREBP1C

NF-κB-binding motif

PPAR

PPRE

Metabolic functionof AMPK↑ β-oxidation↑ GLUT4 translocation↓ ACC (Malonyl-CoA)

Immunologicalfunction ofadiponectin↓ TNF↓ IFNγ↑ IL-10↑ IL-1RA

obese35. Expression of adiponectin is also regulated by other pro-inflammatory mediators such as IL-6, which suppresses adiponectin transcription and translation in an adipocyte cell line36. Weight loss is a potent inducer of adiponectin synthesis37, as is activation of peroxisome-proliferator-activated receptor-γ (PPARγ) by its ligands thiazolidinediones, which are important for the treat-ment of type 2 diabetes mellitus38,39. Circulating levels of adiponectin, however, are affected by many other factors including gender, age and lifestyle.

Role in innate and adaptive immunity. Early studies indicated that adiponectin had an anti-inflammatory effect on endothelial cells through the inhibition of TNF-induced adhesion-molecule expression40. In addition, adiponectin-deficient mice have higher lev-els of expression of mRNA encoding TNF in adipose tissue and higher TNF concentrations in plasma com-pared with adiponectin-sufficient mice35. Adiponectin inhibits NF-κB activation in endothelial cells and interferes with the function of macrophages40,41 (FIGS 2b,3a); treatment of cultured macrophages with adiponectin markedly inhibited their phagocytic activ-ity and production of TNF in response to stimulation with lipopolysaccharide (LPS)41.

Adiponectin also induces the production of important anti-inflammatory cytokines, such as IL-10 and IL-1 receptor antagonist (IL-1RA), by human monocytes, macrophages (FIG. 3a) and dendritic cells (DCs), and suppresses the production of interferon-γ (IFNγ) by LPS-stimulated human macrophages42. Through ADIPOR1, globular adiponectin suppresses TLR-induced NF-κB activation43, indicating that adi-ponectin negatively regulates macrophage responses to TLR ligands, which is probably of relevance in innate immune responses.

The presence of adiponectin in T-cell proliferation assays resulted in a decreased ability to evoke an allo-geneic T-cell response42 (TABLE 1), and adiponectin also markedly reduced the phagocytic capacity of macro-phages. However, stimulation of DCs with adiponectin did not result in any changes in cell-surface marker expression, phagocytic capacity or ability to stimulate allogeneic T-cell proliferation, which might indicate that adiponectin mainly affects the function of macrophages and not DCs42.

There might, however, be certain situations in which adiponectin has pro-inflammatory effects. In the pres-ence of LPS, high-molecular-weight adiponectin was shown to augment the translation of CXC-chemokine ligand 8 (CXCL8; also known as IL-8) by human macro-phages44. Low- and high-molecular-weight adiponectin share some biological effects on monocytes, such as the induction of apoptosis, the activation of AMP-activated protein kinase (AMPK) and the suppression of scavenger-receptor expression by macrophages45. However, in this study45, high-molecular-weight adiponectin also induced the secretion of IL-6 by human monocytes, whereas only the low-molecular-weight form had anti-inflammatory effects by decreasing IL-6 production in response to LPS and inducing IL-10 synthesis. The exact

Figure 2 | Adiponectin: sources, structure and effects on pro- and anti-inflammatory cytokines. a | Adiponectin is produced mainly by adipocytes, but other cell types, such as skeletal and cardiac myocytes and endothelial cells, can also produce this adipocytokine. Adiponectin exists as a full-length trimer (low-molecular-weight form), as well as a proteolytic cleavage fragment (globular adiponectin). The full-length trimer can dimerize to form a hexamer (middle-molecular-weight form), which can then oligomerize to form a polymer (high-molecular-weight form). It has been proposed that cleavage of full-length adiponectin by a leukocyte elastase secreted by activated monocytes and/or neutrophils generates the globular fragment. b | Adiponectin interacts with at least two known cellular receptors (ADIPOR1 and ADIPOR2). Activation of ADIPOR1 and/or ADIPOR2 by adiponectin stimulates the activation of peroxisome-proliferator-activated receptor-α (PPARα), AMP-activated protein kinase (AMPK) and p38 mitogen-activated protein kinase33. Adiponectin regulates the expression of several pro- and anti-inflammatory cytokines. Its main anti-inflammatory function might be related to its capacity to suppress the synthesis of tumour-necrosis factor (TNF) and interferon-γ (IFNγ) and to induce the production of anti-inflammatory cytokines such as interleukin-10 (IL-10) and IL-1 receptor antagonist (IL-1RA). Activation of PPARs exerts anti-inflammatory effects through inhibition of the transcriptional activation of pro-inflammatory response genes. ACC, acetyl-CoA carboxylase; GLUT4, glucose transporter type 4; IKK, inhibitor of nuclear factor-κB (IκB) kinase; NF-κB, nuclear factor-κB; PPRE, peroxisome-proliferator response element; SREBP1C, sterol-regulatory-element-binding protein 1C; TNFR, TNF receptor.

