Reduced oxidized low-density lipoprotein after weight reduction in obese premenopausal women

Lipid Oxidation Products and the Risk of Cardiovascular Diseases: Role of Lipoprotein Transport

Cholesterol has for decades ruled the history of atherosclerotic cardiovascular diseases (CVDs), and the present view of the etiology of the disease is based on the transport of cholesterol by plasma lipoproteins. The new knowledge of the lipoprotein-specific transport of lipid oxidation products (LOPs) has introduced another direction to the research of CVD, revealing strong associations between lipoprotein transport functions, atherogenic LOP, and CVD. The aim of this review is to present the evidence of the lipoprotein-specific transport of LOP and to evaluate the potential consequences of the proposed role of the LOP transport as a risk factor. The associations of cholesterol and lipoprotein LOP with the known risk factors of CVD are mostly parallel, and because of the common transport and cellular intake mechanisms it is difficult to ascertain the independent effects of either cholesterol or LOP. While cholesterol is known to have important physiological functions, LOPs are merely regarded as metabolic residues and able to initiate and boost atherogenic processes. It is therefore likely that with the increased knowledge of the lipoprotein-specific transport of LOP, the role of cholesterol as a risk factor of CVD will be challenged.

Obesity in prenatal medicine: a game changer?

Obesity is recognized by the World Health Organization (WHO) as a disease in its own right. Moreover, obesity is an increasingly concerning public health issue across the world and its prevalence is rising amongst women of reproductive age. The fertility of over-weight and obese women is reduced and they experience a higher rate of miscarriage. In pregnant women obesity not only increases the risk of antenatal complications, such as preeclampsia and gestational diabetes, but also fetal abnormalities, and consequently the overall feto-maternal mortality. Ultrasound is one of the most valuable methods to predict and evaluate pregnancy complications. However, in overweight and obese pregnant women, the ultrasound examination is met with several challenges, mainly due to an impaired acoustic window. Overall obesity in pregnancy poses special challenges and constraints to the antenatal care and increases the rate of pregnancy complications, as well as complications later in life for the mother and child.

Bone matrix quality in a developing high-fat diet mouse model is altered by RAGE deletion

Overweightness and obesity in adolescents are epidemics linked to chronic low-grade inflammation and elevated fracture risk. The increased fracture risk observed in overweight/obese adolescence contrasts the traditional concept that high body mass is protective against fracture, and thus highlights the need to determine why weight gain becomes detrimental to fracture during growth and maturity. The Receptor for Advanced Glycation End products (RAGE) is a central inflammatory regulator that can influence bone metabolism. It remains unknown how RAGE removal impacts skeletal fragility in overweightness/obesity, and whether increased fracture risk in adolescents could result from low-grade inflammation deteriorating bone quality. We characterized the multiscale structural, mechanical, and chemical properties of tibiae extracted from adolescent C57BL/6J (WT) and RAGE null (KO) mice fed either low-fat (LF) or high-fat (HF) diet for 12 weeks starting at 6 weeks of age using micro-computed tomography, strength, Raman spectroscopy, and nanoindentation. Overweight/obese WT HF mice possessed degraded mineral-crystal quality and increased matrix glycoxidation in the form of pentosidine and carboxymethyl-lysine, with HF diet in females only showing reduced cortical surface expansion and TMD independently of RAGE ablation. Furthermore, in contrast to males, HF diet in females led to more material damage and plastic deformation. RAGE KO mitigated glycoxidative matrix accumulation, preserved mineral quantity, and led to increased E/H ratio in females. Taken together, these results highlight the complex, multi-scale and sex-dependent relationships between bone quality and function under overweightness, and identifies RAGE-controlled glycoxidation as a target to potentially preserve matrix quality and mechanical integrity.

Evaluation of Pro/Antioxidant Imbalance in Blood of Women with Polycystic Ovary Syndrome Based on Determination of Oxidized Low-Density Lipoproteins and Ferric Reducing Ability of Plasma Values

We investigated selected pro/antioxidant parameters in a group of women with polycystic ovary syndrome (PCOS) divided according to age, body mass index (BMI), waist-to-hip ratio (WHR), homeostatic model assessment for insulin resistance (HOMA-IR) and quantitative insulin sensitivity check index (Quicki). We chose oxidized low-density lipoproteins (oxLDL-C) as a marker of oxidative stress and the ferric reducing ability of plasma (FRAP) as a marker of antioxidant status. In women with PCOS, the values of BMI, WHR, age and concentration of glucose significantly affected oxLDL-C concentration and FRAP values. FRAP correlated with oxLDL-C level in the whole group and in women who were insulin sensitive (HOMA-IR < 2.0). There was a negative relationship between the concentration of Anti-Müllerian hormone and both oxLDL-C and FRAP. Furthermore, the value of FRAP was inversely correlated with luteinizing hormone (LH), follicle-stimulating hormone (FSH) and androstenedione, whereas it was positively correlated with the LH/FSH ratio. The concentration of oxLDL and the value of FRAP are significantly associated with selected metabolic and hormonal parameters in the course of PCOS.

Eustachian Tube Dysfunction Improvement Secondary to Moderate Weight Loss: Case Report

The Eustachian tube (ET) is an osteocartilaginous canal that connects the middle ear to the nasopharynx. It is one of the critical structures essential for middle ear functions. ET dysfunction causes discomfort in the affected ear and decreased hearing. This is the first case report of improving hearing and middle ear aeration and ET function secondary to body weight reduction. A 27-year-old male patient presented to the otology clinic complaining of decreased hearing for two years. Initial ear examination revealed retraction of TM on the left ear with two retraction pockets, and on the right ear, the TM was dull with one retraction pocket. The patient reported losing some of his body weight during those six months. Ear examination revealed improvement in the TM retraction in both ears. The improvement in hearing was evidenced by a serial audiogram, while the middle ear aeration was evidenced by clinical examination.

Effectiveness of a motivational intervention on overweight/obese patients in the primary healthcare: a cluster randomized trial

BACKGROUND

Overweight and obesity are common health problems which increase the risk of developing several serious health conditions. The main difficulty in the management of weight-loss lies in its maintenance, once it is achieved. The aim of this study was to investigate whether a motivational intervention, together with current clinical practice, was more efficient than a traditional intervention, in the treatment of overweight and obesity and whether this intervention reduces cardiovascular risk factors associated with overweight and obesity.

