Archives of Physiology and Biochemistry, 2009; 115(4): 227239

REVI EW ARTI CLE

Molecular mechanisms involved in obesity-associated
insulin resistance: Terapeutical approach
Sonia Fernndez-Veledo, Iria Nieto-Vazquez, Rocio Vila-Bedmar, Lucia Garcia-Guerra, Maria
Alonso-Chamorro, and Margarita Lorenzo
Departamento de Bioquimica y Biologia Molecular II, Facultad de Farmacia, Universidad Complutense, 28040-
Madrid, Spain. CIBER de Diabetes y Enfermedades Metabolicas asociadas (CIBERDEM)
Address for Correspondence: Sonia Fernndez-Veledo, Departamento de Bioquimica y Biologia Molecular II, Facultad de Farmacia, Universidad
Complutense, 28040 Madrid, Spain. Tel: 34-913941852. Fax: 34-913941779. E-mail: soferve@farm.ucm.es
(Received 03 April 2009; revised 23 June 2009; accepted 06 July 2009)
Introduction
Insulin resistance is an important contributor to the
pathogenesis of type 2 diabetes (T2D) and obesity is a risk
factor for its development. In the obese state an altered
secretion pattern, with increase in pro- infammatory
and decrease in anti-infammatory factors is found
(Trayhurn and Wood, 2005). Insulin resistance cor-
relates with impaired insulin signalling in peripheral
tissues. From the intracellular pathways activated by
insulin, the tyrosine phosphorylation of insulin receptor
substrate (IRS) proteins is a crucial event in mediating
insulin action. Tis step is one of the key molecu-
lar events in insulin resistance associated with both
infammation and hyperinsulinemia. Te mechanisms
afecting IRSs involve proteasome-mediated degrada-
tion, phosphatase-mediated dephosphorylation and
serine phosphorylation of IRSs, which reduces insulin
receptor (IR) tyrosine kinase activity, as previously
reviewed (Pirola et al., 2004). Tis review is focused on
examining alterations in insulin- signalling pathways
in insulin resistance states associated with obesity. In
this regard, stress and pro-infamatory kinases, as well
as phosphatases, seem to be involved in the molecular
ISSN 1381-3455 print/ISSN 1744-4160 online 2009 Informa UK Ltd
DOI: 10.1080/13813450903164330
Abstract
Insulin resistance is an important contributor to the pathogenesis of T2D and obesity is a risk factor for
its development. It has been demonstrated that these obesity-related metabolic disorders are associated
with a state of chronic low-intensity infammation. Several mediators released from adipocytes and macro-
phages, such as the pro-infammatory cytokines TNF-alpha and IL-6, have been suggested to impair insulin
action in peripheral tissues, including fat and skeletal muscle. Such insulin resistance can initially be com-
pensated by increased insulin secretion, but the prolonged presence of the hormone is detrimental for
insulin sensitivity. Stress and pro-infamatory kinases as well as more recent players, phosphatases, seem
to be involved in the molecular mechanisms by which pro-infammatory cytokines and hyperinsulinemia
disrupt insulin signalling at the level of IRSs. Pharmacological approaches, such as treatment with PPAR and
LXR agonists, overcome such insulin resistance, exerting anti-infamatory properties as well as controlling
the expression of cytokines with tissular specifcity.
Keywords: GLUT4; cytokines; hyperinsulinemia; PTP1B; stress and proinfammatory kinases; nuclear receptor
agonists; insulin resistance; obesity
Abbreviations: ACC, acetyl-CoA carboxilase; AMPK, AMP-activated protein kinase; AS160, AKT substrate of
160 kDa; BAT, brown adipose tissue; ERK, extracellular-signal regulated kinase; FAS, fatty acid synthase; FFA,
free fatty acids; GLUT4, insulin-regulated glucose transporter; HSL, hormone sensitive lipase; IL, Interleukin;
IKK, inhibitor kB kinase; IR, insulin receptor; IRS, insulin receptor substrate; JNK, c-Jun N-terminal kinase;
LPL, lipoprotein lipase; LXR, liver X receptor; MAPK, mitogen-activated protein kinase; MCP, monocyte
chemoattractan protein; PDE, phosphodiesterase; PI3K, phosphatidylinositol 3-kinase; PK, protein kinase;
PET, positron-emission tomography; PPAR, peroxisome proliferator activated receptor; PTP, protein-tyrosine
phosphatase; SOCS, supressor of cytokine signalling; T2D, type 2 diabetes; TNF, tumour necrosis factor; TGA,
tryglicerides; TZD, tiazolidindione; UCP, uncoupling protein; WAT, white adipose tissue.
http://www.informahealthcare.com/arp
228 Sonia Fernndez-Veledo et al.
mechanisms by which IRSs signalling could be afected
in these states. Pharmacological and genetic approaches
to overcoming insulin resistance will also be discussed
in this review.