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Globularadiponectin

Phagocytosis

Microorganism

• IL-10• IL-1RA

• TNF• IFNγ

LPS

IκBp50

NF-κB

p65

TLR4CD14ADIPOR1

Macrophage

Apoptosis

Monocytea Adiponectin

Phagocytosis

Leptin

OBRb

Macrophage

• Activation• Proliferation• Migration

↑ NOS2↑ ROS

Monocyte

Monocyte

b Leptin

PSTAT3

p38 ERK

p38

PI3K

ERK

Phagocytosis

Microorganism

Microorganism

Resistin

?

?

LPS

p50 p65

TLR4CD14Unknownreceptor

Macrophage

c Resistin

PPAR

PPRE

P• TNF• IL-6• IL-12

NF-κB-binding motif

• TNF• IL-1β• IL-6• IL-12

roles of the different full-length and globular forms of adiponectin in inflammation and immunity remain to be defined.

Role in insulin resistance and inflammation. In obese animals, treatment with adiponectin decreases hyper-glycaemia and levels of free fatty acids in the plasma, and improves insulin sensitivity9,46. Furthermore, adiponectin-deficient mice develop diet-induced insulin resistance on a high-fat, high-sucrose diet35. Specific PPARγ agonists, such as thiazolidinediones, improve insulin sensitivity by mechanisms that are largely unknown. Circulating levels of adiponectin are significantly upregulated in vivo after activation of PPARγ38,39. Mice lacking adiponectin not only have decreased hepatic insulin sensitivity but also have reduced responsiveness to PPARγ agonists, which indicates that adiponectin is an important contributor to PPARγ-mediated improvements in insulin sensitivity47. Adiponectin stimulates β-oxidation in rat hepatocytes and downregulates expression of sterol-regulatory-element-binding protein 1C (SREBP1C), which is the main transcrip-tion factor regulating expression of genes encoding mediators of lipid synthesis (FIG. 2b). Sustained periph-eral, ectopic expression of adiponectin decreases the development of diet-induced obesity and improves insulin sensitivity48. Together, these studies strongly support a major role for adiponectin in regulating insulin sensitivity.

Figure 3 | Effects of various adipocytokines on the monocyte–macrophage system. Adipocytokines exert different effects on the innate immune system and either suppress or activate the monocyte–macrophage system. a | Adiponectin, through interaction with its receptor ADIPOR1 (and ADIPOR2), suppresses the nuclear factor-κB (NF-κB)-dependent synthesis of tumour-necrosis factor (TNF) and interferon-γ (IFNγ), and induces the production of interleukin-10 (IL-10) and IL-1 receptor antagonist (IL-1RA). Adiponectin also induces apoptosis of monocytes and inhibits phagocytosis by macrophages. b | Leptin signals through its receptor OBRb to induce activation of the mitogen-activated protein kinases (MAPKs) p38 and extracellular-signal-regulated kinase (ERK) and of signal transducer and activator of transcription 3 (STAT3). This results in production of the pro-inflammatory cytokines TNF, IL-6 and IL-12. Leptin also induces the production of nitric-oxide synthase 2 (NOS2) and, thereby, reactive oxygen species (ROS), enhances macrophage phagocytosis, and induces the activation, proliferation and migration of monocytes. c | The receptor for resistin is unknown, but this adipocytokine induces the activation of p38, ERK and phosphatidylinositol 3-kinase (PI3K). Resistin increases the production of TNF, IL-1β, IL-6 and IL-12. Its effect on monocyte and macrophage functions is not known. Whereas adiponectin can be considered an anti-inflammatory strategy of the ‘adipose organ’, leptin and resistin have dominant pro-inflammatory features. IκB, inhibitor of NF-κB; LPS, lipopolysaccharide; PPAR, peroxisome-proliferator-activated receptor; PPRE, peroxisome-proliferator response element; TLR4, Toll-like receptor 4.

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Collagen-like regionThe amino-terminal domain of adiponectin contains a signal sequence that is followed by a stretch of 22 collagen-like repeats, consisting of 7 perfect Gly-X-Pro repeats and 15 ‘imperfect’ Gly-X-Y repeats (where X and Y are different amino acids), which — similar to procollagen — allows the assembly of three full-length adiponectin molecules to an adiponectin trimer.

C1q-like globular domainThe carboxy-terminal globular domain of adiponectin, which has marked homology to several other proteins, including subunits of the complement factor C1q.

