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stockpile energy for future t the dawn of humanity, and for much of may also be inuencing how much energy a per-
use was critical to survival our history since, meals were literally son consumes, expends and stores as fat.
when food was scarce. catch-as-catch-can. Because humans Many critical variables within the body, such
Now, in a world of plenty, evolved in a world where food was available only as blood pressure, body temperature, blood sug-
obesity is the life-threaten- intermittently, survival required that we have ar and water balance, are tightly controlled by
ing problem for an increas-
the capacity to store ingested energy for times automatic mechanisms, but whether body weight
ing number of people.
when none was around. Adipose tissue, famil- is similarly regulated has long been the subject
Scientists are working to iarly known as fat, is the organ specialized for of vigorous debate. Scientists have only recently
understand the mecha- that task. begun to make signicant advances in identify-
nisms the human body Our ability to store fat remains essential to ing pathways of cellular signaling and activity
uses to regulate its storage
life and can allow a person to survive starvation that might participate in such a regulatory sys-
of energy in the form of
for several months. In very recent human histo- tem for fat.
fat, as well as how these
systems can become ry, however, the amount of energy packed away These new insights into how the body senses
unbalanced and lead as fat has been increasing in many populations. and responds to its energy needs and stores are
to obesity. When fat storage approaches a level that com- helping researchers to understand how inherited
promises a persons health, we call it obesity. genetic variations can subtly or powerfully af-
As the components of this
In part, this trend is the result of humanitys fect those mechanisms and how they can also be
regulatory system are
identied, they are provid- technological progress in the face of abundant upset by environmental inuences as well as by
ing new targets for drug food and a reduced need for physical activity, it excess fat itself. As the discoveries accumulate,
treatments that could is all too easy to take in more energy than one scientists gain a clearer picture of the complex
restore energy balance and needs. Yet some people seem to be more suscep- physiological systems involved in controlling fat
help to reverse obesity. tible than others to becoming obese when ex- accumulation and new targets for interventions
JON KRAUSE
The Editors posed to this plentiful environment, which sug- that could help individuals attain greater control
gests that variations in individual physiology in their own battles against bulge.
COMMAND CENTER
The human brain regulates weight by
integrating information about the bodys INFORMATION RESPONSES
energy needs and the status of its stores, STORED ENERGY STATUS ALTER BODYS ENERGY INTAKE
Circulating leptin, a hormone NTS Direct meal timing and size through
then initiating changes in behavior and generated by fat cells, indicates satiety appetite and satiety signals
how much fat they contain center
energy processing in response. Special-
ALTER BODYS ENERGY USE
ized brain areas stimulate feelings of METABOLIC STATUS Reduce or increase physical activity
Circulating glucose represents energy
appetite or satiety to cause more energy, Slow or speed cellular energy use
immediately available to cells
Suppress or restore growth,
in the form of food, to be taken in or to Various indicators of liver activity
TH
APPETITE CONTROL Alpha-MSH
AL
IN THE
AM
In the arcuate nucleus (ARC) of the hypothalamus (far BRAIN AgRP
US
right), indicators of energy and feeding status in the form STEM
of gut peptides such as ghrelin and PYY, and hormones
TY
NTS satiety NPY
including leptin and insulin, act upon groups of neurons center SATIE
associated with appetite (brown) or satiety (blue). Each
Arcuate APPETITE
substance either stimulates (green arrows) or dampens nucleus
(red arrows) the neurons responses. When stimulated, MCH
the ARC cells release peptides such as NPY, AgRP and
Insulin
alpha-MSH, which act on a second set of hypothalamic
neurons that induce appetite or satiety. Leptin and insulin
act through both types of cells simultaneously to promote Leptin Ghrelin
satiety while suppressing appetite. Nerve signals and Vagus CCK PYY
and
the gut peptide cholecystokinin (CCK) also communicate spinal
feeding status directly to the nucleus tractus solitarus nerve
signals SATIETY
(NTS), a satiety center (right) in the brain stem.
