In the UK, rates of obesity have increased by 30% in women, 40% in men, and 50% in children within the last decade resulting in over 25% of adults classified as obese today. Obesity, in particular central obesity, is the dominant risk factor for insulin resistance, metabolic syndrome and type II diabetes. Evidence supporting obesity as an inflammation condition continues to grow and this is directly linked to the development of insulin resistance. This webinar discusses novel approaches for the treatment and prevention of the common morbidities associated with obesity, specifically insulin resistance and type II diabetes, through targeting obesity-induced inflammatory processes.

1. Obesity and Inflammation
Nina Bailey
BSc (hons) MSc PhD ANutr

2. Obesity statistics
In the UK, rates of obesity have increased by 30% in women, 40% in men and 50% in children
within the last decade
A survey published in 2012 found that just over a quarter of all adults (26%) in England are
obese with a further 41% of men and 33% of women classed as overweight
Obesity, particularly central (visceral) obesity, is the prominent risk factor for insulin
resistance, metabolic syndrome and type II diabetes
In recent years, evidence has emerged that obesity is associated with inflammation that is
directly linked to the development of insulin resistance
This webinar will discuss novel approaches for the treatment and prevention of insulin
resistance and type II diabetes by targeting obesity-induced inflammatory processes

3. Why the weight gain?
Sedentary lifestyles, coupled with increased availability and consumption of
energy-dense, nutrient-poor food that is rich in saturated fat and high in added
sugar
Overloading the body with simple carbohydrates is known to be detrimental to
health
Many of the high-carbohydrate foods common to Western diets produce a high
glycaemic response that leads, over time, to obesity, increasing the risk of
insulin resistance, metabolic syndrome and type II diabetes
In addition, today’s Western diets are characterised by increases in total fat,
especially in saturated fat and omega-6 fatty acids, and decreases in omega-3
fatty acids in comparison to the fatty acid intake during evolution, to which our
genes were programmed to respond

4. Obesity associated health risks:
Metabolic syndrome
Type II diabetes
Hypertension
Stroke
Heart failure
Atherosclerosis
Renal failure
Liver disease
Cancer

5. Adipose tissue used to be regarded as a silent and passive organ, storing
excess energy as triglycerides and releasing energy as fatty acids
 now recognised as an active endocrine organ affecting immunological
processes and metabolism of the body
 holds a host of immune cells including B cells, T cells, macrophages
and neutrophils, with obesity influencing both the quantity and the nature
of these immune cell subtypes
 secretes a wide variety of hormones, cytokines, chemokines and
growth factors that influence metabolism, vascular and endothelial function,
appetite and satiety, immunity, fertility, inflammation, tumour growth and
many other body processes

6. A considerable effort has been made over the last two decades to elucidate
the molecular factors responsible for obesity-associated co-morbidities; as a
result, it is now well established that the key pathogenic mechanism is the
presence of a ‘low-grade’ state of inflammation in the white adipose tissue
This low-grade inflammation, also known as metabolic-triggered inflammation
or metainflammation, can be described as a long-term inflammatory response
triggered by nutrients and calorie surplus
It involves a set of molecules/signalling pathways similar to those involved in
classical inflammation, but in obesity-induced inflammation these
molecules/signalling pathways have a dual role as inflammatory mediators as
well as regulators of energy storage and metabolism
Direct link between inflammation and insulin resistance!

7. .
Adipose tissue produces both pro- and anti-inflammatory factors including:
adipokines (cytokines, cell-signalling proteins, such as leptin, adiponectin and
resistin) as well as other chemicals, such as tumour necrosis factor alpha (TNF-a)
and interleukin 6 (IL-6)
Expansion of adipose tissue leads to adipocyte hypertrophy and hyperplasia,
with large adipocytes exceeding the capacity for oxygen supply leading to hypoxia
and cellular stress, leading to inflammation and the release of cytokines and other
pro-inflammatory signals
Increased production of chemotactic factors (such as MCP-1) leads to the
subsequent recruitment of a number of immune cells
Locally secreted chemokines attract pro-inflammatory macrophages into the
adipose tissue where they then release cytokines that further activate the
inflammatory program in neighbouring adipocytes, exacerbating inflammation
Adipose tissue macrophages are a prominent source of proinflammatory
cytokines, such as TNF-α and IL-6, that can block insulin action

8. In obesity, the accumulation of infiltrating macrophages in adipose tissue
and their phenotypic switch to M1-type dysregulated inflammatory
adipokine production lead to obesity-linked insulin resistance
The increased production of pro-inflammatory adipokines (i.e. TNF,-α, IL-
6, and MCP-1) in obese subjects directly correlate with the degree of
glucose intolerance and insulin resistance
TNF-α interferes with glucose uptake by inhibiting phosphorylation of the
insulin receptor
IL-6 reduces lipoprotein lipase activity, which likely results in both
increased concentrations of circulating free fatty acids and
insulin resistance

