Non-invasive methods for the assessment of brown adipose tissue in humans

Are MTV and TLG Accurate for Quantifying the Intensity of Brown Adipose Tissue Activation?

Recent research has suggested that one novel mechanism of action for anti-obesity medications is to stimulate the activation of brown adipose tissue (BAT). 18FDG PET/CT remains the gold standard for defining and quantifying BAT. SUVmax is the most often used quantification tool in clinical practice. However, this parameter does not reflect the entire BAT volume. As a potential method for precisely evaluating BAT, we have utilised metabolic tumour volume (MTV) and total lesion glycolysis (TLG) to answer the question: Are MTV and TLG accurate in quantifying the intensity of BAT activation? After analysing the total number of oncological 18F-FDG PET/CT scans between 2021-2023, we selected patients with active BAT. Based on the BAT SUVmax, the patients were divided into BAT-moderate activation (MA) vs. BAT-high activation (HA). Furthermore, we statistically analysed the accuracy of TLG and MTV in assessing BAT activation intensity. The results showed that both parameters increased their predictive value regarding BAT activation, and presented a significantly high sensitivity and specificity for the correct classification of BAT activation intensity. To conclude, these parameters could be important indicators with increased accuracy for classifying BAT expression, and could bring additional information about the volume of BAT to complement the limitations of the SUVmax.

Emerging technologies in adipose tissue research

Technologies are transforming the understanding of adipose tissue as a complex and dynamic tissue that plays a critical role in energy homoeostasis and metabolic health. This mini-review provides a brief overview of the potential impact of novel technologies in biomedical research and aims to identify areas where these technologies can make the most significant contribution to adipose tissue research. It discusses the impact of cutting-edge technologies such as single-cell sequencing, multi-omics analyses, spatial transcriptomics, live imaging, 3D tissue engineering, microbiome analysis, in vivo imaging, and artificial intelligence/machine learning. As these technologies continue to evolve, we can expect them to play an increasingly important role in advancing our understanding of adipose tissue and improving the treatment of related diseases.

Brown Adipose Tissue-A Translational Perspective

Brown adipose tissue (BAT) displays the unique capacity to generate heat through uncoupled oxidative phosphorylation that makes it a very attractive therapeutic target for cardiometabolic diseases. Here, we review BAT cellular metabolism, its regulation by the central nervous and endocrine systems and circulating metabolites, the plausible roles of this tissue in human thermoregulation, energy balance, and cardiometabolic disorders, and the current knowledge on its pharmacological stimulation in humans. The current definition and measurement of BAT in human studies relies almost exclusively on BAT glucose uptake from positron emission tomography with 18F-fluorodeoxiglucose, which can be dissociated from BAT thermogenic activity, as for example in insulin-resistant states. The most important energy substrate for BAT thermogenesis is its intracellular fatty acid content mobilized from sympathetic stimulation of intracellular triglyceride lipolysis. This lipolytic BAT response is intertwined with that of white adipose (WAT) and other metabolic tissues, and cannot be independently stimulated with the drugs tested thus far. BAT is an interesting and biologically plausible target that has yet to be fully and selectively activated to increase the body's thermogenic response and shift energy balance. The field of human BAT research is in need of methods able to directly, specifically, and reliably measure BAT thermogenic capacity while also tracking the related thermogenic responses in WAT and other tissues. Until this is achieved, uncertainty will remain about the role played by this fascinating tissue in human cardiometabolic diseases.

Comparison of brown adipose tissue activation detected by infrared thermography in men with vs without metabolic syndrome

BACKGROUND

Brown adipose tissue (BAT) high density of mitochondria and its thermogenic characteristics promote the dissipation of chemical energy in the form of heat, increasing body caloric expenditure, decreasing plasma levels of lipids and glucose (GL). This makes BAT a potential therapeutic target of Metabolic Syndrome (MetS). Position Emission Tomography Scanning (PET-CT) is the gold standard for estimating BAT, but it has several limitations, including high cost and high emission of radiation. On the other hand, Infrared Thermography (IRT) is considered a simpler, cheaper and non-invasive method to detect BAT.

OBJECTIVE

The aim of this study was to compare BAT activation through IRT and cold stimulation in men diagnosed without and with MetS.

METHODS

Sample of 124 (35.3 ± 9.4 years old) men was evaluated of body composition, anthropometric measurements and dual X-ray absorptiometry (DXA) hemodynamics, biochemical tests and body skin temperature acquisition. The Student t-test with subsequent effect size by (d) Cohen and two-way repeated measures ANOVA with Tukey post-hoc comparisons were conducted. Level of significance was p < 0.05.

RESULTS

There was significant interaction between group factor (MetS) vs group moment (BAT activation) in supraclavicular skin temperatures right side (maximum (F_(1,122) = 10.4, p < 0.002, η² = 0.062), mean (F_(1.122) = 13.0, p < 0.001, η² = 0.081) and minimal (F_(1,122) = 7.9, p < 0.006, η² = 0.052)) and left side maximum (F_(1,122) = 7.7, p < 0.006, η² = 0.048), mean (F_(1.122) = 13.0, p < 0.037, η² = 0.007) and minimal (F_(1,122) = 9.8, p < 0.002, η² = 0.012)). The MetS risk factor group didn't present significant increase of SCV temperature BAT after cold stimulation.

CONCLUSION

Men diagnosed with MetS risk factors seem to activate less BAT, when exposed to cold stimulation, compared to group without MetS risk factor.