METHODS

Multi-centre cluster randomized trial with a 24-month follow-up included 864 overweight/obese patients randomly assigned. Motivational intervention group (400 patients), delivered by a nurse trained by an expert psychologist, in 32 sessions, 1 to 12 fortnightly, and 13 to 32, monthly, on top of their standard programmed diet and exercise. The control group (446 patients), received the usual follow-up.

RESULTS

Weight reduction was statistically significant in the second year with a mean reduction of 1.0 Kg in the control group and 2.5 Kg in the intervention group (p = 0. 02). While 18.1% of patients in the control group reduced their weight by more than 5%, this percentage rose to 26.9% in the intervention group, which is statistically significant (p = 0.04). Patients in the motivational intervention group had significantly greater improvements in triglycerides and APOB/APOA1ratio.

CONCLUSIONS

The results highlight the importance of the group motivational interview in the treatment of overweight /obese patients in primary care, and in the improvement of their associated cardiovascular risks factors.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01006213 October 30, 2009.

Influence on Adiposity and Atherogenic Lipaemia of Fatty Meals and Snacks in Daily Life

The present work reviewed the connections of changes in consumption of high-fat food with changes in adiposity and lipaemia in adults with overweight or obesity. Hyperlipaemia from higher fat meals and excessive adiposity contributes to atherogenic process. Low-fat diet interventions decrease body fat, lipaemia, and atherosclerosis markers. Inaccuracy of physical estimates of dietary fat intake remains, however, a limit to establishing causal connections. To fill this gap, tracking fat-rich eating episodes at short intervals quantifies the behavioural frequency suggested to measure (by regression of changes in real time) direct effects of this eating pattern on adiposity and atherogenic lipaemia. Such evidence will provide the basis for an approach focused on a sustained decrease in frequency of fatty meals or snacks to reduce obesity, hyperlipaemia, and atherosclerosis.

Chili pepper as a body weight-loss food

Chili has culinary as well as medical importance. Studies in humans, using a wide range of doses of chili intake (varying from a single meal to a continuous uptake for up to 12 weeks), concluded that it facilitates weight loss. In regard to this, the main targets of chili are fat metabolism, energy expenditure, and thermogenesis. To induce weight loss, the active substance of chili, capsaicin, activates Transient Receptor Potential Cation Channel sub-family V member 1 (TRPV1) channels) receptors causing an increase in intracellular calcium levels and triggering the sympathetic nervous system. Apart from TRPV1, chili directly reduces energy expenditure by activating Brown Adipose Tissue. Weight loss by chili is also the result of an improved control of insulin, which supports weight management and has positive effects for treatment for diseases like obesity, diabetes and cardiovascular disorders. This review summarizes the major pathways by which chili contributes to ameliorating parameters that help weight management and how the consumption of chili can help in accelerating weight loss through dietary modifications.

Cannabidiol-2',6'-dimethyl ether stimulates body weight gain in apolipoprotein E-deficient BALB/c. KOR/Stm Slc-Apoe(shl) mice

The biological activities of cannabidiol (CBD), a major non-psychotropic constituent of the fiber-type cannabis plant, have been examined in detail (e.g., CBD modulation of body weight in mice and rats). However, few studies have investigated the biological activities of cannabidiol-2',6'-dimethyl ether (CBDD), a dimethyl ether derivative of the parent CBD. We herein focused on the effects of CBDD on body weight changes in mice, and demonstrated that it stimulated body weight gain in apolipoprotein E (ApoE)-deficient BALB/c. KOR/Stm Slc-Apoe(shl) mice, especially between 10 and 20 weeks of age.

Short-Term Hypocaloric High-Fiber and High-Protein Diet Improves Hepatic Steatosis Assessed by Controlled Attenuation Parameter

OBJECTIVES

Non-alcoholic fatty liver disease is one of the most prevalent liver diseases and increases the risk of fibrosis and cirrhosis. Current standard treatment focuses on lifestyle interventions. The primary aim of this study was to assess the effects of a short-term low-calorie diet on hepatic steatosis, using the controlled attenuation parameter (CAP) as quantitative tool.

METHODS

In this prospective observational study, 60 patients with hepatic steatosis were monitored during a hypocaloric high-fiber, high-protein diet containing 1,000 kcal/day. At baseline and after 14 days, we measured hepatic fat contents using CAP during transient elastography, body composition with bioelectrical impedance analysis, and serum liver function tests and lipid profiles using standard clinical-chemical assays.

RESULTS

The median age was 56 years (25-78 years); 51.7% were women and median body mass index was 31.9 kg/m(2) (22.4-44.8 kg/m(2)). After 14 days, a significant CAP reduction (14.0%; P<0.001) was observed from 295 dB/m (216-400 dB/m) to 266 dB/m (100-353 dB/m). In parallel, body weight decreased by 4.6% (P<0.001), of which 61.9% was body fat. In addition, liver stiffness (P=0.002), γ-GT activities, and serum lipid concentrations decreased (all P<0.001).

CONCLUSIONS

This study shows for the first time that non-invasive elastography can be used to monitor rapid effects of dietary treatment for hepatic steatosis. CAP improvements occur after only 14 days on short-term low-calorie diet, together with reductions of body composition parameters, serum lipids, and liver enzymes, pointing to the dynamics of hepatic lipid turnover.

Co-existence of insulin resistance and high concentrations of circulating oxidized LDL lipids

INTRODUCTION

Insulin metabolism has been previously linked to oxidized low-density lipoproteins (ox-LDL), but corroborating intervention studies are lacking. We investigated whether changes in ox-LDL levels are accompanied by changes in insulin sensitivity in a 32-month life-style intervention study.

MATERIALS AND METHODS

A 2-month weight reduction was followed by 6-month diet and exercise counselling and a 2-year follow-up period. Men of 35-50 years of age, BMI ≥ 30 kg/m(2), and waist circumference > 100 cm were recruited via newspapers in the city of Tampere, Finland. Of the 90 men meeting the inclusion criteria, 67 (76%) completed the study. Ox-LDL was estimated as the presence of oxidized lipids in LDL. Homeostasis model assessment of insulin resistance (HOMA-IR), ox-LDL, and ratio of ox-LDL and high-density lipoprotein cholesterol (ox-LDL/HDL-c) were used as the main outcome measures.

RESULTS

The detected changes in HOMA-IR were strikingly similar to those in ox-LDL and ox-LDL/HDL-c. Compared to the first HOMA-IR quartile, the fourth quartile had 23%-51% higher concentrations in ox-LDL and ox-LDL/HDL-c at all time points (P < 0.05 for all).