Te impact of adipose tissue in energy
metabolism and insulin sensitivity
Te adipose organ consists of several depots
located at various anatomical sites that have difer-
ent physiological functions and pathophysiological
roles. Advances over the last two decades in our
understanding of the adipocyte biology have clarifed
its role as a key regulator of both energy balance and
intermediary metabolism. White adipose tissue (WAT)
has long been recognized as the main site of storage
of energy excess derived from food intake. White
adipocytes store dietary energy in a highly concen-
trated form as triglycerides (TGA), mostly in a single
large lipid droplet. In times of caloric need, these
triglycerides can be rapidly hydrolysed by lipases (a
process known as lipolysis) and the resulting fatty
acids are transported to other tissues (mainly liver
and skeletal muscle) to be oxidized in mitochondria
as an energy source. In contrast, brown adipose tissue
(BAT) is specialized primarily for cold-induced non-
shivering thermogenesis. Brown adipocytes are char-
acterized by multiple, smaller droplets of triglycerides,
which are accessible to a rapid hydrolysis and oxida-
tion of the fatty acids (FA). Te unique thermogenic
capacity of BAT results from the expression of the
uncoupling protein (UCP)1, located in the mito-
chondrial inner membrane. Tis protein allows the
consumption of the energy derived from FA oxidation
for the generation of heat (Nedergaard et al., 2001).
Most fat depots can be characterized as either brown
or white but some brown fat cells can also be found
dispersed through white fat depots (Guerra et al.,
1998). Until quite recently, BAT was thought to be of
metabolic importance only in small mammals and
infant humans. However, recent studies using posi-
tron-emission tomography (PET) scanning, suggest
that adult humans have several discrete areas of met-
abolically active BAT (Nedergaard et al., 2007; Cypess
et al., 2009). In this regard, BAT may have much more
relevance in human metabolism than was previously
appreciated and loss of BAT function is linked to obes-
ity and metabolic disease (Lowell et al., 1993).
Adipose tissue as an endocrine organ
Currently, there is strong evidence that adipose
tissue is not only an inert energy-storage depot, but
it is also an endocrine organ. This tissue secretes a
large number of peptide hormones and cytokines,
known as adipokines, as well as non-peptide
biologically active molecules such as active lipids,
which act at both the local (autocrine/paracrine)
and systemic (endocrine) level (Kershaw and Flier,
2004). The adipose tissue is required for normal
secretion of adipokines such as leptin and adi-
ponectin, which control glucose homeosthasis,
insulin sensitivity and eating patterns through
effects on neuroendocrine pathways (Guilherme
et al., 2008). In fact, human and mice lipodystro-
phies, which are abnormalities of the adipose
tissue associated with total or partial loss of body
fat, are related to impaired adipokine secretion and
insulin resistance (Chehab, 2008). Thus, owing to
its endocrine function and its classical role as lipids
storage, the presence of functional adipose tissue
in proper proportion to body size is essential to
control whole-body metabolism.
Insulin action in adipocytes
Insulin exerts a dominant role in regulating glucose
homeostasis through orchestrated efects on the
promotion of glucose uptake in peripheral tissues,
such as muscle (skeletal muscle and heart) and fat
(white and brown) and in suppressing hepatic glucose
production. Te clearance of circulating glucose in
these organs depends on insulin-stimulated trans-
location of glucose transporter (GLUT)4 to the cell
surface, which is accomplished by the activation of
the insulin intracellular signalling cascade which
includes binding to specifc IR, tyrosine phospho-
rylation of IRS proteins, activation of phosphatidyl
inositol (PI)3K, AKT and protein kinase C isoforms z,
l, a and d (Huang and Czech, 2007). Skeletal muscle
is responsible for the highest glucose disposal in
the body whereas adipose tissue accounts for only a
small fraction of insulin-dependent glucose disposal.
Nevertheless, fat-selective knock-out glut4 gene
mice show impaired glucose tolerance, suggesting
that the functional integrity of the adipose tissue is
crucial in regulating intermediate metabolism (Abel
et al., 2001). Insulin action on lipid metabolism is
similar to its role in glucose metabolism since it
promotes anabolism as well as inhibits catabolism.
Specifcally, insulin upregulates lipoprotein lipase
(LPL) and stimulates gene expression of intracellular
lipogenic enzymes, such as acetyl-CoA carboxylase
(ACC) and fatty acid synthase (FAS), promoting trig-
lyceride storage in the adipose tissue (Kersten, 2001).
However, in human adipocytes, de novo lipogenesis
seems to be of minor importance, as compared to
Molecular mechanisms involved in obesity-associated insulin resistance 229
the uptake and esterifcation of free FA (FFA) derived
from plasma lipoproteins (Diraison et al., 2003). In
addition, insulin inhibits lipolysis by a mechanism
involving the cAMP hydrolysing enzyme phos-
phodiesterase (PDE)-3B, resulting in decreased
a ctivation of protein kinase A (PKA) and hormone
sensitive lipase (HSL) (Belfrage et al., 1981; Smith
and Manganiello, 1989).
Insulin resistance, which can be defned as a
diminished ability of the cell to respond to insulin,
is the most important pathophysiological feature in
many pre-diabetic states and is the frst detectable
defect in T2D. Te pathogenesis of T2D involves
abnormalities in both insulin action and secretion.
Insulin resistance is initially compensated by hyper-
insulinemia. Although moderate hyperinsulinemia
might be tolerated in the short term, chronic
hyperinsulinemia exacerbates insulin resistance
in peripheral tissues, including adipose tissue and
contributes directly to b-cell failure and diabetes
(White, 2003). Resistance to insulin-stimulated
glucose uptake in skeletal muscle is one of the
earliest defects detected in insulin-resistant states
contributing to the hyperglycemia characteristic
of these states. On the other hand, the inadequate
insulin action on the adipose tissue also induces
alterations in glucose as well as in lipid metabolism.