The liver is one of the main insulin-sensitive tis-sues and insulin resistance has an important role in the development of non-alcoholic fatty liver disease. Therefore, several studies have assessed the roles of fat, inflamma tion and adiponectin in experimental liver disease. Adiponectin has anti-inflammatory effects in various animal models of liver inflammation. Administration of adiponectin has beneficial effects in both alcoholic and non-alcoholic fatty liver disease in mice, by suppressing the expression of TNF in the liver. Adiponectin also decreases hepatomegaly, steato-sis and the levels of liver enzymes49. In addition, adipo-nectin attenuates liver fibrosis in the carbon-tetrachloride liver-fibrosis model50 and protects against endotoxin-induced liver injury in another model of fatty-liver disease, the KK-Ay obese mouse model51. Sennello and colleagues studied concanavalin A (ConA)-induced hepatotoxicity in lipodystrophic transgenic mice (which constitutively express a truncated form of SREBP1c and lack virtually all white adipose tissue) and lean, wild-type control mice52. Serum adiponectin levels were low in lipodystrophic mice compared with controls, and the

administration of adiponectin protected lipo dystrophic mice from hepatotoxicity and protected primary hepatocytes from TNF-induced cell death.

AMPK is an evolutionarily conserved sensor of the energy status of a cell, and it has a crucial role in controlling the systemic energy balance by regulating food intake, body weight, and glucose and lipid homeo-stasis53. AMPK increases the sensitivity of a cell to both insulin and thiazolidinediones. Full-length adiponectin stimulates AMPK phosphorylation and activation in the liver, whereas globular adiponectin has this effect in both skeletal muscle and liver tissue54. Each of these effects of adiponectin could be inhibited by the use of a dominant-negative AMPK mutant, further supporting the model that glucose utilization occurs through activa-tion of AMPK54. Adiponectin protects the myocardium from injury by protecting cardiac muscle cells from apoptosis through activation of AMPK signalling55,56. Ischaemia–reperfusion in adiponectin-deficient mice resulted in increased myocardial-infarct size, myocar-dial apoptosis rate and TNF expression compared with adiponectin-sufficient mice. All of these effects were

Table 1 | Effects of adipocytokines on the immune system and linked diseases

Adipocytokine Inflammatory effect Effects on immunity Associated diseases

Innate Adaptive

Adiponectin Anti-inflammatory ↓ Endothelial adhesion molecules40

↓ NF-κB40,41,43

↓ TNF35

↓ IL-6(REF. 42)↓ IFNγ 42

↑ IL-10 (REF. 42)↑ IL-1RA42

↓ Phagocytosis42

↓ B-cell lymphopoiesis117

↓ T-cell responses42• Insulin resistance and type 2 diabetes

mellitus33,35

• Atherosclerosis57,58,60

• Experimentally induced liver disease: non-alcoholic and alcoholic fatty liver disease49; CCl4 liver fibrosis (REF. 50); LPS-treated KK-Ay mice (REF. 51); and experimentally induced hepatitis (ConA)52

• Cardiac injury55,56

• Cancer102,103

• Inflammatory bowel disease112

• Rheumatoid arthritis115

Pro-inflammatory ↑ CXCL8 in presence of LPS44

ND

Leptin Pro-inflammatory ↑ TNF68,71

↑ IL-6 (REF. 68)↑ IL-12 (REF. 68)↑ Neutrophil activation

(CD11b)70

↑ ROS70

↑ Chemotaxis70

↑ NK-cell function72

↑ Lymphopoiesis73

↑ Thymocyte survival73

↑ T-cell proliferation64

↑ TH1 response (IL-2 and IFNγ )64

↓ TH2 response (IL-4)64

• Insulin resistance9

• Experimentally induced hepatitis (ConA)75,76

• EAE and antigen-induced arthritis4,77

• Experimentally induced colitis: CD4+CD45RBhi T-cell transfer78; and IL-10-deficient mice113

• Asthma110

• Cancer104

Resistin Pro-inflammatory ↑ TNF86,87

↑ IL-1β86

↑ IL-6 (REF. 86)↑ IL-12 (REF. 86)↑ NF-κB87

↑ Endothelial adhesion molecules (VCAM1 and ICAM1)88

ND • Insulin resistance (mice)5

• Type 2 diabetes mellitus (mice)80

• Rheumatoid arthritis86

• Atherosclerosis92

• Non-alcoholic fatty liver disease118

• Chronic kidney disease94

Visfatin ND ↑ IL-6 (REF. 119)↑ IL-8 (REF. 119)↓ Apoptosis of

neutrophils98

ND • Insulin resistance and type 2 diabetes mellitus95

• Acute lung injury97

• Sepsis98 X

CCl4, carbon tetrachloride; ConA, concanavalin A; CXCL, CXC-chemokine ligand; EAE, experimental autoimmune encephalomyelitis; ICAM, intercellular adhesion molecule; IFNγ, interferon-γ; IL, interleukin; IL-1RA, IL-1 receptor antagonist; LPS, lipopolysaccharide; ND, not determined; NF-κB, nuclear factor-κB; NK, natural killer; ROS, reactive oxygen species; TH, T helper; TNF, tumour-necrosis factor; VCAM, vascular cell-adhesion molecule.

