Ectopic fat accumulation in the pancreas and its biomarkers: A systematic review and meta-analysis

Prevalence, clinical characteristics, and outcomes of fatty pancreas disease: an updated systematic review and meta-analysis

Fatty pancreas disease (FPD) is a condition characterized by diffuse excessive intrapancreatic fat deposition with relevant metabolic implications but often overlooked by healthcare professionals. Our study aims to provide a comprehensive overview of the prevalence, clinical characteristics, and outcomes of FPD. PubMed and Embase databases were searched from inception to 10 April 2024. Pairwise meta-analysis was performed using the DerSimonian-Laird method. Meta-analysis of proportions was conducted using the inverse-variance method with logit transformation. Between-study heterogeneity was examined, with subsequent subgroup and meta-regression analyses, and publication bias was assessed. Eighteen studies with 111 682 individuals were included in this meta-analysis. The overall prevalence of FPD was 21.11% [95% confidence interval (CI): 11.04-36.58]. Diagnostic method influenced FPD prevalence ( P  < 0.01), with pooled prevalences of 17.53% (95% CI: 16.20-18.95), 30.05% (95% CI: 24.14-36.70), and 21.23% (95% CI: 8.52-43.88) for MRI, computed tomography, and transabdominal ultrasound, respectively. Patients with FPD were more likely to be older, have higher BMI, male, and have metabolic dysfunction. They also had an increased risk of metabolic syndrome, endocrine-related outcomes (i.e. diabetes and glycemic progression), and exocrine-related outcomes (i.e. acute pancreatitis and pancreatic cancer) compared with those without FPD. This study summarizes the epidemiology of FPD and highlights its clinical and prognostic significance. Increased multidisciplinary collaboration is needed to improve understanding of the disease and raise awareness among healthcare professionals. This study was a priori registered in International Prospective Register of Systematic Reviews (PROSPERO) (CRD42024514116).

Gender-specific correlations between serum lipid profiles and intra-pancreatic fat deposition: a cross-sectional study

BACKGROUND

Intra-pancreatic fat deposition (IPFD) is linked to metabolic and pancreatic diseases. MRI, while precise, is not cost-effective for routine IPFD screening, highlighting the need for accessible biomarkers. This study aims to analyze the relationships among serum lipid profiles, lipoprotein ratios, and IPFD, with a focus on sex differences.

METHODS

Data from adults at the Affiliated Hospital of Guizhou Medical University between 2018 and 2019 were analyzed. The subjects underwent routine Siemens 64-slice spiral CT scans, and IPFD was quantified via a quantitative computed tomography post-processing station. Lipid panel components were analyzed in the fasted state. Linear regression models stratified by gender were applied to evaluate these associations.

RESULTS

The study included 1,046 participants after exclusions, with significant sex differences found in the correlations between serum lipids, lipoprotein ratios, and IPFD. In females, remnant cholesterol was strongly associated with total IPFD (R2 = 0.155, P < 0.001), and similarly strong correlations existed with fat deposition in the pancreatic head (R2 = 0.124, P = 0.003), body (R2 = 0.102, P = 0.001), and tail (R2 = 0.146, P = 0.005). Total cholesterol was also positively correlated with IPFD in females, particularly with the total IPFD (R2 = 0.145, P = 0.002) and IPFD in the pancreatic head (R2 = 0.177, P = 0.003) and body (R2 = 0.100, P = 0.001). In males, triglycerides were notably correlated with IPFD in the tail (R2 = 0.200, P = 0.045), but not in other regions. Similarly, total cholesterol was correlated with IPFD in the tail (R2 = 0.197, P = 0.041). Additionally, in males, the triglyceride/high-density lipoprotein cholesterol ratio showed a positive association with tail fat deposition (R2 = 0.200, P = 0.033).

CONCLUSION

Significant differences between genders were evident in the correlations of serum lipids and lipoprotein ratios with IPFD. In women, remnant cholesterol was strongly correlated with IPFD, suggesting its potential as a biomarker.

Relationship of high-density lipoprotein subfractions and apolipoprotein A-I with fat in the pancreas

AIM

To investigate the associations of high-density lipoprotein (HDL) subfractions and apolipoprotein A-I (apo A-I) with fat in the pancreas.

METHODS

A total of 170 individuals were studied. All participants underwent magnetic resonance imaging on a single 3.0-Tesla scanner to determine the presence/absence of fatty pancreas. HDL subfractions were measured using a commercially available lipoprotein subfractions testing system and classed as large, intermediate and small HDL. Both unadjusted and adjusted (accounting for demographics, anthropometrics, insulin resistance and other covariates) logistic regression models were built.

RESULTS

Individuals with fatty pancreas had significantly lower circulating levels of the large HDL class and apo A-I. Every unit decrease in the large HDL class was associated with a 93% increase in the likelihood of fatty pancreas in the most adjusted model (P < .001). Every unit decrease in apo A-I was associated with a 45% increase in the likelihood of fatty pancreas in the most adjusted model (P = .012). The intermediate and small HDL classes were not significantly associated with fatty pancreas.

CONCLUSIONS

Fat in the pancreas is inversely associated with the circulating levels of large HDL particles and apo A-I. Purposely designed studies are warranted to investigate the potential of fatty pancreas as an indicator of the risk of cardiovascular diseases.

The Causal Role of Ectopic Fat Deposition in the Pathogenesis of Metabolic Syndrome

Consuming a "modern" Western diet and overnutrition may increase insulin secretion. Additionally, nutrition-mediated hyperinsulinemia is a major driver of ectopic fat deposition. The global prevalence of metabolic syndrome is high and growing. Within this context, people with congenital lipodystrophy often experience a severe form of metabolic syndrome. Evidence is increasingly supporting that subtle partial lipodystrophy plays an important role in the development of metabolic syndrome in the general population. In individuals in the general population with subtle partial lipodystrophy, as well as in those with congenital lipodystrophy, the subcutaneous adipose tissues are unable to accommodate surplus energy intake. In both conditions, (excess) fat is directed toward the liver, pancreas, and muscles, where it is deposited as ectopic fat, as this fat can no longer be stored in the "safe" subcutaneous fat depots. Ectopic fat depositions cause insulin resistance in the liver and muscles, as well as β-cell dysfunction in the pancreas. Support of a direct pathological role of ectopic fat deposition in this condition is further provided by the rapid normalization of hepatic insulin sensitivity and improvement in pancreatic β-cell function after marked reductions in ectopic fat depositions. Thus, ectopic fat deposition in the liver, pancreas, and muscles may play a causal role in the pathogenesis of metabolic syndrome even in the general population. As such, the prevention of ectopic fat deposition may reduce the risk of metabolic syndrome and mitigate its effects.

Association of HOMA-IR Versus TyG Index with Diabetes in Individuals Without Underweight or Obesity

Background: There are higher numbers of Asian individuals with metabolically obese, normal weight (MONW) who are susceptible to diabetes than other ethnic groups. The homeostatic model assessment for insulin resistance (HOMA-IR) has been used for years to evaluate IR; however, the triglyceride-glucose (TyG) index has been highlighted as a reliable and cost-effective insulin resistance indicator. Thus, this study explored the association of the HOMA-IR versus the TyG index with diabetes in individuals without underweight or obesity. Methods: This cross-sectional study included 10,471 Korean individuals whose body mass index was ≥18.5 and <25.0 kg/m2. Depending on metabolic syndrome criteria, subjects with no conditions, one or two conditions, and three or more conditions were assigned to the metabolically healthy and normal weight (MHNW), pre-MONW, and MONW groups, respectively. Diabetes was diagnosed based on HbA1C and medication information. Results: The HOMA-IR and TyG index discriminated between each group, showing an increasing trend from the MHNW group to the MONW group. However, this trend was more robust for the TyG index. The cut-off values in the TyG index and HOMA-IR were >8.9 and >1.6 in males and >8.7 and >1.6 in females, respectively. The TyG index's area under the curve was higher than that of the HOMA-IR in both sexes. MONWs distinguished by the cut-off values of the TyG index and HOMA-IR were 2.370 and 1.726 for males and 2.249 and 1.710 for females times more likely to develop diabetes. Conclusions: The TyG index showed a stronger association with diabetes in Korean individuals without underweight or obesity than the HOMA-IR.

The gut-pancreas axis: investigating the relationship between microbiota metabolites and pancreatic steatosis

The prevalence of pancreatic steatosis has increased and it has been linked to the rising prevalence of metabolic syndrome. Metabolic syndrome is known to have a strong connection with changes in intestinal microbiota. The aim of this study was to explore the relationship between pancreatic steatosis and the levels of trimethylamine N-oxide (TMAO) and butyrate. In this study, 136 individuals were randomly selected from outpatient clinics at Firat University Hospital. The study evaluated their demographic characteristics, anthropometric measurements, and biochemical parameters. The presence of pancreatic steatosis was assessed using abdominal ultrasonography. Additionally, the levels of TMAO and butyrate were measured. The mean age of individuals in the study was 44.5 ± 14.6. 84 of the subjects were females. Using the waist circumference, 61 were considered obese and 34 overweight. The detection rate of pancreatic steatosis was found to be 70.6%. The study found that individuals with steatosis had higher average age, presence of hepatic steatosis, BMI, waist circumference measurements, and presence of metabolic syndrome than those without steatosis. A significantly higher butyrate level was detected in those without steatosis (p = 0.001). TMAO levels were slightly higher in patients without steatosis than in those with steatosis; however, this was insignificant. Pancreatic steatosis is highly associated with alterations in levels of microbiota metabolites, indicating a potential role of these metabolites in the pathogenesis of the disease and subsequent therapeutic targets. Several other factors, such as age, hepatic steatosis, diabetes, and waist circumference, have also been identified as potential predictors of pancreatic steatosis.