Tus, in the insulin-resistant state an inefcient
trapping of dietary energy occurs both because of
decreased LPL-mediated lipolysis and inefective
inhibition of HSL-mediated lipolysis (Coppack et al.,
1992). Postpandrial lipemia and elevated plasma
FA levels are well-recognized abnormalities in T2D
(Axelsen et al., 1999). Moreover, reduced adipose
tissue uptake and storage of TGA results in greater
partitioning of dietary lipids to nonadipose tissues,
including muscle and liver (Frayn, 2002). It is widely
accepted that increased availability and utilization
of FFA contributes to the development of skeletal
muscle insulin resistance, as well as to increase
hepatic glucose production (White, 2003). In fact,
the progression of insulin resistance in rats on a
high-fat diet is closely related to plasma FFA levels
(Jiao et al., 2008). Both genetic and environmental
factors can contribute to the development of insulin
resistance and, in the latest group, obesity has been
proposed as an important contributor.
Te infammation of adipose tissue during obesity
contributes to insulin resistance
Obesity is a risk factor for developing metabolic
disorders, such as insulin resistance and T2D,
partly due to endocrine function of adipose tissue.
Several factors derived not only from adipocytes,
but also from infltrated macrophages, contribute
to the pathogenesis of insulin resistance. Most of
them are overproduced during obesity, including
leptin, tumour necrosis factor (TNF)-a, monocyte
chemoattractant protein (MCP)-1 and resistin.
Conversely, the expression and plasma levels of
adipokines with anti-infammatory properties, such
as adiponectin, are down-regulated during obesity.
However, body fat distribution appears to be even
more important than the total amount of fat. In this
regard, central (visceral) obesity is more closely
related to insulin resistance and T2D than peripheral
(subcutaneous) obesity (Montague and ORahilly,
2000). Site-depot diferences in human adipocyte
physiology have been demonstrated in numerous
studies. Tus, visceral adipocytes present higher
catecholamine- stimulated lipolysis and lower insu-
lin antilipolytic efects and leptin secretion as com-
pared to subcutaneous adipocytes (van Hamerlen
et al., 2002). Several factors secreted from adipose
tissue, including pro-infammatory cytokines and
FFA, can impair insulin signalling altering insulin-
mediated processes such as glucose homeostasis
and lipid metabolism (Arner, 2003). Accordingly,
obesity is now considered to be a chronic state of
low-intensity infammation. In this regard, recent
studies reveal that obesity is also associated with
an increase in infltration of adipose tissue with
macrophages, which contributes to the infamma-
tory process through the additional secretion of
cytokines (Lumeng et al., 2007). Te mechanisms by
which adipose tissue recruits and maintains mac-
rophages could involve expression of MCP-1 and
intercellular adhesion molecule-1. Recent studies
revealed that those subjects with the highest tran-
scription rates of genes encoding TNF- and IL-6
seemed prone to developing obesity, insulin resist-
ance and T2D (Fernandez-Real and Pickup, 2008).
In this regard, here we review the impact of these
cytokines in modulating insulin action on glucose
transport in adipose tissues and skeletal muscle.
-cell dysfunction afects metabolism of
adipose tissue
Obesity is associated with both insulin resistance
and hyperinsulinemia. Initially, hyperinsulinemia
compensates for the insulin resistance and thereby
maintains normal glucose homeostasis. Actually,
fasting hyperinsulinemia is a widely used surrogate
measure of insulin resistance and predicts T2D.
Although this hyperinsulinemia is necessary for
glycemic control, it can have harmful consequences
230 Sonia Fernndez-Veledo et al.
on many tissues including pancreatic b-cells,
contributing to the development of T2D.
Hyperinsulinemia induces insulin resistance in
human adipocytes
A recent study from our laboratory demonstrated that
long-term treatment with insulin impaired GLUT4
translocation to the plasma membrane and insulin
signalling at IRS-1/AKT level in the human visceral
adipocyte cell line Lisa-2 (Fernandez-Veledo et al.,
2008). Tis in vitro situation may imitate the chronic
elevation of insulin during insulin-resistant states
observed in humans (Bergman and Mittelman,
1998). In addition, hyperinsulinemia also induces
an increase in basal lipolysis, a decrease in isoprot-
erenol responsiveness and an insulin-resistant state,
not only on glucose uptake, also on the antilipolytic
efect, as summarized in Figure 1 (Fernandez-Veledo
et al., 2008). In fact, an alteration of the lipolytic
pathway has also been one of the major hypothesis
linking insulin resistance to hyperlipidemia in obes-
ity and T2D (Bergman and Mittelman, 1998). Te
mechanism involved seems to be dependent on per-
ilipin A, an essential lipid droplet-associated protein,
which functions as both a suppressor of basal lipoly-
sis and a necessary enhancer of PKA-stimulated
lipolysis (Tansey et al., 2004). Hyperinsulinemia
induced a greater movement of perilipin A and B
in basal conditions, producing an increase in basal
glycerol release and a decrease in isoproterenol-
induced lipolysis. In this regard, chronically high
insulin levels inhibit b-adrenergic receptors from
activating PKA (Zhang et al., 2005) and a signifcant
positive relationship between perilipin expression
and obesity has been described (Kern et al., 2004).