CONCLUSION

This weight reduction intervention study adds evidence to support the connection between insulin metabolism and oxidized LDL, possibly contributing to the higher incidence of atherosclerotic cardiovascular diseases among diabetic patients.

Postpartum weight retention is associated with elevated ratio of oxidized LDL lipids to HDL-cholesterol

Oxidized LDL lipids (ox-LDL) are associated with lifestyle diseases such as cardiovascular diseases, metabolic syndrome and type 2 diabetes. The present study investigated how postpartum weight retention effects on ox-LDL and serum lipids. The study is a nested comparative research of a cluster-randomized controlled trial, NELLI (lifestyle and counselling during pregnancy). During early pregnancy (8-12 weeks) and 1 year postpartum, 141 women participated in measurements for determining of plasma lipids: total cholesterol (T-C), LDL-cholesterol (LDL-C), HDL-cholesterol (HDL-C), triacylglycerols (TAG) and ox-LDL. Subjects were stratified into tertiles (weight loss, unaltered weight and weight gain groups) based on their weight change from baseline to follow-up. Ox-LDL was determined by baseline level of conjugated dienes in LDL lipids. Among the group of weight gainers, concentration of TAG reduced less (-0.14 vs. -0.33, p = 0.002), HDL-C reduced more (-0.31 vs. -0.16, p = 0.003) and ox-LDL/HDL-C ratio increased (3.0 vs. -0.2, p = 0.003) when compared to group of weight loss. Both T-C and LDL-C elevated more (0.14 vs. -0.21, p = 0.008; 0.31 vs. 0.07, p = 0.015) and TAG and ox-LDL reduced less (-0.33 vs. 0.20, p = 0.033; -3.33 vs. -0.68, p = 0.026) in unaltered weight group compared to weight loss group. The women who gained weight developed higher TAG and ox-LDL/HDL-C ratio as compared to those who lost weight. Postpartum weight retention of 3.4 kg or more is associated with atherogenic lipid profile.

Plasma IgA antibody levels to malondialdehyde acetaldehyde-adducts are associated with inflammatory mediators, obesity and type 2 diabetes

AIM

Obesity and type 2 diabetes (T2D) associate with increased oxidative stress. Malondialdehyde acetaldehyde (MAA) adducts have been suggested to be one of the antigenic epitopes in MDA-LDL responsible for the antibody recognition. Our aim was to investigate the associations between plasma IgA antibodies to MAA-LDL, inflammatory markers, adipokines, obesity, and T2D.

METHODS

IgA to MAA-LDL were measured in a subsample (n = 1507) of the Finnish Health 2000 survey. The associations between antibody levels, obesity, TNF-α, IL-6, high-sensitivity (hs) CRP, resistin, adiponectin, fasting plasma (fp) glucose, fp-insulin, glycosylated hemoglobin (Hb-A1C), and T2D were investigated.

RESULTS

IgA to MAA-LDL associated positively with fasting plasma insulin. IgA to MAA-LDL were higher among subjects with T2D (P < 0.001) compared to subjects with normal glucose metabolism. IgA to MAA-LDL associated with obesity, but was not independently (P = 0.002, not significant after correction for multiple tests) associated with T2D in logistic regression analysis. IgA to MAA-LDL, obesity, and TNF-α all associated with markers of glucose metabolism.

CONCLUSIONS

T2D subjects had increased IgA to MAA-LDL compared to subjects with normal glucose metabolism. The data suggest that the associations between IgA to MAA-LDL and markers of glucose metabolism were independent of TNF-α but dependent on components of the metabolic syndrome.

Supplementation with a juice powder concentrate and exercise decrease oxidation and inflammation, and improve the microcirculation in obese women: randomised controlled trial data

Obesity and sedentary lifestyle are associated with increased oxidative stress, inflammation and vessel dysfunction. Previous research has shown that an encapsulated fruit/berry/vegetable juice powder (FBV) supplement or controlled exercise training improve the markers of redox biology, low-grade inflammation and circulation. The aim of the present study was to assess the effects of 8 weeks of supplementation with FBV or placebo, and a single bout of controlled walking on the markers of oxidation, inflammation and skin capillary microcirculation in forty-two obese pre-menopausal women (41 (SD 5) years, non-smokers and BMI 34·5 (SD 3·8) kg/m(2)) using a randomised, double-blind, placebo-controlled design. All assessments were made before and after 8 weeks of capsule supplementation, and pre- and post-30 min of controlled treadmill walking at 70 % of VO2max. Venous blood was collected for the determination of carbonyl proteins (CP), oxidised LDL (ox-LDL), total oxidation status (TOS) of lipids, malondialdehyde, TNF-α and IL-6. Capillary blood flow, O2 saturation of Hb (SO2Hb) and the relative concentration of Hb (rHb) were assessed at a 2 mm skin depth. Following 8 weeks of supplementation, compared with placebo, the FBV group had a significant (P< 0·05) reduction in CP, ox-LDL, TOS and TNF-α, and a significant increase in blood flow, SO2Hb and rHb. Independent of supplementation, moderate exercise significantly increased blood flow and rHb, with a trend towards increased SO2Hb. Compared with placebo, 8 weeks of supplementation with FBV decreased the markers of systemic oxidation and inflammation. Both FBV supplementation and a single walking bout improved the markers of the microcirculation in these obese women.

Very-low-energy diets and morbidity: a systematic review of longer-term evidence

Evidence from the literature supports the safe use of very-low-energy diets (VLED) for up to 3 months in supervised conditions for patients who fail to meet a target weight loss using a standard low-fat, reduced-energy approach. There is, however, a need for longer-term outcomes on obesity and associated morbidities following a VLED. The present systematic review aims to investigate longer-term outcomes from studies using VLED, with a minimum duration of 12 months, published between January 2000 and December 2010. Studies conducted in both children and adults, with a mean/median BMI of ≥ 28 kg/m2 were included. PubMed, MEDLINE, Web of Science and Science Direct were searched. Reference lists of studies and reviews were manually searched. Weight loss or prevention of weight gain and morbidities were the main outcomes assessed. A total of thirty-two out of 894 articles met the inclusion criteria. The duration of the studies ranged from 12 months to 5 years. Periods of VLED ranged from 25 d to 9 months. Several studies incorporated aspects of behaviour therapy, exercise, low-fat diets, low-carbohydrate diets or medication. Current evidence demonstrates significant weight loss and improvements in blood pressure, waist circumference and lipid profile in the longer term following a VLED. Interpretation of the results, however, was restricted and conclusions with which to guide best practice are limited due to heterogeneity between the studies. The present review clearly identifies the need for more evidence and standardised studies to assess the longer-term benefits from weight loss achieved using VLED.