Effect of uric acid on lipid metabolism assessed via restricted cubic splines: A new insight

Background

Hyperuricemia can promote both blood lipids and non-alcoholic fatty liver disease (NAFLD). However, the role of the entire uric acid (UA) span, especially low concentrations below hyperuricemia, on lipid metabolism remains unclear.

Methods

A cross-sectional study was designed. Data on the age, sex, UA, triglyceride (TG), total cholesterol (TC), high-density lipoprotein (HDL), and low-density lipoprotein (LDL) of 1977 participants, who underwent physical examination, were collected. NAFLD and non-alcoholic fatty pancreas disease (NAFPD) were diagnosed using abdominal ultrasound. Restricted cubic splines (RCS) linear regression model was used to evaluate the effect of the UA span on TG, TC, HDL, and LDL, respectively. RCS logistic regression model was employed to evaluate the effect of the UA span on NAFLD and NAFPD.

Results

RCS linear regression model showed that TG was negatively correlated with UA at first, then exhibiting a positive correlation. Meanwhile, HDL was positively correlated with UA at first, then negatively correlated. There was a positive linear correlation between TC and UA (P for nonlinear = 0.578) and a positive nonlinear correlation between LDL and UA (P for nonlinear = 0.021). RCS logistic regression model showed that NAFLD and NAFPD were negatively correlated with UA at first and then positively correlated with UA.

Conclusion

our study showed that the entire UA span has a J-shaped effect on some lipids, NAFLD, and NAFPD. Besides, TG and HDL, compared with TC or LDL, may better reflect the status of NAFLD and NAFPD.

Metabolic score for insulin resistance (METS-IR) predicts all-cause and cardiovascular mortality in the general population: evidence from NHANES 2001-2018

BACKGROUND

The prevalence of obesity-associated insulin resistance (IR) is increasing along with the increase in obesity rates. In this study, we compared the predictive utility of four alternative indexes of IR [triglyceride glucose index (TyG index), metabolic score for insulin resistance (METS-IR), the triglyceride/high-density lipoprotein cholesterol (TG/HDL-C) ratio and homeostatic model assessment of insulin resistance (HOMA-IR)] for all-cause mortality and cardiovascular mortality in the general population based on key variables screened by the Boruta algorithm. The aim was to find the best replacement index of IR.

METHODS

In this study, 14,653 participants were screened from the National Health and Nutrition Examination Survey (2001-2018). And TyG index, METS-IR, TG/HDL-C and HOMA-IR were calculated separately for each participant according to the given formula. The predictive values of IR replacement indexes for all-cause mortality and cardiovascular mortality in the general population were assessed.

RESULTS

Over a median follow-up period of 116 months, a total of 2085 (10.23%) all-cause deaths and 549 (2.61%) cardiovascular disease (CVD) related deaths were recorded. Multivariate Cox regression and restricted cubic splines analysis showed that among the four indexes, only METS-IR was significantly associated with both all-cause and CVD mortality, and both showed non-linear associations with an approximate "U-shape". Specifically, baseline METS-IR lower than the inflection point (41.33) was negatively associated with mortality [hazard ratio (HR) 0.972, 95% CI 0.950-0.997 for all-cause mortality]. In contrast, baseline METS-IR higher than the inflection point (41.33) was positively associated with mortality (HR 1.019, 95% CI 1.011-1.026 for all-cause mortality and HR 1.028, 95% CI 1.014-1.043 for CVD mortality). We further stratified the METS-IR and showed that significant associations between METS-IR levels and all-cause and cardiovascular mortality were predominantly present in the nonelderly population aged < 65 years.

CONCLUSIONS

In conjunction with the results of the Boruta algorithm, METS-IR demonstrated a more significant association with all-cause and cardiovascular mortality in the U.S. population compared to the other three alternative IR indexes (TyG index, TG/HDL-C and HOMA-IR), particularly evident in individuals under 65 years old.

Diverse associations between pancreatic intra-, inter-lobular fat and the development of type 2 diabetes in overweight or obese patients

Pancreatic fat is associated with obesity and type 2 diabetes mellitus (T2DM); however, the relationship between different types of pancreatic fat and diabetes status remains unclear. Therefore, we aimed to determine the potential of different types of pancreatic fat accumulation as a risk factor for T2DM in overweight or obese patients. In total, 104 overweight or obese patients were recruited from January 2020 to December 2022. The patients were divided into three groups: normal glucose tolerance (NGT), impaired fasting glucose or glucose tolerance (IFG/IGT), and T2DM. mDixon magnetic resonance imaging (MRI) was used to detect pancreatic fat in all three groups of patients. The pancreatic head fat (PHF), body fat (PBF), and tail fat (PTF) in the IFG/IGT group were 21, 20, and 31% more than those in the NGT group, respectively. PHF, PBF, and PTF were positively associated with glucose metabolic dysfunction markers in the NGT group, and inter-lobular fat volume (IFV) was positively associated with these markers in the IFG/IGT group. The areas under the receiver operating characteristic curves for PHF, PBF, and PTF (used to evaluate their diagnostic potential for glucose metabolic dysfunction) were 0.73, 0.73, and 0.78, respectively, while those for total pancreatic volume (TPV), pancreatic parenchymal volume, IFV, and IFV/TPV were 0.67, 0.67, 0.66, and 0.66, respectively. These results indicate that intra-lobular pancreatic fat, including PHF, PTF, and PBF, may be a potential independent risk factor for the development of T2DM. Additionally, IFV exacerbates glucose metabolic dysfunction. Intra-lobular pancreatic fat indices were better than IFV for the diagnosis of glucose metabolic dysfunction.

Glycaemic Response to a Nut-Enriched Diet in Asian Chinese Adults with Normal or High Glycaemia: The Tū Ora RCT

Nut-based products are a good source of high-quality plant protein in addition to mono- and polyunsaturated fatty acids, and may aid low-glycaemic dietary strategies important for the prevention of type 2 diabetes (T2D). In particular, they may be advantageous in populations susceptible to dysglycaemia, such as Asian Chinese. The present study aimed to compare effects of a higher-protein nut bar (HP-NB, also higher in total fibre and unsaturated fats, comprising mixed almonds and peanuts) vs. an isoenergetic higher-carbohydrate cereal bar (HC-CB) within the diet of 101 Chinese adults with overweight and normo- or hyperglycaemia. Ectopic pancreas and liver fat were characterised using magnetic resonance imaging and spectroscopy (MRI/S) as a secondary outcome. Participants were randomized to receive HP-NB or HC-CB daily as a 1 MJ light meal or snack replacement, in addition to healthy eating advice. Anthropometry and clinical indicators of T2D risk were assessed fasted and during an oral glucose tolerance test (OGTT), pre- and post-intervention. No significant difference was observed between diet groups for body weight, body mass index, waist or hip circumference, blood pressure, glucoregulatory markers, lipid profile or inflammatory markers over 12 weeks (all, p > 0.05). No difference was observed between glycaemic subgroups or those with normal versus high ectopic organ fat. Although HP-NB can attenuate postprandial glycaemia following a meal, no effects were observed for either fasting or glucose-mediated outcomes following longer-term inclusion in the habitual diet of Chinese adults with overweight, including at-risk subgroups.

Metabolic Score for Insulin Resistance and New-Onset Type 2 Diabetes in a Middle-Aged and Older Adult Population: Nationwide Prospective Cohort Study and Implications for Primary Care

BACKGROUND

The metabolic score for insulin resistance (METS-IR) has emerged as a noninsulin-based index for the approximation of insulin resistance (IR), yet longitudinal evidence supporting the utility of METS-IR in the primary prevention of type 2 diabetes mellitus (T2DM) remains limited.

OBJECTIVE

We aimed to investigate the longitudinal association between METS-IR, which combines fasting plasma glucose (FPG), lipid profiles, and anthropometrics that can be routinely obtained in resource-limited primary care settings, and the incidence of new-onset T2DM.

METHODS

We conducted a closed-cohort analysis of a nationwide, prospective cohort of 7583 Chinese middle-aged and older adults who were free of T2DM at baseline, sampled from 28 out of 31 provinces in China. We examined the characteristics of participants stratified by elevated blood pressure (BP) at baseline and new-onset T2DM at follow-up. We performed Cox proportional hazard regression analysis to explore associations of baseline METS-IR with incident T2DM in participants overall and in participants stratified by baseline BP. We also applied net reclassification improvement and integrated discrimination improvement to examine the incremental value of METS-IR.

RESULTS

During a mean follow-up period of 6.3 years, T2DM occurred in 527 participants, among which two-thirds (332/527, 62.9%; 95% CI 58.7%-67.1%) had baseline FPG<110 mg/dL. A SD unit increase in baseline METS-IR was associated with the first incidence of T2DM (adjusted hazard ratio [aHR] 1.33, 95% CI 1.22-1.45; P<.001) in all participants. We obtained similar results in participants with normal baseline BP (aHR 1.41, 95% CI 1.22-1.62; P<.001) and elevated baseline BP (aHR 1.29, 95% CI 1.16-1.44; P<.001). The predictive capability for incident T2DM was improved by adding METS-IR to FPG. In study participants with new-onset T2DM whose baseline FPG was <126 mg/dL and <110 mg/dL, 62.9% (332/527; 95% CI 60%-65.9%) and 58.1% (193/332; 95% CI 54.3%-61.9%) of participants had baseline METS-IR above the cutoff values, respectively.