9. Catalan et al., 2013

10. Inflammation is an adaptive response to infection or tissue injury. Its
purpose is to eliminate the injurious agent and remove damaged tissue
components in an attempt to restore homeostasis
The onset of the inflammatory response is a well-known process that
involves a complex interplay of soluble and cellular components
characterised by changes in blood flow, an increase in permeability of
blood vessels and migration of fluid, proteins and white blood cells from
the circulation to the site of damage

11. Resolution of the inflammatory response is not a passive process but
one that is coordinated by a complex regulatory network of cells and
mediators that switch inflammation off in a specific time-limited manner
Resolvins are potent anti-inflammatory and pro-resolving mediators that
are endogenously generated from omega-3 fatty acids that act as ‘stop-
signals’ of the inflammatory response, promoting the resolution of
inflammation
A deficit in the production of these endogenous anti-inflammatory signals
will result in what is termed silent inflammation

15. Insulin resistance is the physiological condition in which cells fail to respond to the
normal actions of the hormone insulin
• The body produces insulin, but the cells
become resistant, leading to hyperglycaemia
• Beta cells in the pancreas subsequently
increase their production of insulin,
further contributing to hyperinsulinaemia
• If undetected, insulin resistance can
lead to the development of
type II diabetes

16.
Winer & Winer 2012
The pathogenesis of obesity-related insulin resistance and visceral fat inflammation

17. Weight loss improves insulin sensitivity and inflammatory markers
van Kruijsdijk et al., 2009

18. Diet and exercise for weight loss?
Current recommendations from most public health bodies for reducing body fat are based
on increasing physical activity and eating a healthy & balanced diet
Reductions in body weight (calorie restriction, liposuction, or bariatric surgery) correlate
with significant reductions in inflammatory markers and improved insulin sensitivity
However, many people have difficulty complying with these lifestyle changes, particularly
over the longer term
For example: 6 studies directly comparing diet and exercise vs diet alone, with an active
intervention period ranging between 10 and 52 weeks across studies
Diet associated with exercise produced a 20% greater initial weight loss (13 kg vs 9.9 kg)
The combined intervention also resulted in a 20% greater sustained weight loss after 1 y
(6.7 kg vs 4.5 kg) than diet alone
In both groups, almost half of the initial weight loss was regained after 1 year
(Curioni & Lourenco 2005)
More strategies are needed!!

19. Omega-3 for weight loss?
In young, overweight men, the inclusion of either lean or fatty fish, or fish oil as part of
an energy-restricted diet resulted in approximately 1 kg more weight loss after 4
weeks, than did a similar diet without seafood or supplement of marine origin
(Thorsdottir et al., 2007)
A dose-response relationship between cod consumption and weight loss during an 8-
week energy restriction diet is found and 5 x 150 g cod/week results in 1.7 kg
greater weight loss in young overweight or obese adults than an isocaloric diet without
seafood (Ramel et al., 2008)
Weight-loss diets that include oily fish offer more favourable outcomes on blood lipid
levels than diets without fish or fish oil (Gunnarsdottir et al., 2008)

20. Seafood consumption, weight loss and inflammatory markers
8-week intervention trial, 324 subjects (aged 20-40 years, body mass index 27.5-32.5
kg/m(2)
Randomised to one of four energy-restricted diets (-30% relative to estimated
requirements):
Salmon (3 x 150 g/week, 2.1 g LC n-3 PUFA per day)
Cod (3 x 150 g/week, 0.3 g LC n-3 PUFA per day)
Fish oil capsules (1.3 g LC n-3 PUFA per day)
Control (sunflower oil capsules, no seafood)
Body weight, high-sensitivity C-reactive protein (CRP), interleukin-6 (IL-6), glutathione
reductase and prostaglandin F2 alpha (PGEF2alpha) were measured at baseline and end
point
All subjects experienced weight loss, with salmon consumption the most effective with
three of the four measured inflammation markers decreasing significantly in the salmon
group (Ramel et al., 2010)

21. Relationship between omega-3 index and obesity
Polyunsaturated fatty acids (PUFA) are known to beneficially influence fat
metabolism and there are numerous studies in animal models of obesity showing
that consumption of PUFA, particularly the long-chain omega-3 PUFA, can increase
fat loss and counteract adiposity (Buckey & Howe 2009)
Higher plasma levels of total omega-3 PUFA are associated with a healthier BMI,
waist circumference and hip circumference (Micallef et al., 2009)
Correlations between omega-3 index and BMI have been reported in both adults
(with this association appearing to be gender specific) (Howe et al., 2014) and
children (Burrows et al., 2011)