vations have led to certain parts of the hypo- breakdown products of food, such as glucose,
thalamus being labeled as satiety or feeding and gut-derived hormones, such as insulin and
centers. cholecystokinin (CCK). But a critical regulator
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[THE GUT]
MIXED MESSAGES
Important signals that stimulate energy-regulating responses by the brain
and tissues of the body emanate from digestive organs and from fat itself. EMPTY STOMACH
They constitute both short-term indicators of the bodys feeding status, Ghrelin is produced by
such as nerve impulses and secreted peptides generated just before and glands in the stomach
20 to 30 minutes before
after meals, as well as longer-term information about the status of the eating. The trigger for its
bodys stored energy. In addition to leptin, which reports body fat levels to release is unclear, but
ghrelin may signal the
the brain, fat cells secrete nearly a dozen other hormonescollectively stomachs readiness for a
known as adipokines. At least two of these directly alter tissue responses meal to the brain
to insulin, which regulates how much glucose cells take in and use as fuel.
To the brain
FULL OF FOOD
Stomach and intestinal
distension is transmitted
via spinal and vagus
nerves to the brain
Nutrient receptors in the
liver also send neural
signals indicating that
ingested food is being
broken down
Circulating levels of
insulin, secreted from
the pancreas, and
glucose, derived from
ingested food, reect
Nutrient
receptors feeding status and
readily available energy
Cholecystokinin (CCK)
LIVER Ghrelin and PYY are peptides
manufactured by the
intestines and secreted
into the bloodstream
Distension after a meal
sensors
STOMACH
Leptin Insulin
STORED ENERGY
FAT Leptin is manufactured
Distension PYY by adipose tissue in
PANCREAS sensors amounts proportionate
Discovery of RBP4
to the fat it contains
Secreted retinol-binding
leptin opened
pathway.
of how much energy is maintained in storage both parents, the syndrome itself was called ob/
proved elusive until Jeffrey Friedman of the ob. Despite hundreds of studies attempting to
Rockefeller University and his colleagues discov- understand obesity in these mice, Friedmans
ered leptin in 1994. group was the rst to identify the inherited gene
Decades earlier a spontaneous syndrome of mutation responsible. The researchers also de-
severe obesity with increased appetite and de- termined that the newly identied gene was pre-
JEN CHRISTIANSEN
creased energy expenditure appeared in certain dominantly active in fat cells and gave rise to a
mice bred at the Jackson Laboratory in Maine. protein that was not made in functional form in
Because a mouse had to inherit the trait from the mice harboring the ob mutation. The obesity
thalamus that carry a surface protein known as Among these, cholecystokinin is an important
the melanocortin 4 receptor (MC4R), whose ac- factor in causing short-term satiety, but its ac-
tivation reduces appetite and promotes weight tions are limited to signaling termination of in-
FRIENDLY FIRMICUTES:
loss. AgRP, the peptide that promotes feeding, is dividual meals. Another peptide called PYY, re-
Lactobacillus fermentum
an antagonist of this receptor, meaning that it leased from the small intestine, does the same.
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So far only one gut-generated peptide that acts ed with severe obesity attributable to muta-
to spur appetite has been identied: ghrelin is tions in the genes for leptin, the leptin receptor,
made and released in the stomach before feeding or POMC, a precursor of the appetite-depress-
and may signal anticipation of a meal [see illus- ing hypothalamic peptide MSH .
tration on page 76]. Mutations that cause loss of functioning
In people who are already obese, it is possible MC4 receptors the targets of MSH are also
that dysfunctional generation of such short-term very important, accounting for between 3 and 5
signals indicating whether food has recently been percent of patients with severe obesity. In most
consumed, or is about to be, could skew the of those individuals, only one of two copies of
brains energy-regulation mechanisms. Losing as SELF- the gene is affected, leaving them with about 50
little as 10 pounds, for example, can cause ghre- REGULATING percent of normal MC4 receptor function.
lin output to rise, provoking increased hunger. The majority of people with obesity, however,
CELLS?