CONCLUSIONS

METS-IR was significantly associated with new-onset T2DM, regardless of baseline BP level. Regular monitoring of METS-IR on top of routine blood glucose in clinical practice may add to the ability to enhance the early identification of primary care populations at risk for T2DM.

Relationship of Liver Blood Tests and T1 Relaxation Time With Intra-pancreatic Fat Deposition

Background

Liver is well recognised as a metabolically active organ. While intra-pancreatic fat deposition (IPFD) is emerging as an important player in the whole-body metabolism, the interplay between the liver and IPFD has been poorly investigated. This study aimed to investigate the associations of liver blood tests and non-invasive tests for hepatic fibrosis with IPFD.

Methods

Participants underwent a 3.0 Tesla magnetic resonance imaging to measure IPFD and map liver T1 (longitudinal relaxation time). Four liver tests were done on the same sample of blood. Hepatic fibrosis risk score (BARD) was calculated. Linear regression models were built, accounting for age, sex, visceral-to-subcutaneous fat ratio, and other covariates.

Results

A total of 143 individuals were studied. In the most adjusted model, alkaline phosphatase (P < 0.001), alanine aminotransferase (P < 0.001), and γ-glutamyl transferase (P = 0.042) were significantly positively associated with IPFD. The BARD score was not significantly associated with IPFD in the most adjusted model (P = 0.295). T1 relaxation time of the liver was not significantly associated with IPFD in the most adjusted model (P = 0.782).

Conclusions

Elevated alkaline phosphatase, alanine aminotransferase, and γ-glutamyl transferase are associated with increased IPFD. Hepatic fibrosis does not appear to be associated with IPFD.

Predictive value of anthropometric and biochemical indices in non-alcoholic fatty pancreas disease: a cross-sectional study

OBJECTIVES

Triglyceride (TG), triglyceride-glucose index (TyG), body mass index (BMI), TyG-BMI and triglyceride to high-density lipoprotein ratio (TG/HDL) have been reported to be reliable predictors of non-alcoholic fatty liver disease. However, there are few studies on potential predictors of non-alcoholic fatty pancreas disease (NAFPD). Our aim was to evaluate these and other parameters for predicting NAFPD.

DESIGN

Cross-sectional study design.

SETTING

Physical examination centre of a tertiary hospital in China.

PARTICIPANTS

This study involved 1774 subjects who underwent physical examinations from January 2016 to September 2016.

PRIMARY AND SECONDARY OUTCOME MEASURES

From each subject, data were collected for 13 basic physical examination and blood biochemical parameters: age, weight, height, BMI, TyG, TyG-BMI, high-density lipoprotein (HDL), low-density lipoprotein, total cholesterol, TG, fasting plasma glucose, TG/HDL and uric acid. NAFPD was diagnosed by abdominal ultrasonography. A logistic regression model with a restricted cubic spline was used to evaluate the relationship between each parameter and NAFPD. The receiver operating characteristic (ROC) curve was used to calculate the area under the curve for each parameter.

RESULTS

HDL was negatively correlated with NAFPD, height was almost uncorrelated with NAFPD and the remaining 11 parameters were positively correlated with NAFPD. ROC curve showed that weight-related parameters (weight, BMI and TyG-BMI) and TG-related parameters (TyG, TG and TG/HDL) had high predictive values for the identification of NAFPD. The combinations of multiple parameters had a better prediction effect than a single parameter. All the predictive effects did not differ by sex.

CONCLUSIONS

Weight-related and TG-related parameters are good predictors of NAFPD in all populations. BMI showed the greatest predictive potential. Multiparameter combinations appear to be a good way to predict NAFPD.

Automated pancreatic segmentation and fat fraction evaluation based on a self-supervised transfer learning network

Accurate segmentation of the pancreas from abdominal computed tomography (CT) images is challenging but essential for the diagnosis and treatment of pancreatic disorders such as tumours and diabetes. In this study, a dataset with 229 sets of high-resolution CT images was generated and annotated. We proposed a novel 3D segmentation model named nnTransfer (nonisomorphic transfer learning) net, which employs generative model structure for self-supervision to facilitate the network's learning of image attributes from unlabelled data. The effectiveness for pancreas segmentation of nnTransfer was assessed using the Hausdorff distance (HD) and Dice similarity coefficient (DSC) on the dataset. Additionally, a histogram analysis with local thresholding was used to achieve automated whole-volume measurement of pancreatic fat (fat volume fraction, FVF). The proposed technique performed admirably on the dataset, with DSC: 0.937 ± 0.019 and HD: 2.655 ± 1.479. The mean pancreas volume and FVF of the pancreas were 91.95 ± 23.90 cm3 and 12.67 % ± 9.84 %, respectively. The nnTransfer functioned flawlessly and autonomously, facilitating the use of the FVF to evaluate pancreatic disease, particularly in patients with diabetes.

Remnant cholesterol, but not low-density lipoprotein cholesterol, is associated with intra-pancreatic fat deposition

AIM

To investigate the associations of components of the lipid panel (and its derivatives) with intra-pancreatic fat deposition (IPFD).

METHODS

All participants underwent abdominal magnetic resonance imaging on the same 3.0-Tesla scanner and IPFD was quantified. Blood samples were collected in the fasted state for analysis of lipid panel components. A series of linear regression analyses was conducted, adjusting for age, sex, ethnicity, body mass index, fasting plasma glucose, homeostatic model assessment of insulin resistance, and liver fat deposition.

RESULTS

A total of 348 participants were included. Remnant cholesterol (P = 0.010) and triglyceride levels (P = 0.008) were positively, and high-density lipoprotein cholesterol level (P = 0.001) was negatively, associated with total IPFD in the most adjusted model. Low-density lipoprotein cholesterol and total cholesterol were not significantly associated with total IPFD. Of the lipid panel components investigated, remnant cholesterol explained the greatest proportion (9.9%) of the variance in total IPFD.

CONCLUSION

Components of the lipid panel have different associations with IPFD. This may open up new opportunities for improving outcomes in people at high risk for cardiovascular diseases (who have normal low-density lipoprotein cholesterol) by reducing IPFD.

Fatty infiltration of the pancreas: a systematic concept analysis

Fatty infiltration of the pancreas (FIP) has been recognized for nearly a century, yet many aspects of this condition remain unclear. Regular literature reviews on the diagnosis, consequences, and management of FIP are crucial. This review article highlights the various disorders for which FIP has been established as a risk factor, including type 2 diabetes mellitus (T2DM), pancreatitis, pancreatic fistula (PF), metabolic syndrome (MS), polycystic ovary syndrome (PCOS), and pancreatic duct adenocarcinoma (PDAC), as well as the new investigation tools. Given the interdisciplinary nature of FIP research, a broad range of healthcare specialists are involved. This review article covers key aspects of FIP, including nomenclature and definition of pancreatic fat infiltration, history and epidemiology, etiology and pathophysiology, clinical presentation and diagnosis, clinical consequences, and treatment. This review is presented in a detailed narrative format for accessibility to clinicians and medical students.

Circulatory miRNAs as Correlates of Elevated Intra-Pancreatic Fat Deposition in a Mixed Ethnic Female Cohort: The TOFI_Asia Study

Ectopic lipid accumulation, including intra-pancreatic fat deposition (IPFD), exacerbates type 2 diabetes risk in susceptible individuals. Dysregulated circulating microRNAs (miRNAs) have been identified as correlating with clinical measures of pancreatitis, pancreatic cancer and type 1 diabetes. The aim of the current study was therefore to examine the association between circulating abundances of candidate miRNAs, IPFD and liver fat deposition as quantified using magnetic resonance imaging (MRI) and spectroscopy (MRS). Asian Chinese (n = 34; BMI = 26.7 ± 4.2 kg/m2) and European Caucasian (n = 34; BMI = 28.0 ± 4.5 kg/m2) females from the TOFI_Asia cohort underwent MRI and MRS analysis of pancreas (MR-%IPFD) and liver fat (MR-%liver fat), respectively, to quantify ectopic lipid deposition. Plasma miRNA abundances of a subset of circulatory miRNAs associated with IPFD and liver fat deposition were quantified by qRT-PCR. miR-21-3p and miR-320a-5p correlated with MR-%IPFD, plasma insulin and HOMA2-IR, but not MR-%liver fat. MR-%IPFD remained associated with decreasing miR-21-3p abundance following multivariate regression analysis. miR-21-3p and miR-320a were demonstrated to be negatively correlated with MR-%IPFD, independent of ethnicity. For miR-21-3p, this relationship persists with the inclusion of MR-%liver fat in the model, suggesting the potential for a wider application as a specific circulatory correlate of IPFD.

Relationship of Serum Bile Acids with Fat Deposition in the Pancreas, Liver, and Skeletal Muscle

Introduction

Ectopic fat deposition is well appreciated as a key contributor to digestive and liver diseases. Bile acids have emerged as pleiotropic signalling molecules involved in numerous metabolic pathways. The aim was to study the associations of bile acids with ectopic fat deposition and lipid panel.

Methods

A single 3.0 Tesla magnetic resonance imaging scanner was employed to measure fat deposition in the pancreas, liver, and skeletal muscle in 76 adults. Blood samples were drawn to determine total bile acids and lipid panel. Linear regression analyses were run, taking into account age, sex, body mass index, and other covariates.