22. Is there room for clinical application using omega-3?

24. Insulin and desaturase activity
• Patients with obesity or type II diabetes are characterised by a different fatty acid
composition of serum lipids as compared to healthy lean subjects
• Insulin resistance is associated with measures of desaturase activities since there exists
evidence that there are changes of the fatty acid desaturase activities under insulin
resistant conditions
• Such an abnormal fatty acid profile in healthy subjects predicts further development of
type II diabetes
• Patients with type II diabetes exhibit higher plasma AA levels, higher delta-5 desaturase
activity index (indicating poor desaturase activity) , and higher AA to EPA ratios than
healthy controls
(Vessby et al., 2002; Krachler et al., 2008; Imamura et al., 2014)

25. Resoleomics - the process of inflammation resolutionInflammatoryresponse
Initiation Resolution Termination
PGE2
LTB4
Eicosanoid switch Stop signal
Time
Pro-inflammatory reduced
Anti-inflammatory increased
Source: Bosma-den Boer et al., 2012

26. .
Omega-3 and insulin sensitivity
Low omega-3 is common in insulin resistant individuals
Omega-3 index is a useful biomarker of cardiovascular health
Higher omega-3 index is associated with increased insulin sensitivity, lower
omega-6 to omega-3 ratio and lower CRP levels (in middle-aged overweight
men) (Albert et al., 2014)
Dietary intervention with omega-3 fatty acids (as both fish and fish oil)
increases the omega-3 index and improves insulin sensitivity and decreases
CRP and IL-6 (Tsitouras et al., 2008)

27. High AA to EPA ratio is associated with insulin resistance
Significant correlation between AA to EPA ratio and insulin resistance observed in
subjects with metabolic syndrome (Yanagisawa et al., 2010)
High AA to EPA ratio, a direct biomarker of inflammatory status, is associated with insulin
resistance, with visceral fat accumulation correlating significantly with serum AA to EPA
ratio
Subjects with visceral fat accumulation ≥100 cm2
had higher serum AA to EPA ratio (but
not DHA to AA or [EPA+DHA] to AA) and more likely to have metabolic syndrome and
history of CAD, compared to those with visceral fat accumulation <100 cm2
(Inoue et al.,
2013)
“The balance of AA to EPA by lifestyle modification and medication (such as EPA-based
medications) could be useful in reducing the prevalence of the metabolic syndrome and
atherosclerosis” (Inoue et al., 2013)

28. Omega-3 intake and diabetes
Cohort study, involving around 2000 men aged 42 to 60 years from the Kuopio Ischaemic
Heart Disease Risk Factor Study (KIHD), free of diabetes at baseline in 1984–1989
Serum omega-3 PUFA, dietary intake (4-day food diary) and hair mercury levels used as
biomarkers for exposure
Incidence of type II diabetes was assessed by self-administered questionnaires and
glucose tolerance tests (at 4, 11, and 20 years from baseline) and by record linkage to
hospital-discharge registry and the reimbursement register on diabetes medication
expenses
After an average follow-up of 19.3 years, 422 men (19.2%) had developed diabetes, and
those in the highest quartile of serum long-chain omega-3 PUFA concentrations (>5.33%
total serum fatty acids) had a 33% lower risk for incident type II diabetes compared
with men in the lowest quartile (P for trend = .01)
Virtanen et al., 2014

29. There is increasing evidence suggesting that dietary omega-3 may improve
insulin sensitivity or reduce the incidence of type II diabetes
Epidemiological studies have linked both higher dietary and plasma omega-3
PUFA concentrations with lower risk of diabetes
(Villegas et al., 2011; Djoussé et al., 2011; Virtanen et al., 2014)
Fish consumption is associated with lower inflammatory markers levels, among
healthy adults (compared to non-fish consumers, those who consumed >300 g
of fish per week had on average 33% lower CRP, 33% lower IL-6, 21% lower
TNF-α)
(Zampelas et al., 2005)

30. Fish consumption and the metabolic syndrome
Cross-sectional study conducted on 420 Iranian female adults with
usual fish consumption was assessed using a dish-based semi quantitative food frequency
questionnaire (FFQ)
The prevalence of metabolic syndrome was 8.2%
Mean daily intake of fish was 14.4 g per day, individuals in the highest tertile of fish intake
were 65% less likely to have metabolic syndrome than those in the lowest tertile (odds
ratio: 0.35; 95% confidence interval (CI): 0.14-0.88)
After adjustment for potential cofounders, high fish intake was inversely associated with
hypertriglyceridaemia (odds ratio: 0.11; 95% CI: 0.01-0.85), low high-density lipoprotein
cholesterol (odds ratio: 0.57; 95% CI: 0.19-0.89) and elevated blood pressure (odds ratio:
0.23; 95% CI: 0.14-0.89)
Zaribaf et al., 2014