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Visceral obesityAccumulation of adipose tissue inside the abdominal cavity, in particular at omental and mesenteric regions, which are drained by the portal vein and therefore have direct access to the liver.

T-cadherinA member of the cadherin family of transmembrane glycoproteins that mediate cell-adhesive interactions.

Peroxisome-proliferator-activated receptor-γ(PPARγ). A nuclear receptor that is a master transcriptional regulator of metabolism and fat-cell formation. The activity of PPARγ can be modulated by the direct binding of small molecules — thiazolidinediones. PPARγ has anti-inflammatory properties by limiting the availability of limited cofactors or blocking promoters of pro-inflammatory genes.

IL-1 receptor antagonist(IL-1RA). A secreted protein that binds to IL-1R, thereby blocking IL-1R downstream signalling. IL-1RA inhibits the pro-inflammatory properties of IL-1α/β.

Carbon-tetrachloride liver-fibrosis modelIntraperitoneal or oral administration of hepatotoxic carbon tetrachloride (CCl4) to mice is a commonly used model of both acute and chronic liver injury. CCl4 causes hepatocyte injury that is characterized by centrilobular necrosis followed by hepatic fibrosis.

KK-Ay obese miceThe spontaneous Ay mutation (agouti signal protein; yellow) was introduced onto the KK strain background. KK-Ay heterozygous mice have yellow hair pigment and black eyes and develop hyperglycaemia, hyperinsulinaemia, glucose intolerance and obesity by 8 weeks of age.

decreased by the administration of adiponectin in both adiponectin-deficient mice and wild-type mice56. These studies indicate that several important adiponectin-induced effects are mediated through the activation of AMPK (FIG. 2b).

Adiponectin might have an important role in the pathophysiology of atherosclerosis. Adiponectin-deficient mice had a two-fold greater neointimal (that is, inner vessel surface) formation in response to an external vas-cular injury than did wild-type mice57. Furthermore, adi-ponectin protected apolipoprotein E (APOE)-deficient mice (mice lacking a key component in cholesterol metabolism) from atherosclerosis58. This experimental evidence is paralleled by several clinical reports that support the observation that hypoadiponectinaemia is associated with the development of atherosclerosis59–61.

So, adiponectin is an important mediator in the regu-lation of insulin resistance and can suppress inflamma-tion in various animal models. This adipocytokine also has a crucial role in suppressing macrophage activity, not only in adipose tissue but also in other tissues such as the liver. Decreased synthesis of adiponectin, as is observed in individuals who are obese, might lead to dysregulation of the controls that inhibit the production of pro-inflammatory cytokines, thereby leading to the production of increased amounts of pro-inflammatory mediators. One of the main challenges in understanding the physiology of this adipocytokine will be to under-stand why circulating levels decrease with the onset of obesity. Also of great interest is how this decrease might affect the cytokine–adipocytokine milieu, resulting in an overwhelmingly pro-inflammatory state.

LeptinThe role of leptin in modulating the immune response and inflammation has become increasingly evident and has been reviewed recently4. In addition to regulating neuroendocrine function, energy homeostasis, haema-topoiesis and angiogenesis, this adipocytokine is an important mediator of immune-mediated diseases and inflammatory processes4.

Similar to adiponectin, leptin is produced mainly by adipocytes. However, unlike adiponectin, leptin is considered to be a pro-inflammatory cytokine and it has structural similarity to other pro-inflammatory cytokines such as IL-6, IL-12 and granulocyte colony-stimulating factor. The main function of leptin is con-trol of appetite4. Indeed, mice with a mutation in the gene encoding leptin (ob/ob mice) or the gene encoding the leptin receptor (db/db mice) have obese phenotypes and are used in many studies as mouse models of obes-ity. However, these mice also have various defects in cell-mediated and humoral immunity62–64.

Serum levels of leptin reflect the amount of energy stored in the adipose tissue and are proportional to overall adipose mass in both mice and humans4,65. Serum levels are 2–3 times higher in women than in men, even when adjusted for age and body-mass index (BMI). In animal models, expression of leptin is increased in conditions that are associated with the release of pro-inflammatory cytokines, as induced

during acute inflammatory conditions such as sep-sis66,67. An increase in leptin levels and a decrease in expression of mRNA encoding the full-length isoform b receptor (OBR b, which is one of at least six alterna-tively spliced isoforms, each of which has a cytoplas-mic domain of a different length) has been observed in diet-induced obese rats4. In addition to adipose tissue, leptin is produced by several other tissues, including placenta, bone marrow, stomach, muscle and perhaps the brain4. Therefore, pro-inflammatory mediators and obesity seem to be the main factors responsible for increased leptin synthesis.