Results

The studied ectopic fat depots were not significantly associated with levels of total bile acids in serum. Total bile acids were significantly associated high-density lipoprotein cholesterol - consistently in both the unadjusted (p = 0.018) and all adjusted models (p = 0.012 in the most adjusted model). Low-density lipoprotein cholesterol, total cholesterol, and triglycerides were not significantly associated with total bile acids in both the unadjusted and all adjusted models.

Conclusion

Fat deposition in the pancreas, liver, and skeletal muscle is not associated with circulating levels of total bile acids. High-density lipoprotein cholesterol is the only component of lipid panel that is associated with total bile acids.

Intra-pancreatic fat deposition across the pancreatitis spectrum and the influence of gut hormones

BACKGROUND AND AIMS

Acute pancreatitis (AP) and chronic pancreatitis (CP) often represent parts of the spectrum of disease. While growing evidence indicates that intra-pancreatic fat deposition (IPFD) plays an important role in the pathogenesis of pancreatitis, no study of living individuals has investigated IPFD in both AP and CP. Further, the associations between IPFD and gut hormones remain to be elucidated. The aims were to investigate the associations of IPFD with AP, CP, and health; and to study whether gut hormones affect these associations.

METHODS

Magnetic resonance imaging on the same 3.0 Tesla scanner was used to determine IPFD in 201 study participants. These participants were arranged into the health, AP, and CP groups. Gut hormones (ghrelin, glucagon-like peptide-1, gastric inhibitory peptide, peptide YY, and oxyntomodulin) were measured in blood, both after an 8-hour overnight fasting and after ingestion of a standardised mixed meal. A series of linear regression analyses was run, accounting for age, sex, ethnicity, body mass index, glycated haemoglobin, and triglycerides.

RESULTS

Both the AP group and CP group had significantly higher IPFD in comparison with the health group, consistently across all models (p for trend 0.027 in the most adjusted model). Ghrelin in the fasted state had a significant positive association with IPFD in the AP group (but not the CP or health group), consistently across all models (p = 0.019 in the most adjusted model). None of the studied gut hormones in the postprandial state was significantly associated with IPFD.

CONCLUSION

Fat deposition in the pancreas is similarly high in individuals with AP and those with CP. The gut-brain axis, and more specifically overexpression of ghrelin, may contribute to increased IPFD in individuals with AP.

Fatty change of the pancreas: the Pandora's box of pancreatology

Prevention of common diseases of the pancreas or interception of their progression is as attractive in theory as it is elusive in practice. The fundamental challenge has been an incomplete understanding of targets coupled with a multitude of intertwined factors that are associated with the development of pancreatic diseases. Evidence over the past decade has shown unique morphological features, distinctive biomarkers, and complex relationships of intrapancreatic fat deposition. Fatty change of the pancreas has also been shown to affect at least 16% of the global population. This knowledge has solidified the pivotal role of fatty change of the pancreas in acute pancreatitis, chronic pancreatitis, pancreatic cancer, and diabetes. The pancreatic diseases originating from intrapancreatic fat (PANDORA) hypothesis advanced in this Personal View cuts across traditional disciplinary boundaries with a view to tackling these diseases. New holistic understanding of pancreatic diseases is well positioned to propel pancreatology through lasting research breakthroughs and clinical advances.

Lipid droplet biogenesis and functions in health and disease

Ubiquitous yet unique, lipid droplets are intracellular organelles that are increasingly being recognized for their versatility beyond energy storage. Advances uncovering the intricacies of their biogenesis and the diversity of their physiological and pathological roles have yielded new insights into lipid droplet biology. Despite these insights, the mechanisms governing the biogenesis and functions of lipid droplets remain incompletely understood. Moreover, the causal relationship between the biogenesis and function of lipid droplets and human diseases is poorly resolved. Here, we provide an update on the current understanding of the biogenesis and functions of lipid droplets in health and disease, highlighting a key role for lipid droplet biogenesis in alleviating cellular stresses. We also discuss therapeutic strategies of targeting lipid droplet biogenesis, growth or degradation that could be applied in the future to common diseases, such as cancer, hepatic steatosis and viral infection.

A nonlinear associations of metabolic score for insulin resistance index with incident diabetes: A retrospective Chinese cohort study

Background

The Metabolic score of insulin resistance (METS-IR) has recently been accepted as a reliable alternative to insulin resistance (IR), which was demonstrated to be consistent with the hyperinsulinemic-euglycemic clamp. Few pieces of research have focused on the relationship between METS-IR and diabetes in Chinese. The purpose of this research was to explore the effect of METS-IR on new-onset diabetes in a large multicenter Chinese study.

Methods

At the baseline of this retrospective longitudinal research, 116855 participators were included in the Chinese cohort study administered from 2010 to 2016. The subjects were stratified by quartiles of METS-IR. To assess the effect of METS-IR on incident diabetes, the Cox regression model was constructed in this study. Stratification analysis and interaction tests were applied to detect the potential effect of METS-IR and incident diabetes among multiple subgroups. To verify whether there was a dose-response relationship between METS-IR and diabetes, a smooth curve fitting was performed. In addition, to further determine the performance of METS -IR in predicting incident diabetes, the receiver operating characteristic curve (ROC) was conducted.

Results

The average age of the research participators was 44.08 ± 12.93 years, and 62868 (53.8%) were men. METS-IR were significant relationship with new-onset diabetes after adjusting for possible variables (Hazard ratio [HR]: 1.077; 95% confidence interval [CI]: 1.073-1.082, P &lt; 0.0001), the onset risk for diabetes in Quartile 4 group was 6.261-fold higher than those in Quartile 1 group. Moreover, stratified analyses and interaction tests showed that interaction was detected in the subgroup of age, body mass index, systolic blood pressure, diastolic blood pressure, and fasting plasma glucose, there was no significant interaction between males and females. Furthermore, a dose-response correlation was detected between METS-IR and incident diabetes, the nonlinear relationship was revealed and the inflection point of METS-IR was calculated to be 44.43. When METS-IR≥44.43, compared with METS-IR &lt; 44.43, the trend was gradually saturated, with log-likelihood ratio test P &lt; 0.001. Additionally, the area under receiver operating characteristic of the METS-IR in predicting incident diabetes was 0.729, 0.718, and 0.720 at 3, 4, and 5 years, respectively.

Conclusions

METS-IR was correlated with incident diabetes significantly, and showed a nonlinear relationship. This study also found that METS-IR had good discrimination of diabetes.

Association between METS-IR and Prediabetes or Type 2 Diabetes Mellitus among Elderly Subjects in China: A Large-Scale Population-Based Study

The metabolic score for insulin resistance (METS-IR) was recently proposed as a non-insulin-based, novel index for assessing insulin resistance (IR) in the Western population. However, evidence for the link between METS-IR and prediabetes or type 2 diabetes mellitus (T2DM) among the elderly Chinese population was still limited. We aimed to investigate the associations between METS-IR and prediabetes or T2DM based on large-scale, cross-sectional, routine physical examination data. In a total of 18,112 primary care service users, an increased METS-IR was independently associated with a higher prevalence of prediabetes (adjusted odds ratio [aOR] = 1.457, 95% confidence interval [CI]: 1.343 to 1.581, p < 0.001) and T2DM (aOR = 1.804, 95%CI: 1.720 to 1.891, p < 0.001), respectively. The aOR for prediabetes in subjects with the highest quartile of METS-IR was 3.060-fold higher than that in those with the lowest quartile of METS-IR. The aOR for T2DM in subjects with the highest quartile of METS-IR was 6.226-fold higher than that in those with the lowest quartile of METS-IR. Consistent results were obtained in subgroup analyses. Our results suggested that METS-IR was significantly associated with both prediabetes and T2DM. The monitoring of METS-IR may add value to early identification of individuals at risk for glucose metabolism disorders in primary care.

Metabolic traits affecting the relationship between liver fat and intrapancreatic fat: a mediation analysis

AIMS/HYPOTHESIS

The clinical importance of fat deposition in the liver and pancreas is increasingly recognised. However, to what extent deposition of fat in these two depots is affected by intermediate variables is unknown. The aim of this work was to conduct a mediation analysis with a view to uncovering the metabolic traits that underlie the relationship between liver fat and intrapancreatic fat deposition (IPFD) and quantifying their effect.

METHODS

All participants underwent MRI/magnetic resonance spectroscopy on the same 3.0 T scanner to determine liver fat and IPFD. IPFD of all participants was quantified manually by two independent raters in duplicate. A total of 16 metabolic traits (representing markers of glucose metabolism, incretins, lipid panel, liver enzymes, pancreatic hormones and their derivatives) were measured in blood. Mediation analysis was conducted, taking into account age, sex, ethnicity and BMI. Significance of mediation was tested by computing bias-corrected bootstrap CIs with 5000 repetitions.

RESULTS

A total of 353 individuals were studied. Plasma glucose, HDL-cholesterol and triacylglycerol mediated 6.8%, 17.9% and 24.3%, respectively, of the association between liver fat and IPFD. Total cholesterol, LDL-cholesterol, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, γ-glutamyl transpeptidase, insulin, glucagon, amylin, C-peptide, HbA_1c, glucagon-like peptide-1 and gastric inhibitory peptide did not mediate the association between liver fat and IPFD.

CONCLUSIONS/INTERPRETATION

At least one-quarter of the association between liver fat and IPFD is mediated by specific blood biomarkers (triacylglycerol, HDL-cholesterol and glucose), after accounting for potential confounding by age, sex, ethnicity and BMI. This unveils the complexity of the association between the two fat depots and presents specific targets for intervention.