31. Obesity, insulin resistance and the metabolic syndrome
Levels of saturated fatty acids are significantly higher and EPA levels
significantly lower in obese subjects both with and without insulin
resistance compared to controls (p<0.001 for both) (Gunes et al., 2014)
Subjects with metabolic syndrome have been shown to possess tissue
and plasma fatty acid profiles characterised by a relative predominance
of saturated fatty acids and omega-6 polyunsaturated fatty acids, with
corresponding low levels of long-chain omega-3 polyunsaturated fatty
acids
This fatty acid pattern appears to confer a higher risk of both
diabetes and coronary heart disease (CHD) events

32. .
30 patients with coronary artery diseases – six month study
Control group (n=15, conventional therapy)
EPA group (n=15, conventional therapy plus purified EPA 1800 mg/day)
Compared to control group, treatment with EPA:
Significantly reduced the AA to EPA ratio
Significantly reduced both epicardial adipose tissue and
abdominal visceral adipose tissue volumes
Non-significantly reduced abdominal subcutaneous adipose tissue volumes
Significantly reduced CRP levels
Significantly reduced TG
Effects of eicosapentaenoic acid treatment on epicardial and
abdominal visceral adipose tissue volumes in patients with coronary
artery disease
(Sato et al., 2014)

33. Omega-3 Fatty Acids Reduce Adipose Tissue Macrophages in Human Subjects With Insulin
Resistance
Non-diabetic subjects with the metabolic syndrome and insulin resistance were randomised
to either fish oil (4 g/day) or placebo for 12 weeks
Although there were no changes in insulin sensitivity, adipose tissue macrophages were
decreased and adipose capillaries increased in the fish oil-treated subjects (as determined
by adipose biopsy), along with a decrease in adipose and plasma MCP-1
In addition, omega-3 fatty acids suppressed the up-regulation of adipocyte MCP-1 that
occurred when adipocytes were co-cultured with macrophages
MCP-1 contributes to macrophage infiltration into adipose tissue and to insulin resistance
in obesity
Blocking or reducing MCP-1 activity is a potential therapeutic target for reducing the risk of
developing insulin resistance
Spencer et al., 2013

34. .
In vitro and animal studies show us that:
Omega-3 fatty acids
induce a shift for M1 pro-inflammatory macrophage state to a more
favourable M2 state
inhibit a number of signalling pathways that suppress adipose tissue
inflammation
reduce levels of a number of pro-inflammatory products (CRP, TNF-
α, MCP-1, IL-6 etc)
activate PPAR-γ thereby decreasing the expression of molecules (such as
TNF-α) that cause insulin resistance
inhibit adipocyte differentiation
increase anti-inflammatory adiponectin secretion
restore insulin sensitivity
(Sato et al., 2014)

35. Biomarkers for personalising omega-3 fatty acid dosing
Omega-3 index
an early cardiovascular risk indicator
Omega-6 to omega-3 ratio
an established marker of long-term health and chronic illness
AA to EPA ratio
a measure of ’silent’ or chronic inflammation
A personalised plan aims to achieve:
An omega-3 index of more than 8%
An omega-6 to omega-3 ratio of between 3 and 4
An AA to EPA ratio of between 1.5 and 3

36. Base line 4 months ∆ change Outcome
Omega-3 index 3.50 5.98 2.48 Undesirable to desirable
AA to EPA ratio 8.52 3.54 4.98 Suboptimal to acceptable
Case study – subject X
Improvement in both AA to EPA ratio and omega-3 index after 4 months
supplementation with 1.5g EPA (Pharmepa RESTORE)

37. .
Using the Opti-0-3 in practice
 Identify those at risk
Management tool for those suspected to be at risk of developing, or known
to have metabolic syndrome/insulin resistance
 Management tool for those co morbidities related to insulin resistance

38. .
Flock et al., 2014
RBC membrane content of AA versus circulating TNF-α and
IL-6 concentrations in healthy adults

39. Managing the AA to EPA ratio/omega-3 index via EPA supplementation
Individuals with high AA to EPA ratio and low omega-3 index are at a higher risk of
developing insulin resistance and therefore co-morbidities associated with insulin
resistance
 Levels of pro-inflammatory products in obese subjects, directly correlate with
the degree of glucose intolerance and insulin resistance
 Treating with omega-3 improves pro-inflammatory profile patterns in both
healthy and insulin resistant individuals
Treating with omega-3 also lowers elevated cholesterol, lipids and blood
pressure which are factors related to insulin resistance
 Treatment is important, but intervention as prevention is important for long-
term health
 Useful addition to weight loss regimes

40. ninab@igennus.com
www.igennus.com
0044 1223 421434

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