Role in innate and adaptive immunity. In monocytes and macrophages, leptin increases the production of pro-inflammatory cytokines such as TNF, IL-6 and IL-12 (REF. 68) (FIG. 3b). It also upregulates the expres-sion of pro-inflammatory and pro-angiogenic factors, such as CCL2 and vascular endothelial growth factor, respectively, in human hepatic stellate cells69. This effect in human stellate cells is mediated through activation of NF-κB, as well as other signalling intermediates, includ-ing the serine/threonine protein kinase AKT, which is the main downstream target of phosphatidylinositol 3-kinase69. Leptin also activates neutrophils, as assessed by increased expression of CD11b, and stimulates the proliferation of human circulating monocytes in vitro and upregulates the expression of activation markers such as CD25 (also known as IL-2Rα) and CD71 (the transferrin receptor) on these cells9,70. Leptin-induced TNF production by murine peritoneal macrophages is inhibited by globular adiponectin through suppression of the phosphorylation of extracellular-signal-regulated kinase 1 (ERK1), ERK2 and p38 (REF. 71). Furthermore, leptin stimulates neutrophil chemotaxis and the produc-tion of reactive oxygen species (ROS) by these cells, and regulates natural killer (NK)-cell differentiation, pro-liferation, activation and cytotoxicity72. Most of these pro-inflammatory effects are mediated through the long isoform of the leptin receptor (OBRb), which is expressed mainly by endothelial cells and various leukocytes.

The effects of leptin on adaptive immunity have been well studied4 (FIG. 4). Leptin induces the proliferation of naive CD4+CD45RA+ T cells, but inhibits the proliferation of memory CD4+CD45RO+ T cells in a mixed lymphocyte reaction (MLR)64. In T-cell proliferation assays with mouse cells, leptin increased production of the T helper 1 (TH1) cytokines IL-2 and IFNγ, and suppressed produc-tion of the TH2 cytokine IL-4 (REF. 64). Administration of leptin reversed the immunosuppressive effects of acute starvation in mice64 and provided a survival signal for thymocytes, thereby protecting the mice from starvation-induced lymphoid atrophy. Leptin has also been shown to increase thymic cellularity in ob/ob mice73. Despite this evidence of a role for leptin in immune responses in vitro and in mouse models, it is currently unclear whether leptin influences immune responses in humans.

Role in inflammation. The role of leptin in inflamma-tion is incompletely understood. Endogenous leptin protects against TNF-mediated toxicity. Ob/ob mice and

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Adiponectin

B-cell lymphopoiesis↓ B-cell number↑ COX1/COX2 and PGE2 in stromal cells

↑ IgG2a switch

T-cell proliferation

IL-10 TH2 cytokines• IL-4

Leptin

Thymic homeostasis↓ Apoptosis↑ Thymocyte number

↑ CD4+CD8+ T cells↑ CD4+CD8– T cells

TH1 cytokines• TNF• IFNγ

Lipodystrophic transgenic miceTransgenic mice that express a truncated, constitutively active form of the sterol-regulatory-element-binding protein 1C (SREBP1C) transcription factor under the control of the adipose-specific aP2 promoter. Lipodystrophic mice have low plasma leptin levels, hyperphagia, hyperglycaemia and hyperinsulinaemia.

Body-mass index(BMI). This is the most frequently used method to gauge an individual’s deviation from ‘normal’ body weight. The BMI is the quotient of body weight (in kg) through the square of height (m²). Underweight: <20; ideal: 20–25; overweight: >25; obese: >30.

Mixed lymphocyte reactionA tissue-culture technique that is used for the in vitro testing of the proliferative response of T cells from one individual to lymphocytes from another individual.

TNF-mediated toxicityThe injection of tumour-necrosis factor (TNF) into animals, which results in acute anorexia, weight loss, shock and even death.

Experimental autoimmune encephalomyelitis(EAE). An experimental model of multiple sclerosis that is induced by immunization of susceptible animals with myelin-derived antigens, such as myelin basic protein, proteolipid protein or myelin oligodendrocyte glycoprotein.

db/db mice, as well as mice treated with a leptin-receptor antagonist, had increased sensitivity to the lethal effects of TNF74. The addition of exogenous leptin protected against TNF-mediated toxicity in ob/ob mice, but did not increase the protective effect of endogenous leptin in wild-type mice. Also, in various mouse models of inflammation, such as ConA-induced hepatitis, leptin deficiency has a protective effect by decreasing the pro-duction of pro-inflammatory TH1 cytokines and shifting the immune response towards a TH2-type response75.