Over the long term, signals emanating from have no known genetic mutations that could ex-
body fat itself might also contribute to abnormal In obesity, overstuffed fat cells plain their condition. Moreover, their leptin lev-
excrete more leptin, a signal of
energy management. For many years, fat was els are actually higher than those of lean individ-
abundant energy stores to which
viewed primarily or exclusively as a passive site the brain responds by cutting uals, which sounds counterintuitive if leptin is
for energy storage and release in the form of fat- appetite. But do fat cells also put supposed to cause appetite suppression. Indeed,
ty acids, but with the discovery of leptin, adi- out calls for more energy when this discovery led to the idea that most obese pa-
pose tissue was recognized as an endocrine they are running low? Research tients may have leptin resistance for some rea-
published in July indicates that
gland whose activity has widespread effects on son, leptins signal that fat stores are abundant
another hormone generated by
health [see box on opposite page]. fat cells, adiponectin, might play is not being heard by some part of the energy-
Leptin is still the only fat-derived hormone that role. Takashi Kadowaki and regulation pathway. Consistent with this theory
conclusively shown to participate directly in reg- his colleagues at the University of is the fact that attempts to administer leptin
ulation of fat stores, but a group of others, often Tokyo showed that in mice, fast- therapeutically have produced disappointingly
ing raises adiponectin levels in
collectively referred to as adipokines, are under poor responses in typical obese patients lacking
spinal uid and the hormones
investigation as well. Adiponectin, for example, presence in the central nervous specic leptin-associated gene mutations.
is a molecule produced and secreted exclusively system triggers the brains Finding the molecular basis for leptin resis-
by fat cells that normally circulates in the blood- release of the appetite-stimulat- tance is therefore a matter of substantial research
stream in high concentrations. Adiponectin lev- ing peptide NPY. If adiponectin is interest. Two proteins have been implicated
conrmed to be a starvation sig-
els are lower than average in obese subjects for strongly as contributing to leptin resistance by
nal, to which the brain responds
unknown reasons, and experimental mice lack- by increasing food intake, then it acting in the brain and possibly in peripheral tis-
ing adiponectin are extremely heavy, although would represent the second fat- sues. One is called SOCS3 and is produced by hy-
the mechanism underlying this effect is also mys- generated molecule directly pothalamic neurons that normally respond to
terious. Some intriguing research suggests that involved in regulating fat stores. leptin. SOCS3 can block leptins ability to signal
under certain circumstances adiponectin might to those cells. The other protein, PTP1B, squelch-
have a direct appetite-stimulating effect in the es leptin signaling inside the cells. In mouse ex-
brain. Although such ndings are very prelimi- periments, reducing levels of SOCS3 or PTP1B
nary, they point to the possibility that adiponec- in all tissues, or even just in neurons, makes mice
tin, too, could serve as a direct signal from fat more sensitive to leptin and resistant to obesity.
cells to the brain indicating a need to take in en- The precise role of these proteins in human leptin
ergy. As such, it might offset leptins appetite- resistance is still unknown, but based on these
suppressing role in energy regulation. observations in animals it is tempting to specu-
late that such molecules produced by leptin-sen-
Origins of Obesity sitive neurons serve the purpose of modulating
Much remains to be discovered about the leptin signaling so that the cells do not become
extremely complex circuitry regulating the overwhelmed by it. In obese individuals, chroni-
bodys energy use and storage as well as how dis- cally high leptin levels could therefore cause
ruptions within it might help perpetuate exist- these proteins to start overcompensating to pro-
ing obesity or predispose an individual to tect the cells, initiating a cycle of increasing resis-
HYUEK JONG LEE AND STEVE SHOELSON
becoming obese in the rst place. The discovery tance to leptin signaling.