It is well documented that serine-phosphorylation
of IRSs impairs the normal response to insulin and
this situation has been associated with several insu-
lin resistant states including hyperinsulinemia (Gual
et al., 2005). An increase in IRS-1 phosphorylation at
the Ser312 residue and a decrease in insulin-induced
IRS-1 tyrosine-phosphorylation, without changes
in IRS1 expression, have been observed in human
adipocytes under hyperinsulinemic conditions
(Fernandez-Veledo et al., 2008; Danielsson et al.,
2006). Tis mechanism difers from those described
in murine adipocytes where a decrease in IRS-1 levels
was reported (Ricort et al., 1995). On the other hand,
the lipid phosphatase PTEN seems to be involved in the
molecular mechanism disrupting insulin signalling at
the level of IRSs found in hyperinsulinemia-induced
insulin resistance (Figure 1). In this regard, hyperin-
sulinemia increased PTEN protein levels in human
adipocytes (Fernandez-Veledo et al., 2008). Moreover,
compensatory hyperinsulinemia was not produced
in muscle-specifc PTEN-defcient mice (Wijesekara
et al., 2005), whereas inhibition of PTEN expression
in ob/ob mice reduced insulin concentrations
(Butler et al., 2002).
Te desregulation of the endocrine function of
adipose tissue under hyperinsulinemia
Secretion of pro-infammatory cytokines, such as
MCP-1 and IL-6, as well as FFA release was markedly
stimulated in human adipocytes cultured with insulin
for a long-term, in accordance to elevated plasma
concentrations of these factors detected in obese and
diabetic patients (Takahashi et al., 2003; Kern et al.,
2001). In this regard, an increase in MCP-1 expression
has been described in murine adipocytes treated
with insulin (Fasshauer et al., 2004). In contrast,
adiponectin secretion as well as its receptors were
decreased in human and murine adipocytes under
hyperinsulinemic conditions (Fernandez-Veledo
et al., 2008; Tsuchida et al., 2004). Tis desregula-
tion in adipokine secretion may play a crucial role
in the development of insulin resistance not only in
adipocytes but also in other tissues. In fact, signals
coming from undiferentiated or poorly diferenti-
ated human adipocytes (i.e. adiponectin) enhanced
insulin-induced glucose uptake and AKT phos-
phorylation in muscle cells; whereas signals from
more diferentiated adipocytes (i.e IL-6 or MCP-1)
induced an insulin resistant-state, detected earlier
than in adipocytes (Fernandez-Veledo et al., 2008).
Although these results appear to represent a paradox
it cannot rule out the altered secretion profle of adi-
pose tissue as a primary event in obesity-associated
insulin resistance. Tus, hyperinsulinemia induced
a desregulation of adipokines and FFA secretion
by human adipocytes, inducing insulin resistance
on adipocytes as well as on myocytes in which this
insulin-resistant state is detected earlier (Figure 1).
Role of TNF- in obesity-associated insulin
resistance
Markers of infammation such as TNF- have
been proposed as a link between adiposity and the
development of insulin resistance because adipose
tissue-derived TNF- is higher in obese diabetics
Molecular mechanisms involved in obesity-associated insulin resistance 231
than in healthy lean subjects and rodents (Kern et al.,
2001). Obese mice lacking either TNF- or its recep-
tors show protection from developing insulin resist-
ance (Hotamisligil, 2003). Moreover, TNF- blocks
skeletal muscle diferentiation and produces insulin
resistance in skeletal muscle in healthy humans
(Plomgaard et al., 2005). Rather than acting systemi-
cally, TNF- seems to act locally at the site of adipose
tissue through autocrine or paracrine mechanisms,
afecting insulin sensitivity and inducing IL-6 expre-
sion (Arner, 2003). Circulating levels of soluble TNF-a
receptors seem well- correlated with BMI and impair-
ment in TNF- processing can improve systemic
insulin sensitivity (Serino et al., 2007). On the other
hand, TNF- has lipolytic and antiadipogenic efects
on WAT and BAT (Arner, 2003; Valverde et al., 2005).
Tis paradox could be due to proliferative and anti-
apoptotic efects of this cytokine in the obese adi-
pocyte and may be mediated by diferential expression
of its soluble and membrane-anchored receptors.
Desregulation of lipid metabolism by TNF- in
adipocytes
Tis cytokine may cause diabetogenic efects in
obesity indirectly through desregulating lipid
metabolism in adipose tissue. Both FFA and
ceramides were reported to induce insulin resistance
in peripheral tissues. TNF- induced lipolysis in
adipocytes increasing FFA release to the circulation
and ceramide production as a consequence of sphin-
gomyelinase activation (Green et al., 1994; Ryden
et al., 2002; White, 2003; Arner, 2003). TNF- could
potentially contribute to induction of systemic insu-
lin resistance by causing a decrease in FA oxidation
in muscle and thus an increase in plasma FFA levels
(Steinberg et al., 2006). Tus, TNF- defcient mice
exhibit lower circulating FFA and TGA than wild-type
animals (Uysal et al., 1997). Our group has extensively
studied TNF- efects on BAT and skeletal muscle.