Several studies have investigated the susceptibility of ob/ob and db/db mice to experimentally induced auto immune diseases4,9,76. Ob/ob mice are resistant to experimental autoimmune encephalomyelitis, but become susceptible to disease after leptin administration77. Leptin administration also exacerbates disease in wild-type mice through increased synthesis of TH1 cytokines77. Similar data were obtained from models of intestinal inflamma-tion, where CD4+CD45RBhi T cells from db/db mice had a decreased capacity to cause colitis when transferred to severe combined immunodeficient (SCID) mice, com-pared with cells from wild-type mice78. Decreased IFNγ production was observed early on in SCID mice that

received db/db T cells compared with wild-type T cells, indicating that leptin affects the immune response, prob-ably through its interaction with the long isoform of its receptor (OBRb), which is expressed by CD4+CD45RBhi T cells78. Leptin administration also increases disease severity and accelerates autoimmune diabetes in female non-obese diabetic (NOD) mice. Recent clinical reports in patients with autoimmune diseases have shown that high serum levels of leptin might be either a contributing factor to or a marker of disease activity4,70.

Taken together, it seems clear that leptin has pro-inflammatory effects. This could be detrimental in many animal models of inflammatory and autoimmune disease, but it might be protective in several infectious-disease settings, such as during the early immune response to pulmonary tuberculosis, following infec-tion with Gram-negative pneumococci and during viral myocarditis4,9. However, the direct interaction of the two main adipocytokines adiponectin and leptin is not well understood and this might have important implica-tions in understanding the role of these adipocytokines in obesity-associated disorders.

ResistinThe adipocytokine resistin was discovered by three independent groups79–81. Resistin (also known as FIZZ3), which is a 114-amino-acid polypeptide, was originally shown to induce insulin resistance in mice80. It belongs to a family of cysteine-rich proteins, also known as resistin-like molecules (RELMs), that have been implicated in the regulation of inflammatory processes79. Resistin was shown to circulate in two dis-tinct forms: a more prevalent high-molecular-weight hexamer and a substantially more bioactive, but less prevalent, low-molecular-weight complex82.

mRNA encoding resistin can be found in mice and humans in various tissues, including adipose tissue, the hypothalamus, adrenal gland, spleen, skeletal muscle, pancreas and gastrointestinal tract5. Although resis-tin protein synthesis in mice seems to be restricted to adipocytes, in humans, adipocytes, muscle, pancreatic cells and mononuclear cells such as macrophages can synthesize this protein. Expression levels of the gene encoding resistin have been shown to be higher in human peripheral-blood mononuclear cells (PBMCs) than in adipocytes; however, comparative protein data are not available5. So, it still remains to be shown which cell type in humans is mainly responsible for systemic production and for the high circulating levels of resistin. Remarkably, at the protein level, human resistin is only 55% identical to its mouse counterpart, which indicates that it might not be evolutionarily well conserved across species.

In human PBMCs, expression of resistin mRNA is markedly increased by the pro-inflammatory cytokines IL-1, IL-6 and TNF, and by LPS, whereas IFNγ and leptin had no effect83. Similarly, stimulation of human macrophages with LPS led to increased resistin mRNA expression, and administration of LPS to humans resulted in a marked increase in the level of resistin in the serum84. The induction of resistin synthesis can be

Figure 4 | Effects of adipocytokines on adaptive immunity. Only limited data are available to describe the potential effects of adiponectin (and resistin) on adaptive immunity. In terms of T-cell proliferation, adiponectin suppresses the ability to evoke allogeneic T-cell responses. Adiponectin affects T helper 1 (TH1)-cell immunity by suppressing the production of interferon-γ (IFNγ) and tumour-necrosis factor (TNF), and by inducing production of the anti-inflammatory cytokine interleukin-10 (IL-10). In terms of lymphopoiesis, adiponectin suppresses B-cell development through the induction of prostaglandin synthesis. Leptin is the best studied adipocytokine and has many influences on adaptive immunity, such as inducing a switch towards TH1-cell immune responses by increasing IFNγ and TNF secretion, the suppression of TH2-cell responses, and inducing the production of IgG2a by B cells. Leptin promotes the generation, maturation and survival of thymic T cells, and it increases the proliferation of and IL-2 secretion by naive T cells. COX, cyclooxygenase; PGE2, prostaglandin E2.