Thermogenic Brown Fat in Humans: Implications in Energy Homeostasis, Obesity and Metabolic Disorders

In mammals including humans, there are two types of adipose tissue, white and brown adipose tissues (BATs). White adipose tissue is the primary site of energy storage, while BAT is a specialized tissue for non-shivering thermogenesis to dissipate energy as heat. Although BAT research has long been limited mostly in small rodents, the rediscovery of metabolically active BAT in adult humans has dramatically promoted the translational studies on BAT in health and diseases. It is now established that BAT, through its thermogenic and energy dissipating activities, plays a role in the regulation of body temperature, whole-body energy expenditure, and body fatness. Moreover, increasing evidence has demonstrated that BAT secretes various paracrine and endocrine factors, which influence other peripheral tissues and control systemic metabolic homeostasis, suggesting BAT as a metabolic regulator, other than for thermogenesis. In fact, clinical studies have revealed an association of BAT not only with metabolic disorders such as insulin resistance, diabetes, dyslipidemia, and fatty liver, but also with cardiovascular diseases including hypertension and atherosclerosis. Thus, BAT is an intriguing tissue combating obesity and related metabolic diseases. In this review, we summarize current knowledge on human BAT, focusing its patho-physiological roles in energy homeostasis, obesity and related metabolic disorders. The effects of aging and sex on BAT are also discussed.

Reducing White Adipose Tissue Browning Using p38α MAPK Inhibitors Ameliorates Cancer-Associated Cachexia as Assessed by Magnetic Resonance Imaging

Background: Up to 80% of pancreatic cancer patients suffer from cachexia. White adipose tissue (WAT) browning caused by the tumorigenicity and progression aggravates the cancer-associated cachexia (CAC). Cancer-initiated changes in the protein-38 mitogen-activated protein kinases (p38 MAPK) pathway are likely involved in the development of CAC. Methods: p38 MAPK inhibitors, VCP979 or SB203580, were used in the in vitro and in vivo models of pancreatic cancer cachexia. Expression of uncoupling protein 1 (UCP1) in the p38 MARK pathway and the properties and level of white adipocytes were analyzed and correlated to browning, followed by immunohistochemistry and Western blotting validations. Changes in the volume and fat fraction of WAT in animals were monitored by magnetic resonance imaging (MRI). Results: The size of white adipocytes was increased after being treated with the p38 MAPK inhibitors, along with increase in the MRI-measured volume and fat fraction of WAT. Comparing two p38 MAPK inhibitors, the p38α subunit-specific inhibitor VCP979 had a better therapeutic effect than SB203580, which targets both p38α and β subunits. Conclusions: Blockade of p38 MAPK reduced the WAT browning that contributes to CAC. Thus, p38 MARK inhibitors can potentially be used as a therapy for treating CAC. Non-invasive MRI can also be applied to assess the progression and treatment responses of CAC.

Raman studies of the adipose tissue: Current state-of-art and future perspectives in diagnostics

The last decades revealed that the adipose tissue shows an unexplored therapeutic potential. In particular, targeting the perivascular adipose tissue (PVAT), that surrounds blood vessels, can prevent cardiovascular pathologies and browning of the adipose tissue can become an effective strategy against obesity. Therefore, new analytical tools are necessary to analyze this tissue. This review reports on the recent developments of various Raman-based techniques for the identification and quantification of the adipose tissue compared to conventional analytical methods. In particular, the emphasis is on analysis of PVAT, investigation of pathological changes of the adipose tissue in model systems and possibilities for its characterization in the clinical context. Overall, the review critically discusses the potential and limitations of Raman techniques in adipose tissue-targeted diagnostics and possible future anti-obesity therapies.

Computed Tomography Image Analysis of Body Fat Based on Multi-Image Information

Body fat assessment is required as part of an objective health assessment, both for nonobese and obese people. Image-based body fat assessment will enable faster diagnosis. Body fat analysis that accounts for age and sex will help in both diagnosis and correlating diseases and fat distribution. After evaluating computed tomography imaging algorithms to identify and segment human abdominal and subcutaneous fat, we present an improved region growing scale-invariant feature transform algorithm. It applies Naive Bayes image thresholding for key point selection and image matching. This method enables rapid and accurate comparison and matching of images from multiple databases and improves the efficiency of image processing.

Evaluation of brown adipose tissue with intermolecular double-quantum coherence magnetic resonance spectroscopy at 3.0 T

In the current study, we propose a single-voxel (SV) magnetic resonance spectroscopy (MRS) pulse sequence, based on intermolecular double-quantum coherence (iDQC), for in vivo specific assessment of brown adipose tissue (BAT) at 3 T. The multilocular adipocyte, present in BAT, typically contains a large number of small lipid droplets surrounded by abundant intracellular water, while the monolocular adipocyte, present in white adipose tissue (WAT), accommodates only a single large lipid droplet with much less water content. The SV-iDQC sequence probes the spatial correlation between water and fat spins at a distance of about the size of an adipocyte, thus can be used for assessment of BAT, even when mixed with WAT and/or muscle tissues. This sequence for measurement of water-to-fat (water-fat) iDQC signals was tested on phantoms and mouse BAT and WAT tissues. It was then used to differentiate adipose tissues in the supraclavicular and subcutaneous regions of healthy youth human volunteers (n = 6). Phantom results with water-fat emulsions demonstrated enhanced water-fat iDQC signal with increased voxel size, increased energy level of emulsification, or increased distribution balance of water and fat spins. The animal tissue experiments resulted in obvious water-fat iDQC signal in mouse BAT, while this signal was almost absent in the WAT spectrum. The optimal choice of the dipolar coupling distance for the observation was approximately 100 μm, as tested on both emulsion phantom and animal tissue. The water-fat iDQC signals observed in the supraclavicular adipose tissues were higher than in the subcutaneous adipose tissues in healthy young volunteers (0.43 ± 0.36 vs. 0.10 ± 0.06, p = 0.06). It was concluded that the iDQC-based sequence has potential for assessment of mouse and human BAT at 3 T, which is of interest for clinical research and the diagnosis of obesity and associated diseases.