In this regard, ceramide production is activated by
TNF- in brown adipocytes and exogenously added
C2-ceramide inhibits AKT activity throughout
ceramide-activated protein-phosphatase (PP)2A
(Figure 2) (Teruel et al., 2001). In addition, TNF-
also induces long-term efects of gene expression of
many proteins involved in glucose and FFA uptake
and storage take. For example, TNF- has been
shown to downregulate the genes for adiponectin,
GLUT4, IRS-1, C/EBPa, PPARg and perilipin in
adipocytes, involving the transcription factor NF-kB
(Ruan et al., 2002). Moreover, this cytokine repressed
GLUT4 gene expression in brown adipocytes by
HYPERINSULINEMIA
FFA
pro-Inflammatory adlpokines (MCP-1, IL-6)
anti-Inflammatory adlpokines (adiponectin)
Insulin Resistance
PTEN
P-Ser-IRS1
P-Tyr-IRS1
P-AKT
GLUT4 translocation Anti-lipolysis
WHITE ADIPOCYTES
LXR agonists PPAR agonists
MYOCYTES
Insulin resistance
on glucose uptake
Figure 1. Hyperinsulinemia desregulates endocrine function and induces insulin resistance on glucose and lipid metabolism in human
adipocytes. Long-term treatment with insulin deregulates adipocyte secretion pattern (with an increased of pro-infammatory and a
decreased of anti-infammatory factors) inducing insulin resistance on GLUT4 translocation and on antilipolytic efect of insulin. Te
mechanism that involves serine-phosphorylation of IRS1 and modulation of PTEN expression. Moreover, adipocyte secreted factors
modulate insulin sensitivity in skeletal muscle where insulin resistance is detected earlier than in adipocytes. Pharmacological treat-
ments with LXR agonist ameliorate insulin resistance on glucose metabolism whereas PPARg agonist such as rosiglitazone presents
benefcial efects on lipid metabolism.
232 Sonia Fernndez-Veledo et al.
interfering with C/EBPa acumulation (Figure 2)
(Fernandez-Veledo et al., 2006a). Infusion of TNF-
in rodents leads to impairment of insulin-stimulated
skeletal muscle glucose uptake (Nieto-Vazquez
et al., 2007). Accordingly, neutralisation of TNF-
with specifc antibodies has the opposite efect and
improves insulin resistance in rats (Hotamisligil
and Spiegelman, 1994). However, in contrast to the
fndings in rodent models, TNF- neutralisation has
no benefcial efect in terms of insulin sensitivity
in humans. Variations in TNF- genotypes in the
mediation of the TNF- action could explain these
diferent efects ( Fontaine-Bisson et al., 2007).
Infammatory pathways involved in
TNFinduced insulin resistance
Te interaction between TNF- and insulin signal-
ling is most important for local insulin resistance in
obesity. When cells are directly exposed to TNF-,
this adipokine inhibits insulin signalling by afecting
IRS proteins (Hotamisligil, 2003). Stress kinases and
infammatory pathways that are activated in response
to TNF-, such as extracellular-signal regulated kinase
(ERK)1/2, c-Jun N-terminal kinase (JNK) and p38
mitogen-activated protein kinase (MAPK), have been
proposed as mediators of TNF- serine phosphoryla-
tion of IRS-1 in human adipocytes and skeletal muscle
cells (Bouzakri and Zierath, 2007). In this regard,
ablation of jnk1 blunted insulin resistance associ-
ated with dietary obesity. Furthermore, activation of
ERK1/2 and p38MAPKs by TNF- could inhibit insu-
lin signalling at the level of IRS-1 and IRS-2 in 3T3-L1
adipocytes, whereas JNK could mediate the feedback
inhibitory efect of insulin (White, 2003; Pirola et al.,
2004). In brown adipocytes, activation of ERK1/2 and
p38MAPK by TNF- is involved in this impairment of
normal tyrosine phosphorylation by insulin of IRS-2
(Figure 2) (Teruel et al., 2001; Hernandez et al., 2004).
Chronic exposure to TNF- induces a state of
insulin resistance on GLUT4 translocation to the
plasma membrane in murine primary myotubes
(de Alvaro et al., 2004), in accordance with the
efect produced in muscle in vivo, systemically
(Nieto-Vazquez et al., 2007). Te Ser307 residue of
IRS-1 seems to be one of the residues phosphor-
ylated by TNF- via activation of the beta isoform of
p38MAPK. Moreover, activation of inhibitor kappa
B kinase (IKK)b, dependent on the functionality of
p38MAPK, was observed during chronic treatment
with TNF- in murine myotubes (de Alvaro et al.,
2004). Ten, IKKb could act either downstream of
p38MAPK or directly and mediate TNFinduced
serine phosphorylation of IRS-1. Accordingly, IKKb
inhibition with salicylate or targeted disruption
of ikkb reversed obesity and diet-induced insulin
resistance (Gao et al., 2003; de Alvaro et al., 2004). In
this regard, the glucose- lowering efects of the anti-
infamatory compounds, salicylate and its derivative
aspirin, were identifed more than 100 years ago. Te
positive efects of high-dose aspirin are, however,
limited by its toxicity profle on the gastrointestinal
tract, as reviewed (de Luca and Olefsky, 2008).
Contribution of phosphatases to TNFinduced
insulin resistance
Te insulin-signalling cascade could also be nega-
tively regulated by protein tyrosine-phosphatases
such as (PTP)1B, which dephosphorylates the phos-
photyrosine residues of the IR and IRS-1. Te expres-
sion and activity of PTP1B has been found to be
P-Tyr-IRS2 P-AKT
PPAR
agonists
TNF-
Insulin-induced GLUT4 transiocation
ERK1/2
p38MAPK
PP2A PTP1B
LXR
agonists
Figure 2. TNF-a induces insulin resistance in brown adipocytes. TNF-a blocked insulin-induced GLUT4 translocation by a mechanism
that involves serine phosphorylation of the IRS-2 by ERK1/2 and p38MAPK; production of ceramides and activation of PP2A, and
increased activity and expression of PTP1B. Inhibition of ERK1/2 and p38MAPK activation by rosiglitazone and down-regulation of
PTP1B with LXR agonist ameliorates TNF--induced insulin resistance.