Lipoprotein-specific transport of circulating lipid peroxides

BACKGROUND

Serum lipoproteins, the carriers of cholesterol and other lipophilic substances in blood, are known to contain variable amounts of lipid peroxides. We investigated the transport of food-derived and endogenously formed lipid peroxides by serum lipoproteins under physiological conditions.

METHODS

Five independent trials were conducted in which different groups of healthy volunteers either consumed a test meal (a standard hamburger meal rich in lipid peroxides) or underwent strenuous physical exercise. The transport function was characterized by analyzing the kinetics of lipid peroxides in lipoprotein fractions. For evaluation of their potential involvement, indicators of oxidative stress (8-isoprostanes, malondialdehyde, 8-oxo-deoxyguanosine), antioxidant functions (total antioxidant potential, paraoxonase activity), and serum lipids were also analyzed.

RESULTS

We found that food lipid peroxides are incorporated into serum triglyceride-rich lipoproteins and low-density lipoprotein, directing the flow of lipid peroxides towards peripheral tissues. High-density lipoprotein appears to have an opposite and protective function, and is able to respond to oxidative stress by substantially increasing the reverse transport of lipid peroxides.

CONCLUSIONS

We propose that the specific atherosclerosis-related effects of serum lipoproteins are not explained by cholesterol transport alone and may rather result from the transport of the more directly atherogenic lipid peroxides.

Changes on the physiological lactonase activity of serum paraoxonase 1 by a diet intervention for weight loss in healthy overweight and obese women

Low caloric diet (LCD) is used for weight loss. Paraoxonase 1 (PON-1) is associated with the antioxidant functions of high-density lipoprotein (HDL). Among limited data on the relationships between obesity and PON-1, there has been no study on the effects of a stand-alone LCD on the physiological lactonase activity of PON-1. We investigated the prospective effects of LCD intervention (2 months) for weight loss on serum PON-1 activities (lactonase, arylesterase [mono-esterase] and tri-esterase) and HDL cholesterol (HDL-C), and their association with low-density lipoprotein cholesterol (LDL-C) in overweight and non-morbidly obese but otherwise healthy women (n = 30; mean age, 50.3 years; mean body mass index [BMI], 28.5 kg/m²). In addition to the data such as BMI, blood pressure, blood glucose and lipids, PON-1 activities were examined between pre- and post-intervention. The intervention reduced all metabolic outcomes, and PON-1 lactonase activity (determined with 5-[thiobutyl]butyrolactone) significantly decreased by 6.1%, paralleled by arylesterase (by 7.3%) and tri-esterase (by 7.8%). In multiple regression analysis, the percent change of PON-1 lactonase was significantly, positively and independently correlated to that of LDL-C (β = 0.51), HDL-C (β = 0.40), and BMI (β = 0.37). Our results showed that the solo diet treatment on weight loss might reduce serum PON-1 lactonase activity with reduced HDL-C and LDL-C. The relationship between the lactonase and LDL-C may be adaptive, plausibly hypothesizing less need for PON-1 activity as an antioxidant property to protect lipoproteins. Further research is needed to confirm this prediction.

Lycopene, lutein and beta-carotene as determinants of LDL conjugated dienes in serum

Oxidative modification of low-density lipoprotein (LDL) in the vascular endothelium is considered to be important in the development of early atherosclerosis. The aim of this study was to investigate the main determinants of serum LDL conjugated dienes in women (n=124) and men (n=225). We focused on the influence of fat-soluble vitamins and carotenoids on the concentration of conjugated dienes in LDL. In multivariate linear regression models, including age, body mass index, diastolic blood pressure, symptomatic ischaemic heart disease (IHD) or IHD history, statin medication, leukocytes and serum triglycerides as covariates, plasma lycopene (standardized beta=-0.33; P=0.002) and lutein (standardized beta=-0.22; P=0.027) concentrations were the strongest determinants of serum LDL conjugated dienes in women, whereas plasma beta-carotene (standardized beta=-0.23; P=0.002) was the most important factor in men. Furthermore, statin medication, diastolic blood pressure, age and serum triglycerides were significant determinants of LDL conjugated dienes. The regression model with lycopene contributed to 29% in women and 15% in men with beta-carotene of the variation of serum LDL conjugated dienes. Results of the present study suggest that plasma lycopene, lutein and beta-carotene are the most powerful antioxidants for explaining the content of in vivo oxidatively modified LDL in serum.

Homocysteine, fibrinogen and anti-ox-LDL antibody levels as markers of atherosclerosis in prepubertal obese children

BACKGROUND

Homocysteine, fibrinogen and antibodies to oxidised LDL were shown to be important markers of atherosclerosis in adults.

AIM

To investigate the levels of these three risk factors in prepubertal obese children.

METHODS

Fasting homocysteine, fibrinogen and antibodies to oxidised LDL, plasma lipids, insulin, HbA1c and blood glucose levels were investigated in 30 prepubertal obese and 28 control children 6-9 years old. Investigations in the obese group were repeated after an oral glucose tolerance test.

RESULTS

Fasting fibrinogen levels of the obese children were found to be significantly higher than those in the controls. Anti-ox-LDL antibody levels increased significantly after an oral glucose tolerance test.

CONCLUSION

Fasting fibrinogen and postload ox-LDL levels which could act as important markers of coronary heart disease in later life could also be important risk factors in prepubertal obese children.

Oxidized LDL and the metabolic syndrome

The metabolic syndrome is a common and complex disorder combining obesity, dyslipidemia, hypertension and insulin resistance. It is associated with a high cardiovascular risk that can only partially be explained by its components. There is evidence that low-grade inflammation and high oxidative stress add to this risk. Oxidized LDL, a marker of lipoprotein-associated oxidative stress, is an emerging cardiovascular risk factor. In this review, we demonstrate that the metabolic syndrome exacerbates oxidized LDL in a feedback loop. We introduce molecular mechanisms underlying this loop. Finally, we demonstrate that weight loss and statin treatment lower metabolic syndrome factors associated with a reduction of oxidized LDL. The current data warrant further investigation into the role of lifestyle and therapeutic interventions that inhibit tissue-associated oxidation of LDL in the prevention of the metabolic syndrome.