Imaging Adipose Tissue Browning using Mitochondrial Complex-I Tracer [18F]BCPP-EF

Browning of white adipose tissue (WAT) into beige adipocytes has been proposed as a strategy to tackle the ongoing obesity epidemic. Thermogenic stimuli have been investigated with the aim of converting existing white adipose tissue, primarily used for energy storage, into beige adipocytes capable of dissipating energy; however, evaluation is complicated by the dearth of noninvasive methodologies to quantify de novo beige adipocytes in WAT. Imaging with [¹⁸F]FDG is commonly used to measure brown adipose tissue (BAT) and beige adipocytes but the relationship between beige adipocytes, thermogenesis and [¹⁸F]FDG uptake is unclear. [¹⁸F]BCPP-EF, a tracer for mitochondrial complex-I (MC-I), acts as a marker of oxidative metabolism and may be useful for the detection of newly formed beige adipocytes. Mice received doses of the β3-adrenergic agonist CL-316,243 subchronically for 7 days to induce formation of beige adipocytes in inguinal white fat. PET imaging was performed longitudinally with both [¹⁸F]FDG (a marker of glycolysis) and [¹⁸F]BCPP-EF (an MC-I marker) to assess the effect of thermogenic stimulation on uptake in browning inguinal WAT and interscapular BAT. Treatment with CL-316,243 led to significant increases in both [¹⁸F]FDG and [¹⁸F]BCPP-EF in inguinal WAT. The uptake of [¹⁸F]BCPP-EF in inguinal WAT was significantly increased above control levels after 3 days of stimulation, whereas [¹⁸F]FDG only showed a significant increase after 7 days. The uptake of [¹⁸F]BCPP-EF in newly formed beige adipocytes was blocked by pretreatment with an adrenoceptor antagonist suggesting that beige adipocyte formation may be associated with the activation of MC-I. However, in BAT, uptake of [¹⁸F]BCPP-EF was unaffected by β3-adrenergic stimulation, potentially due to the high expression of MC-I. [¹⁸F]BCPP-EF can detect newly formed beige adipocytes in WAT generated after subchronic treatment with the β3-adrenergic agonist CL-316,243 and displays both higher inguinal WAT uptake and earlier detection than [¹⁸F]FDG. The MC-I tracer may be a useful tool in the evaluation of new therapeutic strategies targeting metabolic adipose tissues to tackle obesity and metabolic diseases.

Brown adipose tissue: a protective mechanism in "pre-prediabetes"?

Brown adipose tissue (BAT) is present in a significant number of adult humans and has been postulated to exert beneficial metabolic effects. Lean, non-diabetic patients undergoing clinical positron emission tomography (PET)/computed tomography (CT) imaging are more likely to exhibit incidental BAT activation. The aim of this study was to assess metabolic changes associated with the cold-activation of BAT and to compare baseline blood metabolites in participants with varying amounts of active BAT. Methods: Serum blood samples were collected from healthy adult volunteers (body mass index 18.0-25.0 and age≤35 years) before and after 2 h cold exposure. ¹⁸F-flurodeoxyglucose (FDG) PET/CT imaging was performed immediately following cold exposure. Activated BAT was segmented and fasting glucose, insulin, lipid, and other blood metabolite levels were correlated with volume and intensity of active BAT. Using a median cutoff, subjects were classified as BATHIGH or BATLOW. Results: A higher volume of activated BAT was associated with significantly higher pre-cooling glucose and insulin levels (P<0.001 for each). Pre-cooling thyroid stimulating hormone (TSH) and triglyceride levels were significantly higher in the BATHIGH than in the BATLOW group (P = 0.002 and P<0.001, respectively). Triglyceride levels tended to increase over the cooling period in both BAT groups, but increased significantly more in the BATHIGH group (15.7±13.2 md/dl; P<0.001) than in the BATLOW group (4.5±12.2 mg/dl; P = 0.061). Conclusion: These findings may indicate that BAT is recruited to counteract incipient "pre-prediabetic" states, potentially serving as a first-line protective mechanism against very early metabolic or hormonal variations.

Browning Epicardial Adipose Tissue: Friend or Foe?

The epicardial adipose tissue (EAT) is the visceral fat depot of the heart which is highly plastic and in direct contact with myocardium and coronary arteries. Because of its singular proximity with the myocardium, the adipokines and pro-inflammatory molecules secreted by this tissue may directly affect the metabolism of the heart and coronary arteries. Its accumulation, measured by recent new non-invasive imaging modalities, has been prospectively associated with the onset and progression of coronary artery disease (CAD) and atrial fibrillation in humans. Recent studies have shown that EAT exhibits beige fat-like features, and express uncoupling protein 1 (UCP-1) at both mRNA and protein levels. However, this thermogenic potential could be lost with age, obesity and CAD. Here we provide an overview of the physiological and pathophysiological relevance of EAT and further discuss whether its thermogenic properties may serve as a target for obesity therapeutic management with a specific focus on the role of immune cells in this beiging phenomenon.

Symposium review: The role of adipose tissue in transition dairy cows: Current knowledge and future opportunities

Adipose tissue (AT) is a central reservoir of energy stored in the form of lipids. In addition, AT has been recognized as an immunologically and endocrinologically active tissue of dairy cattle. The recent literature on AT biology of transition dairy cows has often focused on the possible negative effects that originate from excessive body fat. However, the highly efficient energy-storage capability of this tissue is also vital to the adaptability of dairy cattle to the change in nutrient availability, and to support lactation and reproduction. An excessive degree of mobilization of this tissue, however, is associated with high circulating fatty acid concentrations, and this may have direct and indirect negative effects on reproductive health, productivity, and disease risk. Furthermore, rapid lipolysis may be associated with postpartum inflammation. Research on the role of AT is complicated by the greater difficulty of accessing and measuring visceral AT compared with subcutaneous AT. The objective of this review is to provide a transition cow-centric summary of AT biology with a focus on reviewing methods of measuring AT mass as well as to describe the importance for production, health, and reproductive success.

BMP8 and activated brown adipose tissue in human newborns

The classical dogma states that brown adipose tissue (BAT) plays a major role in the regulation of temperature in neonates. However, although BAT has been studied in infants for more than a century, the knowledge about its physiological features at this stage of life is rather limited. This has been mainly due to the lack of appropriate investigation methods, ethically suitable for neonates. Here, we have applied non-invasive infrared thermography (IRT) to investigate neonatal BAT activity. Our data show that BAT temperature correlates with body temperature and that mild cold stimulus promotes BAT activation in newborns. Notably, a single short-term cold stimulus during the first day of life improves the body temperature adaption to a subsequent cold event. Finally, we identify that bone morphogenic protein 8B (BMP8B) is associated with the BAT thermogenic response in neonates. Overall, our data uncover key features of the setup of BAT thermogenesis in newborns.