Molecular mechanisms involved in obesity-associated insulin resistance 233
increased in the muscle of diabetic and obese humans
and rodents (Klaman et al., 2000; Delibegovic et al.,
2007). Moreover, it has been described in various
populations noncoding polymorphisms in the PTP1B
gene which are associated with an increase in phos-
phatase muscle expression and insulin resistance
(Bento et al., 2004). In this regard, transgenic overex-
pression of ptp1b in muscle causes insulin resistance,
showing impaired insulin signalling and decreased
glucose uptake in this tissue (Zabolotny et al., 2004).
By contrast, mice lacking PTP1B (either in total
body or in skeletal muscle) exhibit increased insulin
sensitivity, resistance to weight gain on a high-fat diet
and an increased basal metabolic rate (Klaman et al.,
2000; Delibegovic et al., 2007). Furthermore, PTP1B-
defciency also reduces the diabetic phenotype in
mice with polygenic insulin resistance (Xue et al.,
2007) and treatment with PTP1B anti-sense oligo-
nucleotide improves insulin sensitivity in db/db
mice (Gum et al., 2003). Accordingly, modulation
of genes such as PTP1B might also contribute to
the pathogenesis of TNFainduced insulin resist-
ance. In this regard, brown adipocytes treated with
TNF- showed signifcant enhancement of PTP1B
expression and activity and the lack of ptp1b in these
cells confered protection against TNFainduced
insulin resistance on glucose uptake and insulin sig-
nalling (Figure 2) ( Fernandez-Veledo et al., 2006b).
Additionally, the expression of PTP1B was also found
to be up- regulated by TNF- in murine myoblasts
and in WAT and muscle (Nieto-Vazquez et al., 2007;
Zabolotny et al., 2008). More importantly, chronic
exposure to TNF- does not induce insulin resistance
in PTP1B-defcient myocytes. Moreover, PTP1B
/

mice showed complete protection against TNF
ainduced systemic insulin resistance and glucose
intolerance. Terefore, the lack of PTP1B expression
confers protection against TNFainduced insulin
resistance both in brown adipocytes and myocytes
as well as in vivo (Nieto-Vazquez et al., 2007).
Tus, the diferent mechanisms contributing
to TNFinduced insulin resistance show tis-
sue specifcity. TNF- impairs insulin-stimulated
glucose uptake in peripheral tissues at the level of
IRSs proteins by a mechanism that involves serine
phosphorylation by stress and pro-infammatory
kinases and tyrosine dephosphorylation by phos-
phatases, weakening the tyrosine phosphorylation
induced by insulin.
Dual role of IL-6 in insulin action
IL-6 has a positive role in insulin sensitivity under
physiological conditions since it is strongly induced
in skeletal muscle during and after exercise and this
results in enhanced substrate metabolism and whole
body glucose homeostasis (Penkowa et al., 2003;
Steensberg et al., 2002; Febbraio et al., 2004). In fact,
as IL-6 also activates lipolysis in WAT it might play a
role in energy supply during exercise (van Hall et al.,
2003). In this regard, IL-6 knockout mice showed an
impaired ability to exercise and to oxidize FA and
developed mature-onset obesity (Ruderman et al.,
2006; Wallenius et al., 2002). Tus, IL-6 role seems
to be rather anti-infammatory in such physiological
situations. Moreover, other studies reported lack
of efect or a positive efect of IL-6 on whole body
glucose disposal in rats and humans, respectively
(Rotter et al., 2004; Carey et al., 2006) and some
evidences also suggest anti-obesity efects of IL-6
through central regulation on appetite suppression
and weight loss (Wernstedt et al., 2004; Wallenius
et al., 2002).
Contribution of IL-6 to insulin resistance
Te role of IL-6 in the etiology of insulin resistance
in pathological conditions is not fully understood
and has been a matter of controversy (Kristiansen
and Mandrup-Poulsen, 2005; Carey and Febbraio,
2004). It is known that adipose tissue contributes
to a signifcant proportion of total circulaling IL-6
( Mohamed-Ali et al., 1997). Pretreatment with IL-6
in vivo blunted insulins ability to suppress hepatic
glucose production and has been reported to be an
important contributor to the chronic infammatory
state and hepatic insulin resistance of obesity (Kim
et al., 2004; Klover et al., 2005). In addition, IL-6
induced insulin resistance in hepatocytes, adi-
pocytes and myocytes (Senn et al., 2002; Rotter et al.,
2003; Tzeng et al., 2005) and seems to be involved in
palmitate-induced insulin resistance in myocytes
(Senn, 2006). Alternatively, the IL-6 protein content
in adipose tissue has been negatively correlated with
insulin-stimulated glucose disposal and a chronic
elevation of IL-6 is not desirable since it may com-
promise insulin sensitivity (Bastard et al., 2002; Kern
et al., 2001).
A recent study from our laboratory demonstrated
a dual efect of IL-6 on insulin action: additive at
short-term and negative after chronic-treatment.