An Adapted Deep Convolutional Neural Network for Automatic Measurement of Pancreatic Fat and Pancreatic Volume in Clinical Multi-Protocol Magnetic Resonance Images: A Retrospective Study with Multi-Ethnic External Validation

Pancreatic volume and fat fraction are critical prognoses for metabolic diseases like type 2 diabetes (T2D). Magnetic Resonance Imaging (MRI) is a required non-invasive quantification method for the pancreatic fat fraction. The dramatic development of deep learning has enabled the automatic measurement of MR images. Therefore, based on MRI, we intend to develop a deep convolutional neural network (DCNN) that can accurately segment and measure pancreatic volume and fat fraction. This retrospective study involved abdominal MR images from 148 diabetic patients and 246 healthy normoglycemic participants. We randomly separated them into training and testing sets according to the proportion of 80:20. There were 2364 recognizable pancreas images labeled and pre-treated by an upgraded superpixel algorithm for a discernible pancreatic boundary. We then applied them to the novel DCNN model, mimicking the most accurate and latest manual pancreatic segmentation process. Fat phantom and erosion algorithms were employed to increase the accuracy. The results were evaluated by dice similarity coefficient (DSC). External validation datasets included 240 MR images from 10 additional patients. We assessed the pancreas and pancreatic fat volume using the DCNN and compared them with those of specialists. This DCNN employed the cutting-edge idea of manual pancreas segmentation and achieved the highest DSC (91.2%) compared with any reported models. It is the first framework to measure intra-pancreatic fat volume and fat deposition. Performance validation reflected by regression R² value between manual operation and trained DCNN segmentation on the pancreas and pancreatic fat volume were 0.9764 and 0.9675, respectively. The performance of the novel DCNN enables accurate pancreas segmentation, pancreatic fat volume, fraction measurement, and calculation. It achieves the same segmentation level of experts. With further training, it may well surpass any expert and provide accurate measurements, which may have significant clinical relevance.

Intrapancreatic, Liver, and Skeletal Muscle Fat Depositions in First Attack of Acute Pancreatitis Versus Health

INTRODUCTION

Increased intrapancreatic fat deposition (IPFD) has emerged as a harbinger of pancreatic cancer and chronic pancreatitis. Although it is well recognized that diseases of the exocrine pancreas often lie on a continuum (with acute pancreatitis preceding the development of chronic pancreatitis and/or pancreatic cancer), whether increased IPFD predisposes to acute pancreatitis is unknown. This study aimed to compare fat depositions in the pancreas (as well as the liver and skeletal muscle) between individuals who developed first attack of acute pancreatitis and healthy individuals.

METHODS

This was a matched case-control study nested into population-based cohort. MRI on a single 3 T scanner was used to quantify intrapancreatic, liver, and skeletal muscle fat depositions using the same protocols in all study participants. Binary logistic regression with adjustment for body mass index and other possible confounders was performed.

RESULTS

Fifty individuals with first attack of nonnecrotizing acute pancreatitis comprised the case group and 100 healthy individuals comprised the control group. A 1% increase in IPFD (but not the other fat depositions) was significantly associated with a more than 30% higher chance of developing first attack of acute pancreatitis, consistently in both the unadjusted ( P = 0.004) and all adjusted models. Furthermore, a 1% increase in IPFD (but not the other fat depositions) was significantly associated with up to a 27% higher chance of developing first attack of acute pancreatitis in individuals with normotriglyceridemia, consistently in both the unadjusted ( P = 0.030) and all adjusted models.

DISCUSSION

Increased IPFD may predispose to the development of acute pancreatitis. This opens up opportunities for reducing the burden of acute pancreatitis by means of primary prevention.

Links between ectopic and abdominal fat and systemic inflammation: New insights from the SHIP-Trend study

BACKGROUND

Excessive fat accumulation in adipose tissue depots and organs such as the pancreas and the liver is associated with systemic low-grade chronic inflammation.

AIMS

To investigate the association between abdominal, hepatic, and pancreatic fat and the circulating level of inflammatory biomarkers.

METHODS

We used data from a subsample of the Study of Health in Pomerania (SHIP-Trend, n = 469). The plasma concentration of 37 inflammatory biomarkers was measured using the Bio-Plex-Pro™-Human-Inflammation-Panel-1. Subcutaneous and visceral adipose tissue (SAT and VAT), as well as hepatic and pancreatic fat, were determined by magnetic resonance imaging. We assessed the associations between fat content and inflammatory biomarkers using multiple linear regression.

RESULTS

Hepatic fat was associated with MMP-2 (β -0.11), PTX3 (β -0.14), and TNFSF12 (β -0.06). Pancreatic fat was associated with sTNFR1 (β 0.15), sTNFR2 (β 0.11), and sCD163 (β 0.13). VAT and SAT were associated with sCD163 (βVAT 0.20, βSAT 0.16), MMP-2 (βVAT -0.12, βSAT -0.10), OSTCN (βVAT -0.16, βSAT -0.10), sTNFR1 (βVAT 0.13, βSAT 0.13), sTNFR2 (βVAT 0.13, βSA 0.12), TNFSF12 (βVAT -0.11, βSAT -0.08), and TNFSF14 (βVAT 0.21, βSAT 0.20). VAT was additionally associated with TNFSF13B (β 0.08) and CHI3L1 (β 0.07).

CONCLUSIONS

Our findings provide new insights into the involvement of hepatic and pancreatic fat on systemic inflammation.

Fat Distribution Within the Pancreas According to Diabetes Status and Insulin Traits

A growing body of evidence suggests that intrapancreatic fat is associated with diabetes, but whether distribution of intrapancreatic fat across the regions of the pancreas has a pathophysiologic role is unknown. The aim of this study was to investigate the differences in intrapancreatic fat deposition between the head, body, and tail of the pancreas, as well as the relationship between regional intrapancreatic fat deposition and diabetes status and insulin traits. A total of 368 adults from the general population underwent MRI on a 3 Tesla scanner, and intrapancreatic fat was manually quantified in duplicate. Statistical models included adjustment for age, sex, ethnicity, BMI, and liver fat. Intrapancreatic fat deposition in the head, body, and tail of the pancreas did not differ significantly in adjusted models in either the overall cohort or the three subgroups based on diabetes status. HOMA of insulin resistance and fasting insulin were significantly positively associated with fat in the tail and body of the pancreas. There was no significant association between regional intrapancreatic fat and HOMA of β-cell function. The association of increased intrapancreatic fat deposition in the tail and body regions with increased insulin resistance may have an important role in the early identification of patients at risk for developing insulin resistance and diseases that stem from it.

Low serum pancreatic amylase levels as a novel latent risk factor for colorectal adenoma in non-alcohol drinkers

BACKGROUND AND AIM

Obesity, insulin resistance, and metabolic alterations increase the risk of colorectal cancer and adenoma (CRA). Non-alcoholic fatty liver disease (NAFLD) or pancreatic disease (NAFPD) shares many risk factors with CRA that may have significant roles in its development; however, the relationship between CRA and NAFLD/NAFPD remains unclear.

METHODS

This cross-sectional study recruited 712 eligible participants without current drinking who had undergone total colonoscopy as part of a health checkup. These participants were classified into a CRA group (n = 236) and a control group (n = 439), which consisted of individuals without CRA and a history of polyp resection. NAFLD and NAFPD were diagnosed based on abdominal ultrasonography findings.

RESULTS

Non-alcoholic fatty liver disease was observed more frequently in individuals with CRA than in the control group (55.9% vs 41.6%, P < 0.01). There was no significant association between NAFPD and CRA; however, serum pancreatic amylase (P-amylase) levels were significantly lower in individuals with CRA. Although NAFLD was one of the factors increasing the presence of CRA (odds ratio [OR], 1.50; 95% confidence interval [CI], 1.07-2.10), low P-amylase levels were significantly associated with the presence of CRA (OR, 1.73; 95% CI, 1.04-2.88) independent of age, sex, current smoking, obesity, metabolic alterations including insulin resistance, and NAFLD.

CONCLUSIONS

Low serum P-amylase levels were a possible independent risk factor for CRA in the present study. The latent pancreatic exocrine-endocrine-gut relationship was considered a novel pathway involved in obesity-related CRA development, in non-alcoholic individuals.

Association of Pancreatic Fatty Infiltration With Age and Metabolic Syndrome Is Sex-Dependent

Background and Aims

Fatty infiltration of the pancreas has been shown to be associated with both precancerous pancreatic lesions and pancreatic ductal adenocarcinoma. We aim to determine predictors of fatty infiltration of the pancreas in United States adults.

Methods

In this retrospective cohort study conducted at a large academic hospital in Chicago, Illinois, we calculated the relative fatty infiltration of the pancreas (corrected to spleen) of 265 cancer-free individuals based on their cross-sectional imaging. Demographic data and relevant laboratory results were obtained from medical records.

Results

We found that age was the strongest predictor of fatty infiltration of the pancreas in our series (P < .01). Fatty infiltration of the pancreas was also significantly associated with body mass index (P < .01) and hyperlipidemia (P < .05). In women, in addition to age (P < .05), elevated body mass index (P = .023), hyperlipidemia (P = .013), and fatty liver (P = .017) were predictors of fat in pancreas. We found a sex-dependent association between pancreatic fat and metabolic syndrome including fatty liver (P = .002).

Conclusion

Fatty infiltration of the pancreas increases by age and components of metabolic syndrome. These assertions could be sex-dependent.

