The trials and tribulations of the treatment of nonalcoholic fatty-liver disease

Cardiometabolic aspects of the polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder amongst women of reproductive age and is associated with various metabolic perturbations, in addition to chronic anovulation and factors related to androgen excess. In general, women live longer than men and develop cardiovascular disease at an older age. However, women with PCOS, as compared with age- and body mass index-matched women without the syndrome, appear to have a higher risk of insulin resistance, hyperinsulinemia, glucose intolerance, dyslipidemia, and an increased prothrombotic state, possibly resulting in a higher rate of type 2 diabetes mellitus, fatty liver disease, subclinical atherosclerosis, vascular dysfunction, and finally cardiovascular disease and mortality. Further alterations in PCOS include an increased prevalence of sleep apnea, as well as various changes in the secretion and/or function of adipokines, adipose tissue-derived proinflammatory factors and gut hormones, all of them with direct or indirect influences on the complex signaling network that regulates metabolism, insulin sensitivity, and energy homeostasis. Reviews on the cardiometabolic aspects of PCOS are rare, and our knowledge from recent studies is expanding rapidly. Therefore, it is the aim of the present review to discuss and to summarize the current knowledge, focusing on the alterations of cardiometabolic factors in women with PCOS. Further insight into this network of factors may facilitate finding therapeutic targets that should ameliorate not only ovarian dysfunction but also the various cardiometabolic alterations related to the syndrome.

Fatty liver and global cardiometabolic risk

A nem alkoholos zsírmáj betegség (NAFLD = nonalcoholic fatty liver disease) az „iparilag fejlett” országok felnőtt lakosságának 30%-ában észlelhető. Előrehaladott, súlyosabb formája a nem alkoholos steatohepatitis (NASH = nonalcoholic steatohepatitis), amelyből az esetek 20%-ában cirrhosis alakul ki, a kialakult cirrhosis mintegy 30–40%-a májeredetű halálhoz, elsősorban hepatocellularis carcinomához vezethet. Az NAFLD-t sokan a metabolikus szindróma májbeli manifesztációjának tartják, e két jelenség kapcsolatát tekintjük át, különös tekintettel a hasi elhízás, az inzulinrezisztencia, az oxidatív stressz és a csökkent antioxidáns védelem kóroki szerepére. A májsejtek trigliceridtartalmának növekedése együtt jár az egész szervezet, illetve a máj inzulinrezisztenciájával. Klasszikus tyúk–tojás probléma: a lipidlerakódás oka az inzulinrezisztencia, vagy az inzulinrezisztencia az ectopiás lipidfelhalmozódás következménye? A patogenetikai történések egy lehetséges sorrendje: megnövekedett zsírsavfluxus, a májbeli zsírsavkínálat növekedése → VLDL-túltermelődés, atherogen dyslipidaemia → a zsírsavak fokozott oxidációja és peroxidációja, enormis szabadgyök-terhelés → az antioxidáns védekezőrendszer kimerülése → a gyulladást és az immunválaszt kiváltó mediátorok „cunamiszerű” kiáramlása → a fibrosis progresszióját elősegítő transzkripciós és transzlációs változások → carcinogenesis. Az NAFLD és a metabolikus szindróma egyaránt része a globális kardiometabolikus kockázatnak, így lényeges a korai felismerés, és – amennyiben lehetséges a kezelés – ez ma a metabolikus szindróma részelemeinek kezelési ajánlásaiban testesül meg. Orv. Hetil., 2010, 47, 1946–1950.

Flax oil-mediated activation of PPAR-γ correlates with reduction of hepatic lipid accumulation in obese spontaneously hypertensive/NDmcr-cp rats, a model of the metabolic syndrome

Flax oil feeding has been proposed to have beneficial effects on the outcome of the metabolic syndrome due to the high n-3 fatty acid content of flax oil; however, the mechanisms of its action remain largely unknown. We investigated the effects of flax oil feeding on hyperlipidaemia, hyperglycaemia, hepatic steatosis and oxidative stress in the spontaneously hypertensive (SHR)/NDmcr-cp rats, a genetic model of the metabolic syndrome. Hepatic gene expression of PPAR-α, PPAR-γ and sterol-regulatory element-binding protein-1c was also assessed in order to investigate the possible underlying mechanisms. Obese and lean SHR/NDmcr-cp rats were fed high-fat diets enriched with either lard or flax oil for a period of 4 weeks. Obese rats exhibited higher body weight, liver weight and mesenteric fat-, epididymal fat- and renal fat-pad weights, and also TAG and cholesterol concentrations in serum and VLDL, LDL and HDL fractions, when compared with the lean rats (P < 0·001), irrespective of the diets. Concentrations of fasting serum insulin and urinary thiobarbituric acid reactive substances were lower in flax oil-fed obese (FO) rats compared with the lard-fed obese (LO) rats (P < 0·01). Flax oil feeding also revealed a significant reduction in hepatic TAG and cholesterol concentrations in obese rats compared with the LO rats (P < 0·05). In addition, FO rats exhibited significantly higher hepatic mRNA expression of PPAR-γ, which negatively correlated (r - 0·98, P < 0·05) with their hepatic lipid levels. These findings suggest that flax oil feeding may activate PPAR-γ-dependent pathways to alter the hepatic lipid metabolism and to increase insulin sensitivity in the obese SHR/NDmcr-cp rats.

Omega-3 fatty acid supplementation decreases liver fat content in polycystic ovary syndrome: a randomized controlled trial employing proton magnetic resonance spectroscopy

CONTEXT

There is an association between nonalcoholic fatty liver disease (NAFLD) and the polycystic ovary syndrome (PCOS). Marine-derived omega-3 fatty acids have favorable effects on cardiovascular risk and could reduce liver fat in NAFLD.

OBJECTIVE

The primary aim of this study was to examine the effects of omega-3 fatty acids on liver fat in PCOS. The secondary aim was to assess their effects on traditional cardiovascular risk factors.

DESIGN AND SETTING

We conducted a randomized, crossover study at a tertiary cardiovascular research center.

SUBJECTS

Twenty-five women with PCOS (mean age, 32.7 yr; mean body mass index, 34.8 kg/m(2)) participated in the study.

INTERVENTION

We compared 4g/d of omega-3 fatty acids with placebo over 8 wk.

MAIN OUTCOME MEASURES

The primary outcome measure was hepatic fat content quantified using proton magnetic resonance spectroscopy. Secondary outcome measures included fasting lipids and blood pressure.

RESULTS

Omega-3 fatty acids significantly decreased liver fat content compared with placebo [10.2 (1.1) vs. 8.4 (0.9)%; P = 0.022]. There was also a reduction in triglycerides [1.19 (1.03-1.47) vs. 1.02 (0.93-1.18) mmol/liter; P = 0.002], systolic blood pressure [124.1 (12.1) vs. 122.3 (14.5) mm Hg; P = 0.018], and diastolic blood pressure [73.2 (8.4) vs. 69.7 (8.3) mm Hg; P = 0.005] with omega-3 fatty acids compared with placebo. Omega-3 fatty acids particularly decreased hepatic fat in women with hepatic steatosis, defined as liver fat percentage greater than 5% [18.2 (11.1) vs. 14.8 (9.3)%; P = 0.03].

CONCLUSIONS

Omega-3 fatty acid supplementation has a beneficial effect on liver fat content and other cardiovascular risk factors in women with PCOS, including those with hepatic steatosis. Whether this translates into a reduction in cardiometabolic events warrants further study.