IL-6 per se activated glucose uptake due to the
sequential phosphorylation of LKB1/AMP kinase/
AKT substrate of 160 kDa (AS160) pathway in murine
myotubes (Nieto-Vazquez et al., 2008). Accordingly,
diminished AMPK activity was found in muscle from
the IL-6 knockout mice (Ruderman et al., 2006) and
improvement in glucose and insulin tolerance tests
234 Sonia Fernndez-Veledo et al.
was observed in mice treated with IL-6 for short-
term (Nieto-Vazquez et al., 2008), in a similar way
as after excercise. By contrast, chronic-exposure to
IL-6 impaired insulin-stimulated GLUT4 transloca-
tion and insulin signalling in both myotubes and
skeletal muscle and caused systemic insulin resist-
ance as observed from glucose and insulin tolerance
tests. Tis situation imitates the chronic elevation of
IL-6 that causes insulin resistance when is secreted
by adipose tissue in obesity (Kern et al., 2001).
Tis dual behavior of IL-6 has also been observed
in human skeletal muscle cells (Al-Khalili et al.,
2006). Tree mechanisms seem to operate in IL-6-
induced insulin resistance in myocytes: activation
of JNK1/2, accumulation of suppressor of cytokine
signalling (SOCS) 3 mRNA and increase in PTP1B
activity, which converge at the IRS-1 level. In this
regard, defciency in PTP1B confers protection
against IL-6-induced insulin resistance in skeletal
muscle either in vitro or in vivo (Nieto-Vazquez
et al., 2008). Accordingly, a recent study showed
that JNK1-dependent secretion of IL-6 by adipose
tissue caused increased expression of liver SOCS3,
a protein that induces hepatic insulin resistance
(Sabio et al., 2008). Overall, IL-6 remains likely to
be an important contributor in obesity-associated
disorders such as insulin resistance and T2D.
Agonists of nuclear receptors as therapeutic
tools in ameliorating insulin resistance
Nuclear receptors, such as peroxisome prolifera-
tor activated receptor (PPAR) and liver X receptor
(LXR) comprise a superfamily of related proteins
that act as transcription factors for target genes
involved in glucose and lipid metabolism. These
proteins are activated by naturally produced lipids
as well as by synthetic compounds; some of them
display insulin sensitizing effects and anti-inflam-
matory properties (Lopez-Soriano et al., 2006).
Thus, the effectiveness of different nuclear recep-
tor agonists to overcome hyperinsulinemia- and
cytokine-induced insulin resistance has also been
evaluated in this review.
Benefcial efects of PPAR agonists in glucose and
lipid metabolism
Thiazolidinediones (TZDs) have been used for the
treatment of hyperglycaemia in T2D for the past 10
years. These compounds are agonists for PPARg,
primarily in adipose tissue, which display insulin-
sensitizing actions across a wide spectrum of
insulin-resistant states (Olefsky, 2000). Troglitazone
was the first TZD to be introduced into clinical
practice, but was withdrawn due to liver toxicity.
Currently, pioglitazone and rosiglitazone are the
only PPARg agonists licensed for patients with T2D.
PPARg receptor activation by TZDs improves insu-
lin sensitivity by promoting FFA uptake into the
adipose tissue, increasing adiponectin production
and reducing levels of inflammatory mediators such
as TNF-a and IL-6 (Quinn et al., 2008). The effec-
tiveness of the rosiglitazone to treat TNFainduced
insulin resistance in murine brown adipocytes
is due to the fact that rosiglitazone impairs the
activation of p38MAPK and ERK1/2 produced by
TNF- and restores the insulin signalling cascade
leading to normalization of insulin-induced glu-
cose uptake (Figure 2) (Hernandez et al., 2004).
Moreover, rosiglitazone decreases PTP1B activity,
improves insulin sensitivity and is also related to
an increase in thermogenic differentiation (Teruel
et al., 2005) contributing globally to an accelerated
glucose disposal in BAT. Likewise, rosiglitazone
treatment decreases PTP1B enlargement in muscle
but not in liver of diabetic rats (Wu et al., 2005).
In addition, it has been shown that rosiglitazone
completely restores the antilipolytic effect of insu-
lin under hyperinsulinemia conditions in human
adipocytes (Figure 1) (Fernandez-Veledo et al.,
2008). In accordance with improvement in lipid
metabolism in insulin-resistant human adipocytes,
a decrease postprandial NEFA concentration in T2D
has been reported in vivo. The insulin-sensitizing
effects of PPAR on other tissues such as skeletal
muscle have been shown to be indirect. Muscle-
specific deletion of PPAR induced an increase
in adiposity and whole-body insulin resistance.
However, treatment with TZDs ameliorated these
effects and altered expression of several lipid
metabolism genes in the muscle of these mice
(Norris et al., 2003). These results suggest that
although PPAR is not required for the antidiabetic
effects of TZDs in muscle, it is needed to mantain
whole-body insulin sensitivity via altered lipid
metabolism. On the other hand, PPAR appears
to be the more predominant isoform in skeletal
muscle. In this regard, PPARd activation using a spe-
cific ligand (currently under scrutiny in a clinical trial)
in human skeletal muscle cells enhances FA trans-
port and oxidation (Kramer et al., 2007). However,
a number of side effects are well recognized with
the use of TZDs in clinical practice, such as weight
gain due to expansion of the subcutaneous fat,
secondary insulin resistance in adipose tissue,
fluid retention, hepatotoxicity, detrimental effects
on bone, as well as pro-atherogenic effects.