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Atherosclerotic aneurysmA localized dilation of a blood vessel by more than 50% of its diameter owing to atherosclerotic structural damage of the vessel wall.

attenuated by PPARγ agonists5,84. Accordingly, treatment of patients with type 2 diabetes mellitus with the PPARγ agonist pioglitazone decreased serum levels of resistin85. In addition, several factors such as pituitary, steroid and thyroid hormones, adrenaline, β3-adrenoreceptor activation, endothelin-1 and insulin modulate resistin expression5,84.

Role in immunity. Resistin strongly upregulates the expression of TNF and IL-6 by human PBMCs and induces arthritis after injection into the joints of healthy mice86. These pro-inflammatory properties of resistin were abrogated by an NF-κB inhibitor, showing the important role of NF-κB in resistin-controlled inflammatory reactions. Resistin has also been shown to accumulate in the inflamed joints of patients with rheumatoid arthritis and its levels correlate with markers of inflammation5. Human resistin stimulates synthesis of the pro-inflammatory cytokines TNF, IL-1, IL-6 and IL-12 by various cell types through an NF-κB-dependent pathway83,87 (FIG. 3c). In further support of its pro-inflammatory profile, resistin also upregulates the expression of vascular cell-adhesion molecule 1 (VCAM1), intercellular adhesion molecule 1 (ICAM1) and CCL2 by human endothelial cells and induces these cells to release endothelin-1 (REF. 88).

Role in inflammation and insulin resistance. Resistin has been implicated in the pathogenesis of obesity-associated insulin resistance and type 2 diabetes mellitus in mouse models80, whereas such a role in humans is still debated89–91. Although a clear function for resistin in humans is still lacking, its pro-inflammatory properties indicate that it has a role in inflammatory processes5. Macrophages infiltrating human atherosclerotic aneurysms secrete resistin92. Resistin and adiponectin have reciprocal effects on vascular endothelial cells: resistin induces the expression of VCAM1, ICAM1 and pentraxin-3, whereas adiponectin downregulates the expression of these mol-ecules93. Increased levels of resistin in chronic kidney disease are associated with impaired renal function and inflammation, but not with insulin resistance94.

Therefore, this adipocytokine, at least in humans, has many features of a pro-inflammatory cytokine and could have a role in inflammatory diseases with or without associated insulin resistance. These pro-inflammatory effects, however, are based on a small number of studies and much more information is required to characterize resistin more fully in both mice and humans.

Visfatin and other new adipocytokinesVisfatin (also known as PBEF) has recently been identi-fied as an adipocytokine that is secreted by adipocytes in visceral fat and that decreases insulin resistance95. This molecule binds to and activates the insulin receptor but does not compete with insulin, which indicates that the two proteins bind different sites on the insulin receptor. Visfatin was originally identified as PBEF (pre-B-cell colony-enhancing factor) more than 10 years ago and since then, it has been linked to several inflammatory disease states such as acute lung injury96,97. Furthermore,

expression of visfatin has been shown to be upregulated in activated neutrophils and to inhibit the apoptosis of neu-trophils98. Future studies of the cell biology of this natural insulin mimetic and potential inflammation-regulating adipocytokine should help to define its role in insulin resistance and associated inflammatory disorders.

Hida and colleagues recently identified a new adi-pocytokine termed VASPIN (visceral adipose-tissue-derived serine protease inhibitor), which has similarities to adiponectin in that it improves insulin sensitivity. Preliminary studies indicate that VASPIN might also have anti-inflammatory effects, as it suppresses the production of TNF, leptin and resistin99.

Serum retinol-binding protein 4 (RBP4) is another recently characterized adipocytokine100. Until recently, the sole function of RBP4 was thought to be the deliv-ery of retinol to tissues. However, in patients with type 2 diabetes mellitus, serum levels of RBP4 are increased. Expression of RBP4 is also increased in adipose tissue of mice lacking the glucose transporter GLUT4, and consistent with this, expression of GLUT4 is selectively decreased in adipocytes from obese individuals or indi-viduals with type 2 diabetes. Treatment with fenretinide, a synthetic retinoid that increases urinary excretion of RBP4, normalizes serum levels of RBP4 and decreases insulin resistance in mice with obesity induced by a high-fat diet. Transgenic overexpression of human RBP4 or injection of recombinant RBP4 in normal mice causes insulin resistance. Therefore, decreasing the concentra-tion of RBP4 could be an interesting strategy for the treatment of individuals with type 2 diabetes mellitus.

Role in cancer and immune-mediated diseasesIn humans, the prevalence of cancer and some immune-mediated diseases (such as asthma) is increased or disease activity is more severe in individuals who are obese2,3. Although there is currently only limited evidence for this model, mainly derived from correlative studies, it is proposed that adipocytokines could link obesity with these diseases.