Fatty Pancreas-Centered Metabolic Basis of Pancreatic Adenocarcinoma: From Obesity, Diabetes and Pancreatitis to Oncogenesis

Pancreatic ductal adenocarcinoma (PDAC) is one of the deadliest types of cancer, and it is currently the third most common cause of cancer death in the U.S.A. Progress in the fight against PDAC has been hampered by an inability to detect it early in the overwhelming majority of patients, and also by the reduced oxygen levels and nutrient perfusion caused by new matrix formation through the activation of stromal cells in the context of desmoplasia. One harbinger of PDAC is excess intrapancreatic fat deposition, namely, fatty pancreas, which specifically affects the tumor macro- and microenvironment in the organ. Over half of PDAC patients have diabetes mellitus (DM) at the time of diagnosis, and fatty pancreas is associated with subsequent DM development. Moreover, there is a strong association between fatty pancreas and fatty liver through obesity, and a higher intrapancreatic fat percentage has been noted in acute pancreatitis patients with DM than in those without DM. All these findings suggest that the link between fatty pancreas and PDAC might occur through metabolic alterations, either DM-related or non-DM-related. Based on clinical, in vivo and in vitro evidence, the current review highlights the etiologies of fatty pancreas (including fatty infiltration and replacement) and the fatty pancreas-associated metabolic alterations involved in oncogenesis to provide crucial targets to prevent, detect, and/or effectively treat PDAC.

Intra-pancreatic fat deposition: bringing hidden fat to the fore

Development of advanced modalities for detection of fat within the pancreas has transformed understanding of the role of intra-pancreatic fat deposition (IPFD) in health and disease. There is now strong evidence for the presence of minimal (but not negligible) IPFD in healthy human pancreas. Diffuse excess IPFD, or fatty pancreas disease (FPD), is more frequent than type 2 diabetes mellitus (T2DM) (the most common disease of the endocrine pancreas) and acute pancreatitis (the most common disease of the exocrine pancreas) combined. FPD is not strictly a function of high BMI; it can result from the excess deposition of fat in the islets of Langerhans, acinar cells, inter-lobular stroma, acinar-to-adipocyte trans-differentiation or replacement of apoptotic acinar cells. This process leads to a wide array of diseases characterized by excess IPFD, including but not limited to acute pancreatitis, chronic pancreatitis, pancreatic cancer, T2DM, diabetes of the exocrine pancreas. There is ample evidence for FPD being potentially reversible. Weight loss-induced decrease of intra-pancreatic fat is tightly associated with remission of T2DM and its re-deposition with recurrence of the disease. Reversing FPD will open up opportunities for preventing or intercepting progression of major diseases of the exocrine pancreas in the future.

Nonalcoholic Fatty Pancreas Disease: Role in Metabolic Syndrome, "Prediabetes," Diabetes and Atherosclerosis

Fat accumulation in the pancreas associated with obesity and the metabolic syndrome (MetS) has been defined as "non-alcoholic fatty pancreas disease" (NAFPD). The aim of this review is to describe the association of NAFPD with obesity, MetS, type 2 diabetes mellitus (T2DM) and atherosclerosis and also increase awareness regarding NAFPD. Various methods are used for the detection and quantification of pancreatic fat accumulation that may play a significant role in the differences that have been observed in the prevalence of NAFPD. Endoscopic ultrasound provides detailed images of the pancreas and its use is expected to increase in the future. Obesity and MetS have been recognized as NAFPD risk factors. NAFPD is strongly associated with non-alcoholic fatty liver disease (NAFLD) and it seems that the presence of both may be related with aggravation of NAFLD. A role of NAFPD in the development of "prediabetes" and T2DM has also been suggested by most human studies. Accumulation of fat in pancreatic tissue possibly initiates a vicious cycle of beta-cell deterioration and further pancreatic fat accumulation. Additionally, some evidence indicates a correlation between NAFPD and atherosclerotic markers (e.g., carotid intima-media thickness). Weight loss and bariatric surgery decreases pancreatic triglyceride content but pharmacologic treatments for NAFPD have not been evaluated in specifically designed studies. Hence, NAFPD is a marker of local fat accumulation possibly associated with beta-cell function impairment, carbohydrate metabolism disorders and atherosclerosis.

Associations Between the Metabolic Score for Insulin Resistance Index and the Risk of Type 2 Diabetes Mellitus Among Non-Obese Adults: Insights from a Population-Based Cohort Study

Purpose

The metabolic score for insulin resistance (METS-IR) index is an emerging surrogate predictor of type 2 diabetes mellitus (T2DM). This study aimed to evaluate the association between the METS-IR index and the risk of T2DM in non-obese Japanese adults.

Methods

A total of 12,290 non-obese participants were selected from the NAGALA prospective cohort study conducted from 2004 to 2015. Cox proportional hazards models were used to assess the association between the baseline METS-IR index and risk of T2DM. Generalized additive models were used to identify nonlinear relationships. In addition, we performed subgroup analyses and interaction tests. Results were expressed as hazard ratios (HRs) and 95% confidence intervals (CIs).

Results

During a median follow-up of 2050 days, 176 (1.43%) incident T2DM occurred. The fully adjusted HR (95% CI) for the incidence of T2DM in non-obese adults was 1.17 (HR=1.17, 95% CI: 1.09–1.27, P<0.001) for every 1-unit increase in the METS-IR index. The risk of developing T2DM increased with the quartile of change in the METS-IR index, after adjustment for multiple potential confounding, the HRs for the Q4 group versus the Q1 group was 4.01 (95% CI, 1.39–11.57). Generalized additive models also showed a cumulative increase in the risk of T2DM with increasing the METS-IR index. Time-dependent receiver operating curve suggested helpful discriminative power of the METS-IR index for T2DM. The C-statistics by the clinical risk factors significantly improve with the addition of the METS-IR index (from 0.862 to 0.875, P = 0.035); the discriminatory power and risk reclassification also appeared to be substantially better, with the category-free NRI of 0.216, and the IDI of 0.011.

Conclusion

The METS-IR index was a significant and independent predictor for future T2DM development in non-obese adults. The METS-IR index may have clinical significance in identifying groups at high risk of T2DM.

Association between Intrapancreatic Fat Deposition and the Leptin/Ghrelin Ratio in the Fasted and Postprandial States

BACKGROUND

The clinical relevance of excess intrapancreatic fat deposition (IPFD) is increasingly appreciated. Leptin and ghrelin are key players in the regulation of food intake, energy balance, and body fat mass. The aim was to investigate the associations of the leptin/ghrelin ratio and its components with IPFD.

METHODS

All participants underwent magnetic resonance imaging on a 3T scanner to quantify IPFD. Both fasting and postprandial blood samples were analyzed for leptin and acylated ghrelin. Linear regression analysis was conducted, accounting for visceral/subcutaneous fat volume ratio, glycated hemoglobin, and other covariates.

RESULTS

A total of 94 participants (32 women) with a median age of 56 (interquartile range 44-66) years were studied. Their median IPFD was 9.6% (interquartile range 8.8-10.4%). In the fasted state, the leptin/ghrelin ratio (β = 0.354; 95% confidence interval 0.044-0.663; p = 0.025, in the most adjusted model) and leptin (β = 0.040; 95% confidence interval 1.003-1.078; p = 0.035, in the most adjusted model) were significantly associated with IPFD. Ghrelin in the fasted state was not significantly associated with IPFD. In the postprandial state, the leptin/ghrelin ratio, leptin, and ghrelin were not significantly associated with IPFD.

CONCLUSION

Fasting circulating levels of leptin are directly associated with IPFD. Purposely designed mechanistic studies are warranted to determine how high leptin may contribute to excess IPFD.

Obesity and Pancreatic Cancer: Insight into Mechanisms

Simple Summary

Obesity is recognized as a chronic progressive disease and risk factor for many human diseases. The high and increasing number of obese people may underlie the expected increase in pancreatic cancer cases in the United States. There are several pathways discussed that link obesity with pancreatic cancer. Adipose tissue and adipose tissue-released factors may thereby play an important role. This review discusses selected mechanisms that may accelerate pancreatic cancer development in obesity.

Abstract

The prevalence of obesity in adults and children has dramatically increased over the past decades. Obesity has been declared a chronic progressive disease and is a risk factor for a number of metabolic, inflammatory, and neoplastic diseases. There is clear epidemiologic and preclinical evidence that obesity is a risk factor for pancreatic cancer. Among various potential mechanisms linking obesity with pancreatic cancer, the adipose tissue and obesity-associated adipose tissue inflammation play a central role. The current review discusses selected topics and mechanisms that attracted recent interest and that may underlie the promoting effects of obesity in pancreatic cancer. These topics include the impact of obesity on KRAS activity, the role of visceral adipose tissue, intrapancreatic fat, adipose tissue inflammation, and adipokines on pancreatic cancer development. Current research on lipocalin-2, fibroblast growth factor 21, and Wnt5a is discussed. Furthermore, the significance of obesity-associated insulin resistance with hyperinsulinemia and obesity-induced gut dysbiosis with metabolic endotoxemia is reviewed. Given the central role that is occupied by the adipose tissue in obesity-promoted pancreatic cancer development, preventive and interceptive strategies should be aimed at attenuating obesity-associated adipose tissue inflammation and/or at targeting specific molecules that mechanistically link adipose tissue with pancreatic cancer in obese patients.

Association of metabolic score for insulin resistance and its 6-year change with incident type 2 diabetes mellitus

BACKGROUND

The evidence for the association between metabolic score for insulin resistance (METS-IR) and type 2 diabetes mellitus (T2DM) is limited. We aimed to explore the association of METS-IR and its 6-year change with risk of incident T2DM in a rural Chinese population.