Molecular Imaging of Brown Adipose Tissue Mass

Brown adipose tissue (BAT), a uniquely thermogenic tissue that plays an important role in metabolism and energy expenditure, has recently become a revived target in the fight against metabolic diseases, such as obesity, diabetes, and non-alcoholic fatty liver disease (NAFLD). Different from white adipose tissue (WAT), the brown adipocytes have distinctive features including multilocular lipid droplets, a large number of mitochondria, and a high expression of uncoupling protein-1 (UCP-1), as well as abundant capillarity. These histologic characteristics provide an opportunity to differentiate BAT from WAT using imaging modalities, such as PET/CT, SPECT/CT, MRI, NIRF and Ultrasound. However, most of the reported imaging methods were BAT activation dependent, and the imaging signals could be affected by many factors, including environmental temperatures and the states of the sympathetic nervous system. Accurate BAT mass detection methods that are independent of temperature and hormone levels have the capacity to track the development and changes of BAT throughout the lifetime of mammals, and such methods could be very useful for the investigation of potential BAT-related therapies. In this review, we focus on molecular imaging modalities that can detect and quantify BAT mass. In addition, their detection mechanism and limitations will be discussed as well.

Physically active men with high brown adipose tissue activity showed increased energy expenditure after caffeine supplementation

This study measured the effect of caffeine on brown adipose tissue (BAT) activity and the energy expenditure (EE) of subjects with high (HBAT) or low (LBAT) activation. We performed a quasi-experimental double-blind protocol in which 24 physically active healthy men were measured (age: 24.1 ± 6.0 yrs; BM: 75.3 ± 14.4 kg; HT: 171.8 ± 5.9 cm; BMI: 25.5 ± 4.9 kg/m²). Infrared thermography (IRT) protocol was used to separate the participants into the groups according to the BAT activation: high (HBAT; n = 11) and low (LBAT; n = 13). All participants ingested a single supplement caffeine capsule (CAF) of 375 mg (~5 mg/kg BM) or placebo (PLA). Our experimental protocol measured two groups (HBAT and LBAT) under two conditions (CAF and PLA), with intake 30-min before the data collection. BAT activity lasted 60-min (0, 10, 20, 30, 40, 50, 60 min) and was estimated by IRT in subclavicular (Δ SCV) and external (Δ EXT) regions of interest (ROI) and EE by indirect calorimetry. The main results indicated that HBAT at 40-min showed an increased EE versus the other groups and conditions (p = 0.009). There was a significant difference for BAT activation at the 30 (p = 0.019), 40 (p = 0.009), 50 (p = 0.007) and 60 min (p = 0.012) between HBAT-CAF vs. LBAT-CAF. There was also a significant difference at the 20 (p = 0.024), 30 (p = 0.036), 50 (p = 0.05) and 60 min (p = 0.011) between HBAT-CAF vs. HBAT-PLA. In conclusion CAF intake (≈5 mg) increases the thermogenic activity of BAT in healthy young men and increases EE in HBAT subjects.

Perspectives on Brown Adipose Tissue Imaging: Insights from Preclinical and Clinical Observations from the Last and Current Century

Brown adipose tissue (BAT) was first described in the 16th century, but until late last century had mainly been considered a tissue with the function of nonshivering thermogenesis, maintaining body temperature in key organs in newborns who have high body surface areas relative to their weight and thus marked radiative heat loss. BAT was believed to have substantially disappeared by adulthood. Molecular imaging with ¹⁸F-FDG PET and PET combined with CT, as well as imaging with ¹³¹I-metaiodobenzylguanidine (MIBG) beginning late last century have shown BAT to be present and active well into adulthood. This review highlights key aspects of BAT biology, early empiric observations misidentifying BAT, pitfalls in image interpretation, and methods to intentionally reduce BAT uptake, and outlines multiple imaging methods used to identify BAT in vivo. The therapeutic potential of increasing the amount or activity of BAT for weight loss and improvement of glucose and lipid profiles is highlighted as a major opportunity. Molecular imaging can help dissect the physiology of this complex dynamic tissue and offers the potential for addressing challenges separating "active BAT" from "total BAT." Research in BAT has grown extensively, and ¹⁸F-FDG PET is the key imaging procedure against which all other BAT imaging methods must be compared. Given the multiple functions of BAT, it is reasonable to consider it a previously unrecognized endocrine tissue and thus an appropriate topic for review in this supplement to The Journal of Nuclear Medicine.

[Comparison of 1H-MRS, Dixon fat-water separation and Z-spectral imaging for quantification of brown adipose tissue in rats]

OBJECTIVE

To evaluate the performance of ¹H-magnetic resonance spectroscopy (¹H-MRS), Dixon fat-water separation and Z-spectral magnetic resonance imaging (ZS-MRI) for quantification of fat content in phantoms and brown adipose tissues in rats.

OBJECTIVE

First, six water-oil mixture phantoms with different fat fractions (0, 20%, 40%, 60%, 80% and 100%) were prepared and placed in a 50-mL centrifuge tube. ZS-MRI, ¹H-MRS and Dixon's method were used to quantitatively evaluate the fat content of the phantom, and the results were compared against the actual fat fractions. Then, ZS-MRI and Dixon's method were used to collect the data in the interscapular region of 6 rats, the fat-water distribution map was calculated, and the results were compared with ¹H-MRS.

OBJECTIVE

ZS-MRI accurately quantified fat contents in the phantoms (Y=0.95*X+1.48). ZS-MRI was capable of distinguishing brown adipose tissue from white adipose tissue and defining the spatial distribution of the adipose tissue, and the results were highly consistent with those obtained by Dixon's method. No significant differences were found in the results derived by ZS-MRI and ¹H-MRS for quantification of brown adipose tissue (P=0.35).