A novel oxidized low-density lipoprotein marker, serum amyloid A-LDL, is associated with obesity and the metabolic syndrome

BACKGROUND

The putative association between the novel oxidized low-density lipoprotein markers, serum amyloid A-LDL (SAA-LDL) and alpha1-antitrypsin-LDL (AT-LDL), and obesity and the metabolic syndrome (MetS) has not been previously studied. In the present report, we investigated the levels of SAA-LDL and AT-LDL in relation to the components of the MetS. We also assessed the effect of weight reduction therapy on serum SAA-LDL and AT-LDL levels among obese subjects.

METHODS

The study population included 421 obese Japanese outpatients (185 men and 236 women, mean age: 51.1 years) enrolled in the multicenter Japan Obesity and Metabolic Syndrome Study (JOMS). The novel oxidized low-density lipoprotein markers, serum SAA-LDL and AT-LDL, were measured in all participants.

RESULTS

Circulating SAA-LDL levels were independently associated with the presence and the number of components of the MetS. SAA-LDL levels were also significantly and independently correlated with high-sensitivity C-reactive protein. Notably, successful weight reduction resulted in a significant decrease in circulating SAA-LDL concentrations. Levels of AT-LDL were not associated with the MetS.

CONCLUSIONS

We documented, for the first time, that serum SAA-LDL levels correlate positively with the number of components of the MetS and weight reduction. Whether SAA-LDL may be involved in the pathophysiology of MetS and atherosclerosis deserves further investigation.

Association of changes in oxidative and proinflammatory states with changes in vascular function after a lifestyle modification trial among obese children

BACKGROUND

The association of changes in oxidative and proinflammatory states with vascular function after diet and exercise intervention among obese children has not been previously explored.

METHODS

In this 6-week diet and exercise intervention study in 35 obese children, age 12 to 18 years, we evaluated the relationship between changes in anthropometric indices, measures of insulin resistance, C-reactive protein (CRP), oxidized LDL (ox-LDL), and oxidative stress markers with changes in carotid intima-media thickness (C-IMT) and flow mediated dilation (FMD) of the brachial artery.

RESULTS

At the end of the study, body mass index (BMI), waist circumference, and percentage body fat were decreased (P <0.05), but participants remained overweight (BMI > or = 95th percentile). Although FMD improved (P <0.05), the improvement in C-IMT did not reach statistical significance. The changes in BMI, waist circumference, fat mass, ox-LDL, malondialdehyde (MDA), CRP, insulin, and homeostasis model assessment for insulin resistance (HOMA-IR) had an inverse correlation with the changes in mean FMD after adjustment for age and sex, with the highest correlations documented for ox-LDL, CRP, and WC. The age- and sex-adjusted changes in ox-LDL, waist circumference, CRP, MDA, and body fat mass had the highest correlations with changes in C-IMT.

CONCLUSIONS

Our findings suggest that a common inflammatory stress condition associated with childhood obesity, notably with abdominal fat deposition, may play a role in the development of the earliest stages of proatherosclerotic inflammatory processes and subsequent vascular dysfunction. These changes might be partially reversible by short-term diet and exercise intervention, even if patients do not reach ideal body weight.

Walking and Non‐HDL‐C in Adults: A Meta‐Analysis of Randomized Controlled Trials

An elevated level of non-high-density lipoprotein cholesterol (non-HDL-C) is a major risk factor for cardiovascular disease. The purpose of this study was to use the meta-analytic approach to examine the effects of walking on non-HDL-C in adults. Twenty-two randomized controlled trials representing 30 outcomes from 948 subjects (573 exercise, 375 control) met our inclusion criteria. Across all designs and categories, random effects modeling resulted in a significantly greater decrease in the walking group when compared with the control group of approximately 4% for non-HDL-C (+/- standard error of the mean, -5.6+/-1.8 mg/dL, 95% confidence interval, -8.8 to -2.4 mg/dL). Meta-regression showed a statistically significant association between changes in non-HDL-C and the year of publication, with greater reductions associated with more recent publication year (R2 = 0.23, p = 0.005). The results of this meta-analytic review suggest that walking reduces non-HDL-C in adult humans.

Successful weight maintenance preserves lower levels of oxidized LDL achieved by weight reduction in obese men

OBJECTIVE

We studied the association between weight maintenance, oxidized low-density lipoprotein (ox-LDL) and other lipoproteins in obese men.

METHODS

A 2-month weight reduction phase (WRP) with a very-low-energy diet was followed by a 6-month weight maintenance period and an unsupervised 2-year follow-up. Ninety men entered and 68 (76%) completed the study. Subjects were analyzed as one group and after division into two subgroups: 20 most successful men in maintaining the lost weight (subgroup 1) and the remaining (n=48) men (subgroup 2). Ox-LDL was measured by quantifying the amount of conjugated dienes in LDL particles.

RESULTS

The mean (+/-s.d.) weight reduction at the end of the WRP (n=68) was 14% (confidence interval (CI) 12.9-14.7%, 14.5+/-4.2 kg, P<0.001). Ox-LDL decreased by 22% (CI 16.9-28.1, 12.3+/-15.4 micromol/l, P<0.001). At the end of the 2-year follow-up, the regain in weight from the end of the WRP was 11% (CI 9.0-12.4, 9.6+/-6.2 kg, P<0.001). The regain in ox-LDL was 30% (CI 18.7-41.2, 8.2+/-15.4 micromol/l, P<0.001). In subgroup 1 vs 2, the respective regains were 3% (CI 0.9-4.2, 2.2+/-3.0 kg, P=0.006) vs 14% (CI 12.7-15.6, 12.9+/-4.0 kg, P<0.001) regarding weight and 9% (2.0+/-6.9 micromol/l, P=NS) vs 39% (CI 23.7-53.9, 11.2+/-17.2 micromol/l, P</=0.001) in ox-LDL.

CONCLUSION

The favorable changes seen in ox-LDL particles and serum lipids during weight reduction could be maintained by keeping the weight reduced, which may indicate decreased risk of atherosclerosis. But weight regain causes a resurge of ox-LDL.

Adipocyte: a potential target for the treatment of atherosclerosis

Obesity is an independent risk factor for coronary heart disease, whereas the underlying mechanisms have not been fully elucidated. Adipocytes may produce various adipokines with favorable and unfavorable cardiovascular effects. The dysregulated secretion of adipokines by adipocytes may contribute to obese associated atherosclerosis. Adipocytes can also function as phagocytes to uptake and degrade oxidized low-density lipoprotein (Ox-LDL), suggesting that adipocytes possibly involve in clearance of Ox-LDL in blood. The dysfunctional adipocytes might be implicated in the atherogenesis. Some cardioprotective drugs mediate their cardiovascular benefits partly through their direct beneficial effects on adipocytes. Therefore, we hypothesized that adipocytes might be potential target for the treatment of atherosclerosis.