METHODS

We analyzed data for 12 107 participants (mean age 50.48 years). A Cox proportional-hazard model was used to estimate the association of METS-IR with incident T2DM by using hazard ratios (HRs) and 95% confidence intervals (CIs); a logistic regression model was used to assess the association of 6-year METS-IR change with incident T2DM by using odds ratios (ORs) and 95% CIs. We used subgroup analyses of the association of METS-IR and its 6-year change with incident T2DM by sex, age, and baseline fasting plasma glucose (FPG) level as well as restricted cubic splines to describe the dose-response association.

RESULTS

The association of METS-IR and 6-year METS-IR change with incident T2DM was significant (per SD unit increase: HR = 1.80, 95% CI: 1.60-2.02 for METS-IR, OR = 1.42, 95% CI: 1.28-1.57 and OR = 1.59, 95% CI: 1.44-1.76 for relative and absolute METS-IR change). The significant association remained on subgroup analyses by sex, age, and baseline FPG level. Dose-response analysis demonstrated that the probability of incident T2DM was significantly increased with increasing METS-IR and 6-year METS-IR change.

CONCLUSIONS

Increased METS-IR and 6-year METS-IR change were positively associated with risk of incident T2DM in a rural Chinese population. METS-IR may be a vital indicator for identifying T2DM.

Dietary carbohydrate intake and insulin traits in individuals after acute pancreatitis: Effect modification by intra-pancreatic fat deposition

OBJECTIVES

Current knowledge of the link between dietary carbohydrate intake and insulin regulation in individuals after an attack of pancreatitis is limited. We aimed to investigate the associations between dietary carbohydrate intake and insulin traits in post-pancreatitis versus healthy individuals, taking into account intrapancreatic fat deposition (IPFD).

METHODS

All participants underwent magnetic resonance imaging (using the same protocol and 3T scanner) to quantify IPFD. Dietary carbohydrate intake was assessed using a validated 131-item food frequency questionnaire. Insulin, HOMA-IR, HOMA-β were determined in the fasted state. Linear regression and effect modification analyses were conducted in unadjusted and adjusted models (accounting for age, sex, body mass index, daily energy intake, use of anti-diabetic medications, and recurrence of acute pancreatitis).

RESULTS

The study included 111 post-pancreatitis individuals (categorized into low IPFD (n = 33), moderate IPFD (n = 40), high IPFD (n = 38)) and 47 healthy controls. In the high IPFD group, starch intake was negatively associated with fasting insulin and HOMA-β in both the unadjusted (p < 0.001 both) and fully adjusted models (p < 0.001 both); and with HOMA-IR in the fully adjusted model (p < 0.001) only. Total sugar intake was positively associated with fasting insulin (p = 0.015) and HOMA-β (p = 0.007) in the fully adjusted model but not associated with HOMA-IR. None of the above associations was statistically significant in the low IPFD, moderate IPFD, and healthy controls groups. The studied associations were more pronounced in the high IPFD group but not in the moderate IPFD or low IPFD groups (when compared with the healthy controls group).

CONCLUSIONS

Dietary carbohydrate intake is differentially associated with insulin traits in individuals after an attack of pancreatitis and the associations are modified by IPFD. These findings will be helpful for the development of dietary guidelines specifically for individuals after an attack of pancreatitis.

The Plasma Metabolomic Profile is Differently Associated with Liver Fat, Visceral Adipose Tissue, and Pancreatic Fat

CONTEXT

Metabolic differences between ectopic fat depots may provide novel insights to obesity-related diseases.

OBJECTIVE

To investigate the plasma metabolomic profiles in relation to visceral adipose tissue (VAT) volume and liver and pancreas fat percentages.

DESIGN

Cross-sectional.

SETTING

Multicenter at academic research laboratories.

PATIENTS

Magnetic resonance imaging (MRI) was used to assess VAT volume, the percentage of fat in the liver and pancreas (proton density fat fraction [PDFF]) at baseline in 310 individuals with a body mass index ≥ 25 kg/m2 and with serum triglycerides ≥ 1.7 mmol/l and/or type 2 diabetes screened for inclusion in the 2 effect of omega-3 carboxylic acid on liver fat content studies.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Metabolomic profiling with mass spectroscopy enabled the determination of 1063 plasma metabolites.

RESULTS

Thirty metabolites were associated with VAT volume, 31 with liver PDFF, and 2 with pancreas PDFF when adjusting for age, sex, total body fat mass, and fasting glucose. Liver PDFF and VAT shared 4 metabolites, while the 2 metabolites related to pancreas PDFF were unique. The top metabolites associated with liver PDFF were palmitoyl-palmitoleoyl-GPC (16:0/16:1), dihydrosphingomyelin (d18:0/22:0), and betaine. The addition of these metabolites to the Liver Fat Score improved C-statistics significantly (from 0.776 to 0.861, P = 0.0004), regarding discrimination of liver steatosis.

CONCLUSION

Liver PDFF and VAT adipose tissue shared several metabolic associations, while those were not shared with pancreatic PDFF, indicating partly distinct metabolic profiles associated with different ectopic fat depots. The addition of 3 metabolites to the Liver Fat Score improved the prediction of liver steatosis.

Parallels between non-alcoholic fatty liver disease and non-alcoholic fatty pancreatic disease: looking for points of contact or regard through the lens of metabolic syndrome

The aim. The aim of our study was to analyze the available data from literature sources concerning the issues of etiology, pathogenesis, clinic, diagnosis and features of treatment of non-alcoholic fatty liver disease (NAFLD) and non-alcoholic fatty pancreatic disease (NAFPD).

Materials and methods. We conducted a retrospective analysis of foreign literature sources that contain up-to-date information about the state of the problem of NAFLD and NAFPD.

Results. NAFLD and NAFPD develop against the background of metabolic syndrome (MS), systemic insulin resistance, oxidative stress, changes in lipid metabolism. The natural course of NAFPD is associated with high risk of MS progression, occurrence of NAFLD, arterial hypertension, type 2 diabetes mellitus, exocrine pancreatic insufficiency, acute and chronic pancreatitis, pancreas cancer. Correction of the components of MS can reduce the severity of NAFLD and NAFPD; enzyme replacement therapy can improve the function of β-cells in pancreas steatosis.

Conclusion. The alternatives of the pharmacological treatment of NAFLD and NAFPD continue to be actively explored. We emphasize the need of including medications containing pancreatic enzymes in the treatment of NAFLD.

A Systematic Review of Intra-pancreatic Fat Deposition and Pancreatic Carcinogenesis

BACKGROUND

Excess adiposity is considered causally related to pancreatic cancer. While most knowledge on the topic comes from studies on general and visceral adiposity, the role of intra-pancreatic fat deposition in pancreatic carcinogenesis just begins to be elucidated. The aim was to conduct a comprehensive systematic review of clinical studies on intra-pancreatic fat deposition in individuals with pancreatic cancer or pre-malignant lesions.

METHODS

A literature search was conducted independently by two reviewers using three electronic databases. Studies were included if they reported on intra-pancreatic fat deposition determined based on modern radiology or histology. Summary estimates were presented as pooled prevalence or relative risk and 95% confidence interval.

RESULTS

A total of 13 studies (encompassing 2178 individuals) were included. The pooled prevalence of intra-pancreatic fat deposition in individuals with pancreatic cancer or pre-malignant lesions was 52% (95% confidence interval, 38-66%). The presence of pancreatic cancer or pre-malignant lesions was associated with a significantly increased risk of intra-pancreatic fat deposition (relative risk 2.78 (95% confidence interval, 1.56-4.94, p < 0.001).

CONCLUSION

Individuals with pancreatic cancer or pre-malignant lesions are characterized by increased intra-pancreatic fat deposition. There are sound grounds for conceptually viewing intra-pancreatic fat deposition as a combination of fat accumulation in the pancreas (due to expansion of excess visceral fat) and fatty replacement of the pancreas (due to changes in cellular identity within the pancreas). Guidelines on reporting intra-pancreatic fat deposition need to be developed with a view to informing a comprehensive and standardized characterization of this clinical entity in future studies.

Iron metabolism and the exocrine pancreas

Although the pathophysiological mechanisms and consequences of gross derangements in iron metabolism are well known, little is known about the pathophysiological mechanisms underlying mild-to-moderate alterations in iron metabolism and their consequences. Growing evidence indicates that the exocrine pancreas has a bidirectional relationship with iron metabolism. Studies have shown alterations in circulating markers of iron metabolism, iron absorption, and intra-pancreatic iron deposition in pancreatitis. At the same time, exocrine pancreatic dysfunction has been shown in iron overload disorders. These observations reveal a compelling connection between the exocrine pancreas and iron metabolism, which are further elucidated by observations of therapeutic benefits of iron chelating agents and pancreatic enzyme replacement therapy. While the pancreas is not a major reservoir of iron in the body, better understanding of its relationship with iron metabolism may yield unexpected insights.

Research status and prgoress of nonalcoholic fatty pancreatic disease

Nonalcoholic fatty pancreatic disease (NAFPD) is a disease characterized by an increase in pancreatic fat accumulation. It is a component of the metabolic syndrome and often coexists with nonalcoholic fatty liver disease. Once the diagnosis is established, it is closely related to acute and chronic pancreatitis, type 2 diabetes mellitus, pancreatic fibrosis, and pancreatic cancer. In recent years, it has been confirmed that NAFPD is closely related to cardiovascular disease, liver fibrosis, and liver cancer. The prevalence of NAFPD ranges between 11% and 69%, and increases with age. It is worth noting that the prevalence in obese children is twice as high as that in non-obese children. The high prevalence rate and complexity of the disease have aroused people's high attention. Therefore, to improve the understanding of NAFPD, fully understand the clinical significance of NAFPD, and further study its pathogenesis, diagnosis, and treatment require the collaboration and joint efforts of multiple disciplines, including hepatopathy, gastroenterology, endocrine metabolism, cardiovascular disease, imaging, pathology, and others. In this paper, we review the clinical significance, pathogenesis, and imaging diagnosis of NAFPD and propose our personal understanding of the key points in future research.