of leptin in mice led to the identication of a few Such physiological feedback mechanisms
humans whose severe obesity could be explained could help perpetuate and worsen obesity, and
by a single genetic defect. Such monogenic FAT CELLS in lean (top) and
variations in genes involved in fat-regulating
obesities are quite rare but very informative. For obese (bottom) mice. pathways may have a similar role in unbalanc-
example, a handful of patients have been identi- ing the system. Indeed, we believe that varia-
tions in genes that inuence body weight through is bound to accelerate. At present, however, the
as yet undiscovered mechanisms are a likely prevalence of obesity and its complications are
source of at least some susceptibility to obesity. continuing to rise, making it clear that highly ef-
Whether there are many such genes whose vari- fective therapies are not yet available.
ation affects weight to a small extent or a few
dominant genes whose variation affects weight Intervening in Obesity
in most people remains to be seen. With power- Simple recommendations such as reducing food
ful techniques for scanning human genes within intake, changing the composition of ones diet
large populations becoming more widely avail- and increasing physical exercise are always
able, discovery of new weight-regulatory path- appropriate for an obese person. And by them-
ways and new insights into known mechanisms selves, such behavior changes can help individu-
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[TREATMENT STRATEGIES]
OVERRIDING OBESITY
As the mechanisms that can give rise to obesity become clearer, so do the reasons why losing body fat
and keeping it off through behavioral changes alone can be difcult for many individuals. Existing therapies
are only modestly effective, and developing new drugs that are safe for prolonged use has been difcult
because energy-regulation systems are intertwined with other vital processes in the body and brain, creating
a risk of serious side effects. Therapeutic approaches currently in development attempt to more precisely
target the molecules and mechanisms that control how much energy the body takes in as food or how much
energy it stores and burns.
SIBUTRAMINE: APPETITE
Raises available serotonin Block activity of the
and norepinephrine, brain appetite-stimulating
chemicals that affect neuropeptides MCH or NPY
appetite as well as mood or gut peptide ghrelin
and other functions Boost appetite-suppressing
RIMONABANT: activity of cellular MC4
BRAIN receptors or certain
Suppresses activity of CB1
receptors in brain and body Appetite serotonin receptor subtypes
and satiety
tissues, which stimulate centers Inhibit neural proteins
appetite and are involved SOCS3 and PTP1B to
in cellular fat processing. counteract leptin resistance
(Not approved in U.S.)
BARIATRIC SURGERY:
Reduces and/or bypasses ENERGY STORAGE
stomach pouch and part Reduce fat cells intake of
of intestine to decrease the energy and manufacture of
amount of food taken in LIVER triglyceride by inhibiting
intestines hormonal
therapy responses to food
STOMACH STORED ENERGY USE
for obesity will FAT
Increase rate at which fat
cells release triglyceride
eventually to bloodstream for use as
fuel by stimulating PPAR
involve multiple ORLISTAT: Blocks fat
INTESTINE and beta3-adrenergic
cellular receptors in body
absorption in intestines to
drugs acting reduce calorie intake
tissues
Increase FGF21 protein,
through which causes liver cells
to burn fat
independent
pathways.
als lose up to 10 percent of their body weight, gests that gastric bypass may cause a reduction
although maintaining that weight loss is often in appetite, in part by altering levels of gut hor-
difcult. mones such as ghrelin and PYY, which indicates
Bariatric surgery is now performed on hun- that drugs to accomplish the same end might
dreds of thousands of patients every year. In gen- someday substitute for these operations in many
eral, these operations either tie off part of the patients.
stomach with a band to limit its size or actually Any new drug to treat obesity will be held to
reroute the gut to both reduce the stomach pouch very high standards of efcacy, tolerability and
and bypass part of the intestine. Both proce- safety. Because the pathways regulating energy
JEN CHRISTIANSEN
dures are substantially more successful than any storage are so critical to other processes in the
current drug therapies at promoting and main- body and brain, developing drug interventions
taining weight loss. Recent research also sug- that meet all those criteria is challenging. Unfor-
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