Circulating oxidized LDL is associated with increased waist circumference independent of body mass index in men and women

BACKGROUND

Obesity is associated with oxidative stress, and the oxidation of LDL is thought to play a crucial role in the generation of atherosclerotic lesions.

OBJECTIVE

The objective was to describe the association of waist circumference (WC) and body mass index (BMI; in kg/m2) with plasma circulating oxidized LDL (ox-LDL) and C-reactive protein (CRP).

DESIGN

This cross-sectional study included data for circulating ox-LDL and CRP from a subpopulation of 586 men and women enrolled in a population-based survey conducted in 2000 in Girona, Spain. Multivariate analysis was performed to describe the independent association of WC and BMI with ox-LDL and CRP.

RESULTS

Multivariate logistic regression analysis adjusted for lifestyle, educational level, and dietary confounders showed a direct association of WC (quartile distribution) and BMI categories with ox-LDL (P for linear trend = 0.002) and CRP (P for linear trend = 0.004). Subjects in the top quartile of WC and with a BMI > 29.9 were at high risk of elevated circulating concentrations of ox-LDL and CRP. Further adjustment for cardiovascular disease risk factors did not substantially modify these associations. The risk of high ox-LDL concentrations in overweight (BMI = 25.0-29.9) or obese (BMI > or = 30) subjects with a WC < 102 cm (men) or < 88 cm (women) was not significantly different from that in normal-weight subjects with these WCs. In contrast, overweight or obese subjects with higher WCs (WC > or = 102 cm for men and > or = 88 cm for women) were at significantly higher risk of increased ox-LDL.

CONCLUSION

High WC was associated with high concentrations of ox-LDL independently of BMI in the study population.

Weight loss associated with reduced intake of carbohydrate reduces the atherogenicity of LDL in premenopausal women

The effect of a 3-tier intervention including dietary modifications (ie, moderate energy restriction, decreased carbohydrate, increased protein), increased physical activity, and the use of carnitine as a dietary supplement was evaluated on plasma lipids and the atherogenicity of low-density lipoprotein (LDL) particles in a population of overweight and obese premenopausal (aged 20-45 years) women. Carnitine or a placebo (cellulose) was randomly assigned to the participants using a double-blind design. Carnitine supplementation was postulated to enhance fat oxidation resulting in lower concentrations of plasma triglycerides. Seventy women completed the 10-week protocol, which followed a reduction in their energy intake by 15% and a macronutrient energy distribution of 30% protein, 30% fat, and 40% carbohydrate. In addition, subjects increased the number of steps taken per day by 4500. As no differences were observed between the carnitine and placebo groups in all the measured parameters, all subjects were pooled together for statistical analysis. Participants decreased (P<.01) their caloric intake (between 4132.8 and 7770 kJ) and followed prescribed dietary modifications as assessed by dietary records. The average number of steps increased from 8950+/-3432 to 12764+/-4642 (P<.001). Body weight, plasma total cholesterol, LDL cholesterol, and triglyceride were decreased by 4.5%, 8.0%, 12.3%, and 19.2% (P<.0001), respectively, after the intervention. Likewise, apolipoproteins B and E decreased by 4.5% and 15% (P<.05) after 10 weeks. The LDL mean particle size was increased from 26.74 to 26.86 nm (P<.01), and the percent of the smaller LDL subfraction (P<.05) was decreased by 26.5% (P<.05) after 10 weeks. In addition, LDL lag time increased by 9.3% (P<.01), and LDL conjugated diene formation decreased by 23% (P<.01), indicating that the susceptibility of LDL to oxidation was decreased after the intervention. This study suggests that moderate weight loss (<5% of body weight) associated with reduced caloric intake, lower dietary carbohydrate, and increased physical activity impacts the atherogenicity of LDL.

Diet and lipoprotein oxidation: analysis of oxidized triacylglycerols in pig lipoproteins

Oxidized lipoproteins have a recognized role in atherogenesis, but molecular-level research on oxidized lipids in lipoproteins and the effect of diet on these molecules have been limited. In the present study, the effects of three sunflower seed oil diets differing in oxidation levels (PV in oils 1, 84, and 223 mequiv O2/kg) on lipoprotein lipid oxidation in growing pigs were investigated. The emphasis was on the investigation of oxidized TAG molecules found in chylomicrons and VLDL. A method based on RP-HPLC and electrospray ionization-MS was used for the analysis of oxidized TAG molecules. The baseline diene conjugation method was used for the estimation of in vivo levels of lipoprotein lipid oxidation. Several oxidized TAG structures were found in the samples. These products consisted of TAG molecules with a hydroxy, an epoxy, or a keto group attached to a FA, and of TAG molecules containing an aldehyde structure derived from a FA. The lipoprotein lipids and TAG were more oxidized in the pigs fed on the most oxidized oil compared with those fed on nonoxidized oil. Oxidation of dietary fat was reflected in the lipoprotein oxidation. New, detailed information on oxidized TAG molecules of chylomicrons and VLDL was obtained.

Changes in plasma antioxidant capacity and oxidized low-density lipoprotein levels in men after short-term cranberry juice consumption

Low-density lipoprotein (LDL) oxidation is closely implicated in the development of atherosclerotic cardiovascular disease (CVD), and thus, reducing LDL susceptibility to oxidation with antoxidants could be of importance in CVD prevention. Flavonoids, polyphenolic compounds found in a large selection of fruits and vegetables, have been characterized as having a strong antioxidant potential, and intake of flavonoid-rich foods has been related to decreased morbidity and mortality from heart disease. The present study was therefore undertaken to investigate the effect of flavonoid-rich cranberry juice supplementation on plasma lipoprotein levels and LDL oxidation. For that purpose, 21 men (age +/- SD, 38 +/- 8 years) were enrolled in a 14-day intervention and instructed to drink cranberry juice 7 mL/kg body weight per day. Physical and metabolic measures including plasma lipid and oxidized LDL (OxLDL) concentrations as well as antioxidant capacity were performed before and after the intervention. At baseline, we found that plasma OxLDL levels were significantly associated with waist circumference ( r = 0.47, P = .0296) as well as plasma triglyceride ( r = 0.68, P = .0007) and apolipoprotein B ( r = 0.91, P < .0001) concentrations. The intervention led to a reduction in plasma OxLDL levels (-9.9% +/- 17.8%, P = .0131) and increase in antioxidant capacity (+6.5% +/- 10.3%, P = .0140). However, no relationship was found between both of these changes ( r = -.01, not significant). The intervention did not result in any improvement of plasma lipoprotein-lipid or inflammatory marker concentrations. Our results show that short-term cranberry juice supplementation is associated with significant increase in plasma antioxidant capacity and reduction in circulating OxLDL concentrations. Although the physiological relevance of our observations needs to be further examined, our study supports the potential role of antioxidant-rich foods in maintaining health and preventing CVD.