The Relationship between Abdominal Fat Phenotypes and Insulin Resistance in Non-Obese Individuals after Acute Pancreatitis

Both type 2 prediabetes/diabetes (T2DM) and new-onset prediabetes/diabetes after acute pancreatitis (NODAP) are characterized by impaired tissue sensitivity to insulin action. Although the outcomes of NODAP and T2DM are different, it is unknown whether drivers of insulin resistance are different in the two types of diabetes. This study aimed to investigate the associations between abdominal fat phenotypes and indices of insulin sensitivity in non-obese individuals with NODAP, T2DM, and healthy controls. Indices of insulin sensitivity (homeostasis model assessment of insulin sensitivity (HOMA-IS), Raynaud index, triglyceride and glucose (TyG) index, Matsuda index) were calculated in fasting and postprandial states. Fat phenotypes (intra-pancreatic fat, intra-hepatic fat, skeletal muscle fat, visceral fat, and subcutaneous fat) were determined using magnetic resonance imaging and spectroscopy. Linear regression and relative importance analyses were conducted. Age, sex, and glycated hemoglobin A1c were adjusted for. A total of 78 non-obese individuals (26 NODAP, 20 T2DM, and 32 healthy controls) were included. Intra-pancreatic fat was significantly associated with all the indices of insulin sensitivity in the NODAP group, consistently in both the unadjusted and adjusted models. Intra-pancreatic fat was not significantly associated with any index of insulin sensitivity in the T2DM and healthy controls groups. The variance in HOMA-IS was explained the most by intra-pancreatic fat (R² = 29%) in the NODAP group and by visceral fat (R² = 21%) in the T2DM group. The variance in the Raynaud index was explained the most by intra-pancreatic fat (R² = 18%) in the NODAP group and by visceral fat (R² = 15%) in the T2DM group. The variance in the TyG index was explained the most by visceral fat in both the NODAP group (R² = 49%) and in the T2DM group (R² = 25%). The variance in the Matsuda index was explained the most by intra-pancreatic fat (R² = 48%) in the NODAP group and by visceral fat (R² = 38%) in the T2DM group. The differing association between intra-pancreatic fat and insulin resistance can be used to differentiate NODAP from T2DM. Insulin resistance in NODAP appears to be predominantly driven by increased intra-pancreatic fat deposition.

The relationship between pancreas steatosis and the risk of metabolic syndrome and insulin resistance in Chinese adolescents with concurrent obesity and non-alcoholic fatty liver disease

BACKGROUND

The incidence of childhood obesity and associated comorbidities are on an increasing trend worldwide. More than 340 million children and adolescents aged between 5 and 19 years old were overweight or had obesity in 2016, from which over 124 million children and adolescents (6% of girls and 8% of boys) had obesity.

OBJECTIVE

To describe the relationship between pancreas steatosis, body fat and the risk of metabolic syndrome, insulin resistance in Hong Kong Chinese adolescents with both obesity and non-alcoholic fatty liver disease (NAFLD).

METHODS

Fifty two adolescents with obesity and NAFLD were analysed (14-18 years), stratified into fatty and non-fatty pancreas groups using chemical shift encoded MRI-pancreas proton density fat fraction ≥5%. Pancreatic, abdominal subcutaneous adipose tissue (SAT)/visceral adipose tissue (VAT) volumes, biochemical and anthropometric parameters were measured. Mann-Whitney U test, multiple linear/binary logistic regression analyses and odds ratios were used.

RESULTS

Fifty percent had fatty pancreas, 38% had metabolic syndrome and 81% had insulin resistance. Liver proton density fat fraction (PDFF) and VAT were independent predictors of insulin resistance (P = .006, .016). Pancreas and liver PDFF were both independent predictors of beta cells dysfunction (P = .015, .050) and metabolic syndrome (P = .021, .041). Presence of fatty pancreas in obesity was associated with insulin resistance (OR = 1.58, 95% CI = 0.39-6.4) and metabolic syndrome (OR = 1.70, 95% CI = 0.53-5.5).

CONCLUSION

A significant causal relationship exists between fatty pancreas, fatty liver, body fat and the risk of developing metabolic syndrome and insulin resistance.

KEY POINTS

Fatty pancreas is a common finding in adolescents with obesity, with a prevalence rate of 50% in this study cohort. Liver PDFF and VAT are independent predictors of insulin resistance while pancreas PDFF and liver PDFF are independent predictors of both beta cells dysfunction and metabolic syndrome. Presence of fatty pancreas at imaging should not be considered as a benign finding but rather as an imaging biomarker of emerging pancreatic metabolic and endocrine dysfunction.

Chronic Pancreatitis Is Characterized by Elevated Circulating Periostin Levels Related to Intra-Pancreatic Fat Deposition

Background

Periostin is a matricellular protein that induces fibrillogenesis and activates cell migration. It is overexpressed in common fibrotic diseases and is also associated with abdominal adiposity/ectopic fat phenotypes. The study aimed to investigate circulating levels of periostin in health and after an attack of pancreatitis, as well as their associations with abdominal adiposity/ectopic fat phenotypes.

Methods

Blood samples were obtained from healthy controls, as well as definite chronic pancreatitis (CP) and acute pancreatitis (AP) individuals during follow-up visits. Fat depositions in the pancreas, liver, skeletal muscle, as well as visceral and subcutaneous fat volumes, were quantified with the use of magnetic resonance imaging. A series of multivariable analyses were conducted, accounting for possible confounders.

Results

A total of 121 individuals were included. Periostin levels were significantly higher in the CP group compared with the other groups in both unadjusted (F = 3.211, P = 0.044) and all adjusted models (F = 4.165, P = 0.019 in the most adjusted model). Intra-pancreatic fat deposition (but not the other fat phenotypes) was significantly associated with periostin concentration in the CP group (β = 49.63, P = 0.034) and explained most of its variance (32.0%).

Conclusions

Individuals with CP, but not healthy individuals or those after clinical resolution of AP, are characterized by elevated circulating levels of periostin that are positively associated with intra-pancreatic fat deposition.

Implications of Tobacco Smoking and Alcohol Consumption on Ectopic Fat Deposition in Individuals After Pancreatitis

OBJECTIVES

Tobacco smoking and alcohol consumption are established risk factors for pancreatitis. This study investigated the associations between tobacco smoking/alcohol consumption in people after an attack of pancreatitis and intrapancreatic fat deposition (IPFD), intrahepatic fat deposition (IHFD), and skeletal muscle (SMFD) fat deposition.

METHODS

In this cross-sectional study, magnetic resonance imaging was used to quantify IPFD, IHFD, and SMFD by 2 independent raters. A validated questionnaire was used to determine tobacco smoking and alcohol consumption.

RESULTS

A total of 119 individuals after an attack of pancreatitis were included. Average tobacco smoking contributed most to variance in IPFD (R = 6.5%) and least to variance in SMFD (R = 0.4%). Average alcohol consumption contributed most to variance in variance in IPFD (R = 2.8%) and least to IHFD (R = 1.1%). Packs/day contributed more than years of smoking to variance in IPFD (R = 4.9 and 0.2%, correspondingly), whereas years of drinking contributed more than average daily alcohol consumption (R = 3.9 and 3.2%, correspondingly).

CONCLUSIONS

Tobacco smoking and alcohol consumption contributed more to variance in IPFD than IHFD and SMFD. Smoking contributed more than drinking to variance in IPFD. The daily amount of tobacco smoked appeared to be more important than years of smoking for IPFD.

The Impact of Education and Age on Metabolic Disorders

Metabolic disorders, such as obesity, elevated blood pressure, dyslipidemias, insulin resistance, hyperglycemia, and hyperuricemia have all been identified as risk factors for an epidemic of important and widespread chronic-degenerative diseases, such as type 2 diabetes and cardiovascular disease, that constitute some of the world's most important public health challenges. Their increasing prevalence can be associated with an aging population and to lifestyles within an obesogenic environment. Taking educational level as a proxy for lifestyle, and using both logistic and linear regressions, we study the relation between a wide set of metabolic biomarkers, and educational level, body mass index (BMI), age, and sex as correlates, in a population of 1,073 students, academic and non-academic staff at Mexico's largest university (UNAM). Controlling for BMI and sex, we consider educational level and age as complementary measures-degree and duration-of exposure to metabolic insults. Analyzing the role of education across a wide spectrum of educational levels (from primary school to doctoral degree), we show that higher education correlates to significantly better metabolic health when compared to lower levels, and is associated with significantly less risk for waist circumference, systolic blood pressure, glucose, glycosylated hemoglobin, triglycerides, high density lipoprotein and metabolic syndrome (all p < 0.05); but not for diastolic blood pressure, basal insulin, uric acid, low density lipoprotein, and total cholesterol. We classify each biomarker, and corresponding metabolic disorder, by its associated set of statistically significant correlates. Differences among the sets of significant correlates indicate various aetiologies and the need for targeted population-specific interventions. Thus, variables strongly linked to educational level are candidates for lifestyle change interventions. Hence, public policy efforts should be focused on those metabolic biomarkers strongly linked to education, while adopting a different approach for those biomarkers not linked as they may be poor targets for educational campaigns.