OBJECTIVE

ZS-MRI can generate an artifact-free fat distribution map for quantitative measurement of the content and distribution of brown adipose tissues in rats.

Repeatability of Radiomic Features of Brown Adipose Tissue

The aim of this study was to assess the repeatability of activated brown adipose tissue (BAT) radiomic features. To decipher radiomic features that may provide useful information on BAT, the impact of reconstruction methods and imaging modality choice was also evaluated. Methods: Twenty-seven healthy adults enrolled in this study. After a cooling procedure to activate BAT, volunteers underwent ¹⁸F-FDG imaging. Participants underwent repeat imaging using the same imaging protocols and a similar ¹⁸F-FDG dose within 14 d. Active BAT was segmented using the BARCIST 1.0 methods. Radiomic features were extracted from each region of interest on high-definition PET (HD PET), non-HD PET, and CT images. Lin's concordance correlation coefficient was used to estimate the repeatability of the extracted radiomic features. To determine whether BAT radiomic feature repeatability correlates with BAT SUV_max repeatability, participants were stratified based on the relative difference in SUV_max between sessions. Non-HD PET repeatable features were clustered together using hierarchical clustering, and the normalized dynamic range of each feature was computed to identify the most informative feature within each cluster. Results: Eighteen of the 27 volunteers had sufficient BAT activity for radiomic analysis. Sixty-six HD PET, 66 non-HD PET, and 6 CT features showed high repeatability (concordance correlation coefficient ≥ 0.80). Feature repeatability was significantly higher for PET than for CT, but there was no statistically significant difference between HD and non-HD PET in radiomic feature repeatability. The repeatability of radiomic features extracted from each modality and reconstruction method type followed the trend in SUV_max, as participants with lower relative differences in SUV_max between initial and repeated imaging sessions had higher radiomic feature repeatability. Hierarchical clustering of the high-repeatability PET features resulted in 10 highly correlated clusters (R ² ≥ 0.95). Seven features, including SUV_max, did not cluster with any other features. Conclusion: Several clusters of highly repeatable BAT radiomic features derived from ¹⁸F-FDG PET/CT appear to provide information regarding BAT activity distinct from SUV_max These features might be explored as quantitative imaging biomarkers of BAT activity in future studies.

Distribution of Brown Adipose Tissue Radiodensity in Young Adults: Implications for Cold [18F]FDG-PET/CT Analyses

PURPOSE

Nowadays, 2-deoxy-2-[¹⁸F]fluoro-D-glucose ([¹⁸F]FDG) positron emission tomography (PET)/X-ray computed tomography (CT) is considered the best available technique to in vivo determination of human BAT volume. The most used Hounsfield unit (HU) threshold for BAT quantification is from - 250 to - 50 HU. Therefore, the main objective of the present study is (i) to examine the influence of SUV and HU thresholds on BAT quantification by [¹⁸F]FDG-PET/CT scan, (ii) to identify the proportion of BAT which is not detected by [¹⁸F]FDG-PET/CT scan when limiting the range between - 10 and - 50 HU, and (iii) to describe the distribution of BAT radiodensity by weight status and sex in young healthy individuals.

PROCEDURES

We measured 125 individuals after a personalized cooling protocol with a static [¹⁸F]FDG-PET/CT scan. We quantified BAT using different combination of threshold in every single HU for all participants.

RESULTS

We observed that the SUV threshold influences BAT quantification by [¹⁸F]FDG-PET/CT scans more than the HU range. We found that the range from - 50 to - 10 HU had the highest proportion of total BAT volume (43.2 %), which represents 41.4 % of the total BAT metabolic activity in our cohort. We also observed that BAT volume was not different between categories of body mass index, as well as BAT activity (SUV_mean). In addition, BAT was less dense in women than in men, although the BAT activity (SUV_mean) was higher in all ranges of HU. We also observed that the radiodensity of BAT located in the cervical area was mainly in the range from - 50 to - 10 HU.

CONCLUSION

Therefore, all future human studies using static [¹⁸F]FDG-PET/CT scans should include BAT in the radiodensity range from - 50 to - 10 HU.

Rotator cuff tear degeneration and the role of fibro-adipogenic progenitors

The high prevalence of rotator cuff tears poses challenges to individual patients and the healthcare system at large. This orthopedic injury is complicated further by high rates of retear after surgical repair. Outcomes following repair are highly dependent upon the quality of the injured rotator cuff muscles, and it is, therefore, crucial that the pathophysiology of rotator cuff degeneration continues to be explored. Fibro-adipogenic progenitors, a major population of resident muscle stem cells, have emerged as the main source of intramuscular fibrosis and fatty infiltration, both of which are key features of rotator cuff muscle degeneration. Improvements to rotator cuff repair outcomes will likely require addressing the muscle pathology produced by these cells. The aim of this review is to summarize the current rotator cuff degeneration assessment tools, the effects of poor muscle quality on patient outcomes, the role of fibro-adipogenic progenitors in mediating muscle pathology, and how these cells could be leveraged for potential therapeutics to augment current rotator cuff surgical and rehabilitative strategies.

The role of brown adipose tissue and the thermogenic adipocytes in glucose metabolism: recent advances and open questions

PURPOSE OF REVIEW

Brown adipose tissue (BAT) and the thermogenic adipocytes in white adipose tissue (WAT) are considered emerging targets against obesity-related metabolic perturbations given their high capacity for thermogenesis and glucose and lipid disposal. This manuscript summarizes and critically evaluates the recent advances on the role of BAT and thermogenic adipocytes in glucose homeostasis in humans.