Lipid peroxides in obese patients and effects of weight loss with orlistat on lipid peroxides levels

OBJECTIVE

Obesity is a well-known risk factor of atherosclerosis. Recent studies showed that obesity is associated with enhanced lipid peroxidation. The aim of this study is to investigate the effect of weight reduction with orlistat treatment on lipid peroxidation levels. We assessed lipid peroxidation by measuring the concentration of plasma malondialdehyde (MDA).

DESIGN

A randomized, controlled, open-label 6-month study.

SUBJECTS

In total, 36 obese (body mass index (BMI) >30 kg/m2) and 11 healthy age-matched control subjects were enrolled in the study.

MEASUREMENTS

Fasting glucose, triglyceride, total cholesterol, HDL cholesterol and LDL cholesterol and MDA levels were measured in both groups. Obese subjects received orlistat, 120 mg three times daily together with hypocaloric diet. After 6 months of treatment laboratory tests were repeated.

RESULTS

MDA levels were significantly higher in obese patients than the control group (P<0.0001). After 6 months of treatment in obese subjects, the mean weight of the patients decreased by 6.8 kg, the BMI by 3.2 kg/m2. Plasma MDA levels were significantly reduced by weight loss from 2+/-0.77 to 0.89+/-0.41 nmol/ml (P<0.001). BMI correlated with MDA levels at baseline (r=0.6, P<0.0001). Changes in BMI was positively associated with plasma MDA level reduction (r=0.36, P<0.05).

CONCLUSION

These results indicate that obesity is associated with increases in endogenous lipid peroxides. Our data show that the indicator of lipid peroxidation-MDA-falls markedly in association with weight loss with orlistat. The demonstration of decreased free radical generation has important implications for oxidative mechanism underlying obesity-associated disorders.

Blood lipid and oxidative stress responses to soy protein with isoflavones and phytic acid in postmenopausal women

BACKGROUND

Postmenopausal women are at risk of cardiovascular disease (CVD) as a result of unfavorable blood lipid profiles and increased oxidative stress. Soy protein consumption may help protect against these risk factors.

OBJECTIVE

Our objective was to ascertain the effect of the soy protein components isoflavones and phytate on CVD risk in postmenopausal women.

DESIGN

In a double-blind 6-wk study, 55 postmenopausal women were randomly assigned to 1 of 4 treatments with soy protein (40 g/d) isolate (SPI): low phytate/low isoflavone (LP/LI); normal phytate/low isoflavone (NP/LI); low phytate/normal isoflavone (LP/NI); or normal phytate/normal isoflavone (NP/NI). Blood lipids (total, LDL, and HDL cholesterol and triacylglycerol) and oxidative stress indexes (protein carbonyls, oxidized LDLs, and 8-iso-prostaglandin-F(2alpha)) were measured at baseline and 6 wk.

RESULTS

The oxidative stress indexes were not significantly affected by either phytate or isoflavones. Phytate treatment had a minimal but nonsignificant effect in reducing protein carbonyls and 8-iso-prostaglandin-F(2alpha); the reductions were 6-8% and 4-6% in the NP/LI and NP/NI groups and 1-4% and 3-4% in the LP/LI and LP/NI groups, respectively. Similarly, circulating lipids were not significantly affected by either phytate or isoflavones. The decline in total (6%-7% compared with 2%-4%) and LDL (10%-11% compared with 3%-7%) cholesterol did not differ significantly between the normal- and low-isoflavone groups, respectively.

CONCLUSION

In postmenopausal women, neither phytate nor isoflavones in SPI have a significant effect of reducing oxidative damage or favorably altering blood lipids.

Serum Oxidized Low-Density Lipoprotein Levels and Risk of Colorectal Cancer: A Case-Control Study Nested in the Japan Collaborative Cohort Study

Oxidative stress plays an important role in carcinogenesis, but few epidemiologic studies have examined associations with risk of colorectal cancer. Relationships between serum levels of oxidized low-density lipoprotein (oxLDL) and oxLDL antibody (oLAB) and colorectal cancer risk were investigated in a case-control study nested in the Japan Collaborative Cohort Study for Evaluation of Cancer Risk. Serum samples and lifestyle information were collected at baseline from 39,242 men and women between 1988 and 1990. Of these, 161 incidents and deaths from colorectal cancer were identified through 1999, and 395 controls were matched for gender, age, and study area. Measurements were taken of serum oxLDL levels in 119 cases and 316 controls and serum oLAB levels in 153 cases and 376 controls. Odds ratios (95% confidence intervals) across quartiles, adjusted for confounding factors, were 1.55 (0.70-3.46), 1.90 (0.84-4.28), and 3.65 (1.50-8.92) for oxLDL (Ptrend = 0.004) and 0.98 (0.54-1.80), 0.75 (0.39-1.48), and 1.68 (0.90-3.13) for oLAB (Ptrend = 0.140). Further adjustment for serum total cholesterol and α-tocopherol did not materially change these associations. Odds ratio (95% confidence interval) of the highest quartile of serum oxLDL compared with the lowest quartile was 3.40 (1.09-10.58; Ptrend = 0.045). Analyses restricted to colon cancer cases and corresponding controls yielded similar relationships between serum oxLDL and oLAB levels and risk. In conclusion, higher levels of serum oxLDL may increase risk of colorectal cancer.