Adiponectin has anti-angiogenic effects, through the inhibition of endothelial-cell proliferation and migra-tion101. In a mouse tumour model, adiponectin markedly inhibited primary tumour growth in a caspase-dependent manner and it resulted in endothelial-cell apoptosis102. Prostate cancer is also associated with obesity, and full-length adiponectin inhibits the growth of prostate-cancer cells at physiological concentrations103. Many studies have investigated the effect of leptin on different cancer types in experimental cellular and animal models104. Most of the studies indicate that leptin can potentiate the growth of cancer cells (breast, oesophageal, gastric, pancre-atic, colorectal, prostate, ovarian and lung carcinoma cell lines), whereas adiponectin seems to decrease cell proliferation.

Epidemiological studies indicate that obesity is a significant risk factor for the development of cancer, although the exact mechanisms of this have not yet been identified2. Recently, it has been shown that patients with various types of cancer, including gas-tric, endometrial, prostate and breast cancer, have low

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In patients with rheumatoid arthritis, serum leptin levels correlate with BMI rather than with disease stage. In addition, increased levels of adiponectin and resistin are observed in the synovial fluid of patients with rheumatoid arthritis compared with patients with osteoarthritis86,115. Intra-articular injection of resistin also induces arthritis in healthy mouse joints86. An association of obesity with the presence and development of rheumatoid arthritis, however, is less clear116.

ConclusionsGreat strides have been made towards understanding the molecules linking obesity, inflammation and immu-nity and understanding why obesity leads to chronic inflammation. It is now evident that there are prototypic adipocytokines, such as adiponectin and leptin, that are synthesized mainly in the fat tissue, circulate at high concentrations (in particular, adiponectin), function in a hormone-like manner and have many of the features of classical cytokines. These two mediators have dominated the field of adipocytokine research recently and there is increasing evidence that they are involved in many diseases and, under certain circumstances, might crossregulate each other.

Other adipocytokines, such as resistin and visfatin, are also produced by adipocytes but an important site of synthesis might be outside the adipose tissue, in particu-lar by monocytes and macrophages. Resistin, although differing in several functions between mice and humans, seems to be mainly a pro-inflammatory mediator. Other adipocytokines, such as VASPIN and RBP4, have only recently been identified. Understanding the mecha-nisms that lead from obesity to inflammation will have important implications for the design of new therapies to reduce the morbidity and mortality of obesity.

levels of circulating adiponectin105–108. Another study indicated an association of obesity and decreased adi-ponectin serum concentrations with colorectal adeno-mas and a higher risk of colorectal cancer109. Although these first studies are only descriptive and do not allow further conclusions to be drawn, adipocytokines could be attractive candidates as the missing link between obesity and cancer.

An association between obesity and increased asthma incidence and severity has been reported in some studies3. Administration of leptin increases air-way hyperresponsivness and the production of TH2 cytokines in ovalbumin-sensitized mice110. High leptin levels have been observed in asthmatic children com-pared with a control group with similar BMI, indicat-ing that in addition to BMI, other factors might affect leptin levels in these patients9. However, the association of obesity with asthma in this study might also be influ-enced by other factors, such as the increased prevalence of gastro-oesophageal reflux disease observed in the obese population.

Overexpression of adipocytokines, including adi-ponectin, leptin and resistin, in the mesenteric adipose tissue of patients with Crohn’s disease after ileocoecal surgical resection has been reported111. In Crohn’s disease, leptin and adiponectin are highly expressed in the mesenteric fat tissue, indicating that both pro- and anti-inflammatory adipocytokines are overexpressed in this type of inflammation111,112. Leptin-deficient mice are protected from inflammation in some experimen-tal models of inflammatory bowel disease113. However, there is no clear association between obesity and the development of inflammatory bowel disease, although obesity has been associated with increased disease severity114.

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AcknowledgementsWe gratefully acknowledge A. Kaser for helpful discussions and critical reading of the manuscript. We are supported by grants from the Austrian Science Foundation and the Christian-Doppler Research Society (Austria).

Competing interests statementThe authors declare no competing financial interests.

DATABASESThe following terms in this article are linked online to:Entrez Gene: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=geneadiponectin | ADIPOR1 | ADIPOR2 | APOE | CCL2 | CRP | CXCL8 | GLUT4 | granulocyte colony-stimulating factor | ICAM1 | IKKβ | IL-1 | IL-1RA | IL-4 | IL-6 | IL-10 | IL-12 | IFNγ | IRS1 | JNK1 | leptin | OBR | pentraxin-3 | plasminogen-activator inhibitor type 1 | PPARγ | RBP4 | resistin | SOCS1 | SOCS2 | SOCS3 | SREBP1C | TNF | vascular endothelial growth factor | VASPIN | VCAM1 | visfatin | XBP1Access to this links box is available online.

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