RECENT FINDINGS

Recent studies support that BAT has high capacity for glucose disposal not only during cold but during rewarming and thermoneutrality as well. Moreover, BAT is now considered a metabolic sink for the disposal of branched-chain amino acids improving whole-body glucose metabolism in rodents and, potentially, in humans. β3 adrenergic agonism and glucagon-like peptide 1 increase BAT metabolic activity for glucose and/or induce the browning of WAT. Finally, recent findings support the association of glucose disposal in BAT with subclinical atherosclerosis and the reproducibility of two advanced medical imaging methods for the assessment of BAT using a glucose radiotracer.

SUMMARY

Recent studies provide new insights on the role of human BAT and thermogenic adipocytes in glucose metabolism. However, further research is needed to unequivocally establish the clinical significance of BAT and the thermogenic adipocytes in glucose homeostasis in humans.

Toward noninvasive quantification of adipose tissue oxygenation with MRI

BACKGROUND

Molecular oxygen (O₂) plays a key role in normal and pathological adipose tissue function, yet technologies to measure its role in adipose tissue function are limited. O₂ is paramagnetic and, in principle, directly influences the magnetic resonance (MR) ¹H longitudinal relaxation rate constant of lipids, R₁; thus, we hypothesize that MR imaging (MRI) can directly measure adipose O₂ via a simple measure of R₁.

METHODS

R₁ was measured in a 4.7T preclinical MRI system at discrete oxygen partial pressure (pO₂) levels. These measures were made in vitro in an idealized system and in vivo in subcutaneous and visceral white adipose of rodents. pO₂ was determined using an invasive fiber-optic oxygen monitor. From the MRI and fiber optic data we determined the "relaxivity" of O₂ in lipid, a critical parameter in converting the MRI-based R₁ measurement into pO₂. We used breathing gas challenge to estimate the changes in lipid pO₂ (ΔpO₂).

RESULTS

The relaxivity of O₂ in lipid was determined to be 1.7·10^-3 ± 4·10^-4 mmHg^-1s^-1 at 4.7T and 37 °C, and was consistent between in vitro and in vivo adipose tissue. There was a strong, significant correlation between MRI- and gold standard OxyLite-based measurements of lipid ΔpO₂ for in vivo visceral and subcutaneous fat depots in rodents.

CONCLUSION

This study lays the foundation for a direct, noninvasive measure of adipose pO₂ using MRI and will allow for noninvasive measurement of O₂ flux in adipose tissue. The proposed approach would be of particular importance in the interrogation of the pathogenesis of type 2 diabetes, where it has been suggested that adipose tissue hypoxia is an independent driver of insulin resistance pathway.

Magnetic Resonance Imaging Techniques for Brown Adipose Tissue Detection

Magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) methods can non-invasively assess brown adipose tissue (BAT) structure and function. Recently, MRI and MRS have been proposed as a means to differentiate BAT from white adipose tissue (WAT) and to extract morphological and functional information on BAT inaccessible by other means. Specifically, proton MR (¹H) techniques, such as proton density fat fraction mapping, diffusion imaging, and intermolecular multiple quantum coherence imaging, have been employed to access BAT microstructure; MR thermometry, relaxometry, and MRI and MRS with ³¹P, ²H, ¹³C, and ¹²⁹Xe have shown to provide complementary information on BAT function. The purpose of the present review is to provide a comprehensive overview of MR imaging and spectroscopy techniques used to detect BAT in rodents and in humans. The present work discusses common challenges of current methods and provides an outlook on possible future directions of using MRI and MRS in BAT studies.

Infrared Thermography for Estimating Supraclavicular Skin Temperature and BAT Activity in Humans: A Systematic Review

OBJECTIVE

Brown adipose tissue (BAT) is a thermogenic tissue with potential as a therapeutic target in the treatment of obesity and related metabolic disorders. The most used technique for quantifying human BAT activity is the measurement of 18 F-fluorodeoxyglucose uptake via a positron emission tomography/computed tomography scan following exposure to cold. However, several studies have indicated the measurement of the supraclavicular skin temperature (SST) by infrared thermography (IRT) to be a less invasive alternative. This work reviews the state of the art of this latter method as a means of determining BAT activity in humans.

METHODS

The data sources for this review were PubMed, Web of Science, and EBSCOhost (SPORTdiscus), and eligible studies were those conducted in humans.

RESULTS

In most studies in which participants were first cooled, an increase in IRT-measured SST was noted. However, only 5 of 24 such studies also involved a nuclear technique that confirmed increased activity in BAT, and only 2 took into account the thickness of the fat layer when measuring SST by IRT.

CONCLUSIONS

More work is needed to understand the involvement of tissues other than BAT in determining IRT-measured SST; at present, IRT cannot determine whether any increase in SST is due to increased BAT activity.

Cold exposure induces dynamic, heterogeneous alterations in human brown adipose tissue lipid content

Brown adipose tissue undergoes a dynamic, heterogeneous response to cold exposure that can include the simultaneous synthesis, uptake, and oxidation of fatty acids. The purpose of this work was to quantify these changes in brown adipose tissue lipid content (fat-signal fraction (FSF)) using fat-water magnetic resonance imaging during individualized cooling to 3 °C above a participant's shiver threshold. Eight healthy men completed familiarization, perception-based cooling, and MRI-cooling visits. FSF maps of the supraclavicular region were acquired in thermoneutrality and during cooling (59.5 ± 6.5 min). Brown adipose tissue regions of interest were defined, and voxels were grouped into FSF decades (0-10%, 10-20%…90-100%) according to their initial value. Brown adipose tissue contained a heterogeneous morphology of lipid content. Voxels with initial FSF values of 60-100% (P < 0.05) exhibited a significant decrease in FSF while a simultaneous increase in FSF occurred in voxels with initial FSF values of 0-30% (P < 0.05). These data suggest that in healthy young men, cold exposure elicits a dynamic and heterogeneous response in brown adipose tissue, with areas initially rich with lipid undergoing net lipid loss and areas of low initial lipid undergoing a net lipid accumulation.