Circulating leptin is associated with oxidized LDL in postmenopausal women

Recently, leptin has been suggested as a possible cause of atherosclerotic disease. In the present study, we have investigated in postmenopausal women (n = 60; age: 52 +/- 13) the relationship between circulating levels of leptin, oxidized LDL (Ox-LDL) and other biochemical and anthropometric variables of atherosclerotic risk. In addition, we have evaluated soluble thrombomodulin (sTM) as a marker of endothelial damage. An additional study was conducted in a subgroup of obese subjects to determine the short-term effects of weight loss on selected variables. Ox-LDL showed a positive correlation with leptin circulating levels (r = 0.65, P < 0.0001). A significant association was also found between Ox-LDL and body mass index (r = 0.69, P < 0.0001), waist-to-hip ratio (r = 0.50, P < 0.0001), insulin levels (r = 0.65, P < 0.0001), HOMA index (r = 0.55, p < 0.0001) and sTM (r = 0.74, P < 0.0001) levels. After multivariate regression analysis leptin was still related to Ox-LDL levels (P = 0.007). In obese women who completed the program of weight reduction, leptin changes persisted as a significant predictor of plasma changes in Ox-LDL levels. These findings suggested a novel link between leptin and Ox-LDL, possibly involved in atherosclerotic disease.

New approach to the analysis of oxidized triacylglycerols in lipoproteins

The oxidation of human LDL lipids and the structures of oxidized TAG molecules found in LDL were investigated. Pooled samples of 10 normolipidemic and 10 hyperlipidemic subjects were analyzed. For determination of the oxidation levels, the LDL baseline diene conjugation (LDL-BDC) method was used. A method based on HPLC and electrospray ionization-MS was optimized and applied to the analysis of molecular structures of oxidized TAG in LDL. Differences were found between the oxidation levels of the samples. The LDL-BDC value was 22.2 micromol/L serum in the normolipidemic group, and 88.1 micromol/L serum in the hyperlipidemic group. The amounts of oxidized TAG molecules were small. However, several species of oxidized TAG were identified. These included TAG molecules with a keto or an epoxy group attached to a FA, and TAG molecules with a FA core aldehyde. In some TAG, the keto/epoxy ratio was greater in the hyperlipidemic group compared to the normolipidemic group. The results show that our approach is applicable to research on lipid oxidation in lipoproteins.

Oxidized low-density lipoprotein autoantibodies in patients with primary gout: effect of urate-lowering therapy

BACKGROUND

Uric acid is a strong scavenger of reactive oxygen species, which are known to contribute to the development of atherosclerosis, while the incidence of atherosclerotic diseases is rather high in patients with gout. Among the established risk factors for atherosclerosis, oxidized LDL is believed to play a major role in its development and progression. Allopurinol and its active metabolite, oxypurinol, have been suggested to possess an antioxidant ability to scavenge the hydroxyl radical. Therefore, allopurinol may be beneficial in the prevention of LDL oxidation, as well as in the treatment of hyperuricemia. The objective of this work was to determine the degree of LDL oxidation in gout and the effect of allopurinol on LDL oxidation.

METHODS

Age-matched male patients with primary intercritical gout and healthy male adults were included in the study. The serum concentrations of oxidized LDL autoantibodies and total antioxidant status were measured using an enzyme immunoassay.

RESULTS

Serum concentrations of oxidized LDL autoantibodies were significantly higher in patients with gout than the control subjects (p < 0.05) and were significantly decreased after allopurinol treatment (p < 0.05), but not by benzbromarone treatment, in spite of the similar concentrations of uric acid and total antioxidant status in serum following their separate administration.

CONCLUSIONS

Although the exact mechanism remains unclear, increased serum concentrations of oxidized LDL may play a role in the high incidence of coronary artery disease in gout. In addition, allopurinol may be more preferable to benzbromarone for treatment of gout in light of its inhibitory action toward LDL oxidation.

Weight Reduction With Very-Low-Caloric Diet and Endothelial Function in Overweight Adults: Role of Plasma Glucose

OBJECTIVE

Obesity is associated with endothelial dysfunction that may contribute to the development of atherosclerosis. We studied whether weight reduction improves endothelial function in overweight individuals.

METHODS AND RESULTS

Flow-mediated endothelium-dependent vasodilation of the brachial artery was measured in 67 adults (age: 46+/-7 years, body mass index: 35.2+/-5.4 kg/m2) before and after a 6-week weight reduction program induced by very-low-calorie diet (daily energy: 580 kcal/2.3 MJ). Caloric restriction reduced body weight from 101+/-18 to 90+/-17 kg. Flow-mediated vasodilation increased from 5.5%+/-3.7 to 8.8%+/-3.7% (P<0.0001). Nitrate-mediated vasodilation was not significantly affected. The improvement in flow-mediated dilation was associated with the reduction in plasma glucose concentration (P=0.0003). This relationship was independent of changes in weight, serum lipids, oxidized LDL, C-reactive protein, adiponectin, blood pressure, and insulin.

CONCLUSIONS

Weight reduction with very-low-calorie diet improves flow-mediated vasodilation in obese individuals. This improvement is related to the reduction in plasma glucose concentration. These observations suggest that changes in glucose metabolism may determine endothelial vasodilatory function in obesity.

Morbidity of severe obesity

Although obesity is an easy diagnosis to make, its etiologies, pathophysiology, and symptomatology are extraordinarily complex. Progress in surgical technique and anesthesiological management has substantially improved the safety of performing operations on the severely obese in the last 20 years. These improvements have occurred more or less empirically, without a full understanding of etiology or pathophysiology, although this has advanced concomitantly with improvements in practice. This review has attempted to provide a framework to facilitate progress in the neglected areas of patient selection and choice of operation, in an effort to improve long-term outcome. Despite the disparate etiologies of obesity and its diverse comorbidities and complications, there are unifying interdependent pathogenetic mechanisms of great relevance to the practice of antiobesity surgery. The rate of eating, whether driven by HPA dysfunction, ambient stress, or related hereditary susceptibility factors including the increased energy demands of an expanded body fat mass, participates in a cycle that results in disordered satiety (see Fig. 3). This leads to substrate overload, causing extensive metabolic abnormalities such as atherogenesis, insulin resistance, thrombogenesis, and carcinogenesis. This interpretation of the pathophysiology of obesity ironically accords with the original meaning of the word obesity: "to overeat." The ultimate solution to the problem of obesity--preventing it--will not be forthcoming until the food industry is forced to lower production and change its marketing strategies, as the liquor and tobacco industries in the United States were compelled to do. This cannot occur until the large and fast-growing populations of industrialized nations become educated in the personal implications of the energy principle. Regardless of whether school curricula are modified to prioritize health education, the larger problems of cultural and economic change remain for the groups most susceptible to obesity. In this context, antiobesity surgery will continue to thrive, especially in the absence of effective alternatives.