Molecular mechanisms involved in obesity-associated insulin resistance 235
LXR as targets for drug treatment of insulin
resistance
LXRs have recently been proposed as important regu-
lators of glucose metabolism. In this regard, synthetic
LXR agonists, such as T0901317 and GW3965, have
been reported to improve glucose tolerance in
genetic and dietary models of T2D (Cao et al., 2003;
Laftte et al., 2003) and to increase glucose-induced
insulin secretion by islets (Efanov et al., 2004). In
addition, LXR agonist treatment suppresses hepatic
gluconeogeneis (Cao et al., 2003) and induces desir-
able changes in cholesterol metabolism (Bruemmer
and Law, 2005), favourable features for a potential
drug against T2D. Furthermore, LXR regulates the
expression of GLUT4 in vivo as well as in murine and
human adipocytes, through direct interaction with a
conserved LXR response element in the GLUT4 pro-
moter (Laftte et al., 2003). In addition, the ability
of LXR ligands to regulate GLUT4 expression was
abolished in mice lacking LXRs (Laftte et al., 2003;
Dalen et al., 2003). On the other hand, recent studies
in vitro demonstrate that LXR agonists overcome
insulin resistance both in adipocytes and skeletal
muscle. Tus, T0901317 and GW3965 ameliorate
TNFainduced insulin resistance in brown adi-
pocytes, completely restoring insulin-stimulated
GLUT4 translocation to the plasma membrane.
Tis efect is parallel to the recovery of the insulin
signalling cascade and could be due to the fact that
these compounds preclude the enlargement in
PTP1B expression produced by TNF- (Figure 2)
(Fernandez-Veledo et al., 2006b). Furthermore,
insulin sensitivity on glucose uptake in human
adipocytes under hyperinsulinemic conditions was
completely restored by T0901317 treatment (Figure 1)
(Fernandez-Veledo et al., 2008). Furthermore, it has
been also shown that LXR activation may regulate
infammatory response. Tus, it has been shown
that LXR agonists inhibit synthesis of proinfamma-
tory cytokines in lymphocytes (Walcher et al., 2006)
and astrocytes (Zhang-Gandhi and Drew, 2007).
More recently, benefcial efects on the endocrine
function of adipose tissue have been reported since
LXR agonists inhibit MCP-1 and IL-6 secretion
in insulin-resistant human adipocytes (Figure 1)
(Fernandez-Veledo et al., 2008).
On the other hand, LXR agonists may lead to
increased utilization of lipids and glucose in human
skeletal muscle cells (Cozzone et al., 2006; Kase
et al., 2005). However, T0901317-induced lipogen-
esis and lipid formation was more pronounced
in myotubes from T2D patients than from lean
individuals suggesting that increased intramyocel-
lular lipid content in these patients may involve an
altered response to activation of components in the
LXR pathway (Kase et al., 2007). Furthermore, when
a pharmacological approach was used to ameliorate
IL-6-induced insulin resistance, only LXR agonists
completely restored insulin-stimulated glucose
uptake (Nieto-Vazquez et al., 2008), an efect that
was not produced by the PPARd agonist. Accordingly,
a decrease in ptp1b gene expression by treatment
with LXR agonists confers protection against insulin
resistance by IL-6 (Nieto-Vazquez 2008) in a similar
fashion as the mechanism described in brown
adipocytes treated with TNF-a (Fernandez-Veledo
et al., 2006b).
In conclusion, LXR and PPAR agonists overcome
cytokine-induced insulin resistance, exerting anti-
infamatory properties such as controlling the
expression of cytokines with tissular specifcity. Tus,
nuclear receptors are interesting targets for drug
treatment of insulin-resistant conditions.
Conclusion
Te close association between obesity and insulin
resistance and their progression to T2D is a severe
health problem. Te identifcation of the factors
contributing to the development of insulin resistance
and the level at which insulin signalling is impaired,
is the frst step for establishing the molecular basis
of insulin resistance in peripheral tissues. In this
regard, pro-infammatory cytokines such as TNF-
and IL-6, have been suggested to impair insulin
action. Although insulin resistance can initially
be compensated by increased insulin secretion,
chronic hyperinsulinemia is detrimental for insulin
sensitivity. Stress and pro-infamatory kinases as
well as phosphatases, seem to be key factors in the
molecular mechanisms by which insulin signalling
is disrupted; however, the mechanisms involved
in obesity-related insulin resistance show tissue
specifcity. Pharmacological approaches based on
nuclear receptor agonists overcome such insulin
resistance, exerting anti-infamatory properties
as well as controlling the expression of cytokines.
Nevertheless, several limitations with this therapy
have now emerged and new generations of selective
nuclear receptors are currently being developed to
improve insulin sensitivity minimizing secondary
efects.
Acknowledgements
Tis work was supported by grants BFU2008-04043
from Ministerio de Ciencia e Innovacion, Spain,
S-SAL-0159-2006 from Comunidad de Madrid, Spain.
236 Sonia Fernndez-Veledo et al.
CIBER de Diabetes y Enfermedades Metabolicas
Asociadas is an ISCIII project. We also acknowl-
edge the support of COST Action BM0602 from the
European Commission. We thank L. Muoz and
E. Gonzalez from Universidad Complutense for their
experimental and administrative support.
Decleration of Interest: Te authors report no confict
of interest.
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