An optimal condition for the evaluation of human brown adipose tissue by infrared thermography

Brown adipose tissue (BAT) is responsible for non-shivering thermogenesis and is an attractive therapeutic target for combating obesity and related diseases. Human BAT activity has been evaluated by ¹⁸F-fluorodeoxyglucose-positron emission tomography/computed tomography (¹⁸FDG-PET/CT) under acute cold exposure, but the method has some serious limitations, including radiation exposure. Infrared thermography (IRT) may be a simple and less-invasive alternative to evaluate BAT activity. In the present study, to establish an optimal condition for IRT, using a thermal imaging camera, skin temperature was measured in the supraclavicular region close to BAT depots (T_scv) and the control chest region (T_c) in 24 young healthy volunteers. Their BAT activity was assessed as the maximal standardized uptake value (SUV_max) by ¹⁸FDG-PET/CT. Under a warm condition at 24–27°C, no significant correlation was found between the IRT parameters (T_scv, T_c,, and the difference between T_scv and T_c,, Δtemp) and SUV_max, but 30–120 min after cold exposure at 19°C, T_scv and Δtemp were significantly correlated with SUV_max (r = 0.40–0.48 and r = 0.68–0.76). Δtemp after cold exposure was not affected by mean body temperature, body fatness, and skin blood flow. A lower correlation (r = 0.43) of Δtemp with SUV_max was also obtained when the participant’s hands were immersed in water at 18°C for 5 min. Receiver operating characteristic analysis revealed that Δtemp after 30–60 min cold exposure can be used as an index for BAT evaluation with 74% sensitivity, 92% specificity, and 79% diagnostic accuracy. Thus, IRT may be useful as a simple and less-invasive method for evaluating BAT, particularly for large-scale screening and longitudinal repeat studies.

Relationships between cardiorespiratory fitness/muscular strength and 18F-fluorodeoxyglucose uptake in brown adipose tissue after exposure to cold in young, sedentary adults

Humans have metabolically active brown adipose tissue (BAT). However, what is the relation between exercise or physical activity with this tissue remains controversial. Therefore, the main aim of the present study is to examine whether cardiorespiratory fitness and muscular strength are associated with brown adipose tissue (BAT) volume and activity after exposure to cold in young, sedentary adults. Cardiorespiratory fitness was determined in 119 young, healthy, sedentary adults (68% women, age 21.9 ± 2.1 years, body mass index 25 ± 4.8 kg/m2) via the maximum treadmill exercise test, and their muscular strength assessed by the handgrip strength test and the 1-repetition maximum bench and leg press tests. Some days later, all subjects were exposed to 2 h of personalized exposure to cold and their cold-induced BAT volume and activity determined by a combination of 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography and computed tomography scan. Cardiorespiratory fitness was associated with neither the BAT volume nor BAT activity (P ≥ 0.05). However, handgrip strength with respect to lean body mass was positively (though weakly) associated with BAT activity as represented by the 18F-FDG mean standardised uptake value (SUV) (β = 3.595, R2 = 0.039, P = 0.031) and SUVpeak value (β = 15.314, R2 = 0.037, P = 0.035). The above relationships remained after adjusting for several confounders. No other associations were found. Handgrip strength with respect to lean body mass is positively associated with BAT activity (SUVmean and SUVpeak) in young adults after exposure to cold - but only weakly. Further studies are needed to reveal the relationship between muscular fitness and human BAT characteristics.

Imaging adipose tissue browning using the TSPO-18kDa tracer [18F]FEPPA

Objectives

The browning of white adipose tissue (WAT) into beige has been proposed as a strategy to enhance energy expenditure to combat the growing epidemic of obesity. Research into browning strategies are hampered by the lack of sensitive, translatable, imaging tools capable of detecting beige fat mass non-invasively. [¹⁸F]FDG is able to detect activated beige fat but provides little information on unstimulated beige fat mass. We have assessed the use of [¹⁸F]FEPPA, a tracer for the TSPO-18KDa found on the outer mitochondrial membrane, as an alternative imaging agent capable of detecting unstimulated brown fat (BAT) and beige fat.

Methods

Female Balb/c mice (n = 5) were treated for 7 days with the β3 adrenergic agonist CL-316,243 to induce the browning of inguinal WAT (beige fat). Animals were imaged longitudinally with [¹⁸F]FDG and [¹⁸F]FEPPA and uptake in interscapular BAT and inguinal WAT assessed. The browning of inguinal WAT was confirmed using H&E and immunohistochemical detection of UCP-1 and TSPO.

Results

Repeated dosing with β3-adrenergic agonist CL-316,243 caused a significant increase in [¹⁸F]FDG uptake in both interscapular BAT and inguinal WAT associated with the increased metabolic activity of brown and beige adipocytes respectively. [¹⁸F]FEPPA uptake was likewise increased in inguinal WAT but showed no increase in BAT uptake due to stimulation over the same time course. Furthermore, inguinal WAT uptake was unaffected by pharmacological blockade, indicating that [¹⁸F]FEPPA uptake is associated with the expression of mitochondria in BAT and beige adipocytes and independent of activation.

Conclusion

These data show that [¹⁸F]FEPPA can detect BAT and newly formed beige fat under non-stimulated, thermoneutral conditions and that uptake after stimulation is linked to mitochondrial expression as opposed to activation.

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TSPO-18kDa tracers can detect BAT under non-stimulated, thermoneutral conditions.

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TSPO-18kDa tracers can detect the formation of beige adipocytes in white adipose tissue.

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TSPO-18kDa tracers may aid in the development of new approaches to treat obesity.

Exercise training alters lipoprotein particles independent of brown adipose tissue metabolic activity

Introduction

New strategies for weight loss and weight maintenance in humans are needed. Human brown adipose tissue (BAT) can stimulate energy expenditure and may be a potential therapeutic target for obesity and type 2 diabetes. However, whether exercise training is an efficient stimulus to activate and recruit BAT remains to be explored. This study aimed to evaluate whether regular exercise training affects cold‐stimulated BAT metabolism and, if so, whether this was associated with changes in plasma metabolites.

Methods

Healthy sedentary men (n = 11; aged 31 [SD 7] years; body mass index 23 [0.9] kg m⁻²; VO_{2 max} 39 [7.6] mL min⁻¹ kg⁻¹) participated in a 6‐week exercise training intervention. Fasting BAT and neck muscle glucose uptake (GU) were measured using quantitative [¹⁸F]fluorodeoxyglucose positron emission tomography–magnetic resonance imaging three times: (1) before training at room temperature and (2) before and (3) after the training period during cold stimulation. Cervico‐thoracic BAT mass was measured using MRI signal fat fraction maps. Plasma metabolites were analysed using nuclear magnetic resonance spectroscopy.

Results

Cold exposure increased supraclavicular BAT GU by threefold (p < 0.001), energy expenditure by 59% (p < 0.001) and plasma fatty acids (p < 0.01). Exercise training had no effect on cold‐induced GU in BAT or neck muscles. Training increased aerobic capacity (p = 0.01) and decreased visceral fat (p = 0.02) and cervico‐thoracic BAT mass (p = 0.003). Additionally, training decreased very low‐density lipoprotein particle size (p = 0.04), triglycerides within chylomicrons (p = 0.04) and small high‐density lipoprotein (p = 0.04).

Conclusions

Although exercise training plays an important role for metabolic health, its beneficial effects on whole body metabolism through physiological adaptations seem to be independent of BAT activation in young, sedentary men.

Techniques and Applications of Magnetic Resonance Imaging for Studying Brown Adipose Tissue Morphometry and Function

The present review reports on the current knowledge and recent findings in magnetic resonance imaging (MRI) and spectroscopy (MRS) of brown adipose tissue (BAT). The work summarizes the features and mechanisms that allow MRI to differentiate BAT from white adipose tissue (WAT) by making use of their distinct morphological appearance and the functional characteristics of BAT. MR is a versatile imaging modality with multiple contrast mechanisms as potential candidates in the study of BAT, targeting properties of ¹H, ¹³C, or ¹²⁹Xe nuclei. Techniques for assessing BAT morphometry based on fat fraction and markers of BAT microstructure, including intermolecular quantum coherence and diffusion imaging, are first described. Techniques for assessing BAT function based on the measurement of BAT metabolic activity, perfusion, oxygenation, and temperature are then presented. The application of the above methods in studies of BAT in animals and humans is described, and future directions in MR study of BAT are finally discussed.

In Vivo Detection of Human Brown Adipose Tissue During Cold and Exercise by PET/CT

The role of brown adipose tissue (BAT) in non-shivering thermogenesis is well established in animals. BAT is activated following cold exposure, resulting in non-shivering thermogenesis, to ensure a constant body temperature. In mitochondria of brown adipocytes, glucose and fatty acids are used as substrate for uncoupling resulting in heat production. Activated BAT functions as a sink for glucose and fatty acids and this hallmark has designated BAT a target in the fight against metabolic diseases like type 2 diabetes mellitus and obesity. In order to make valid claims regarding BAT activity in humans, BAT activity needs to be quantified. The combination of positron emission tomography (PET) and computer tomography (CT) analysis is currently the most frequently used imaging technique to determine BAT activity in humans. Here, we will discuss the history of PET/CT and radioisotopes used to determine BAT activity in humans. Moreover, we will assess how PET/CT is used to determine BAT activity following cold and exercise.

Modulation of thermogenesis and metabolic health: a built environment perspective

Lifestyle interventions, obviating the increasing prevalence of the metabolic syndrome, generally focus on nutrition and physical activity. Environmental factors are hardly covered. Because we spend on average more that 90% of our time indoors, it is, however, relevant to address these factors. In the built environment, the attention has been limited to the (assessment and optimization of) building performance and occupant thermal comfort for a long time. Only recently well-being and health of building occupants are also considered to some extent, but actual metabolic health aspects are not generally covered. In this review, we draw attention to the potential of the commonly neglected lifestyle factor 'indoor environment'. More specifically, we review current knowledge and the developments of new insights into the effects of ambient temperature, light and the interaction of the two on metabolic health. The literature shows that the effects of indoor environmental factors are important additional factors for a healthy lifestyle and have an impact on metabolic health.

Brown Adipose Tissue Energy Metabolism in Humans

The demonstration of metabolically active brown adipose tissue (BAT) in humans primarily using positron emission tomography coupled to computed tomography (PET/CT) with the glucose tracer 18-fluorodeoxyglucose (18FDG) has renewed the interest of the scientific and medical community in the possible role of BAT as a target for the prevention and treatment of obesity and type 2 diabetes (T2D). Here, we offer a comprehensive review of BAT energy metabolism in humans. Considerable advances in methods to measure BAT energy metabolism, including nonesterified fatty acids (NEFA), chylomicron-triglycerides (TG), oxygen, Krebs cycle rate, and intracellular TG have led to very good quantification of energy substrate metabolism per volume of active BAT in vivo. These studies have also shown that intracellular TG are likely the primary energy source of BAT upon activation by cold. Current estimates of BAT's contribution to energy expenditure range at the lower end of what would be potentially clinically relevant if chronically sustained. Yet, 18FDG PET/CT remains the gold-standard defining method to quantify total BAT volume of activity, used to calculate BAT's total energy expenditure. Unfortunately, BAT glucose metabolism better reflects BAT's insulin sensitivity and blood flow. It is now clear that most glucose taken up by BAT does not fuel mitochondrial oxidative metabolism and that BAT glucose uptake can therefore be disconnected from thermogenesis. Furthermore, BAT thermogenesis is efficiently recruited upon repeated cold exposure, doubling to tripling its total oxidative capacity, with reciprocal reduction of muscle thermogenesis. Recent data suggest that total BAT volume may be much larger than the typically observed 50-150 ml with 18FDG PET/CT. Therefore, the current estimates of total BAT thermogenesis, largely relying on total BAT volume using 18FDG PET/CT, may underestimate the true contribution of BAT to total energy expenditure. Quantification of the contribution of BAT to energy expenditure begs for the development of more integrated whole body in vivo methods.