Genetics of Human Obesity JANIS S. FISLER AND NANCY A. SCHONFELD-WARDEN University of California, Davis, California
II. GENETIC EPIDEMIOLOGY OF HUMAN OBESITY
Complex and incompletely deﬁned interactions between environment and genetics determine each individual’s height and weight, as well as many other human traits. The result is a population in which individuals vary widely for height and weight, but no one factor can be identiﬁed as controlling either trait. In humans, long-term adult weight is relatively stable, as evidenced by the difﬁculty of sustaining intentional weight loss and the automatic return to previous weight following brief periods of overeating. This drive to constancy of body weight is due to both behavioral and physiological alterations that accompany weight change. Further convincing evidence of the biological basis of the regulation of body fat stores comes from the identiﬁcation of single-gene mutations that result in spontaneous massive obesity or in adipose tissue atrophy. There are also Mendelian disorders in which obesity or abnormalities of fat distribution are a prominent feature and for which the chromosomal locations, but not the genes or their functions, are known. Most human obesity, however, is not due to mutations in single genes but exhibits a complex, non-Mendelian inheritance. Obesity is usually dependent on a permissive environment. Fat deposition can occur uniformly or there can be preferential deposition of fat, for example, in the abdominal area. There are also likely to be interactions among genes such that some alleles of one gene will not cause obesity unless speciﬁc alleles of another gene are present. Although animal models clearly demonstrate that gene–gene interactions are common and can have substantial effects on many traits, technical difﬁculties have made it more difﬁcult to identify such interactions in human studies. Expression of an obesity gene may also be age or gender dependent. Thus, identiﬁcation of all the genes promoting human obesity is not a trivial task. Genetics is a rapidly progressing ﬁeld, and knowledge of the genetic basis for obesity is expanding exponentially. Therefore, the reader should use this chapter only as the starting point for an understanding of this exciting body of knowledge.
Nutrition in the Prevention and Treatment of Disease
Genetic epidemiology of human obesity is the study of the relationships of the various factors determining the frequency and distribution of obesity in the population. Such studies of obesity are limited in that they do not examine DNA and rarely directly measure the amount or location of body fat. However, genetic epidemiology studies do provide information as to whether there is a genetic basis for the trait, whether inheritance is maternal or paternal, and whether expression of the trait is gender or age dependent. Genetic epidemiology studies of human obesity employ a variety of designs and statistical methods, each giving somewhat different heritability estimates for obesity. For a discussion of genetic epidemiology methods employed in the study of obesity, see Bouchard et al. . The heritability estimates for human obesity are derived from a large number of studies of adoptees, twins, and families. Heritability of human obesity may be as low as 10%, as estimated from some adoption studies, or as high as 80%, as estimated from some twin studies  (Table 1). Two studies that incorporated twins, adoptees, and nuclear families into the analyses yielded heritability estimates for obesity of approximately 25–40%. These studies indicate that familial environment has only a minor impact on obesity. The number of genes involved in human obesity has not been estimated, primarily because such estimates are complicated by the conclusion that genes implicated in obesity have major, minor, and polygenic effects. A major gene is a single gene that has a large effect on the phenotype. Polygenic effects are due to many genes, each with a small effect on the phenotype. Segregation analyses1 indicate that the percentage of minor gene transmission ranges from 25 to 42% and that there is a single major gene for high body mass segregating from the parents to their offspring. These data do not mean that there is only one major gene contributing to obesity in humans. Rather, the speciﬁc obesity gene may Segregation analysis is used to determine whether the trait is segregating in families according to Mendelian expectations. 1
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C. Genetic Influence on Nutritional Health
Overview of the Genetic Epidemiology of Human Body Fat/Obesitya
Nuclear families Adoption studies Twin studies Combined strategies
Maternal or paternal effectb
30–50 10–30 50–80 25–40
No Mixed results No No
Minor Minor No Minor
Source: Reprinted from Bouchard, C., Pe´russe, L., Rice, T., and Rao, D. C. (1998). The genetics of human obesity. In ‘‘Handbook of Obesity’’ (G. A. Bray, C. Bouchard, and W. P. T. James, Eds.), p. 166, by courtesy of Marcel Dekker, Inc., New York. a Based on the trends in about 50 different studies. In most of the studies, the BMI was the phenotype considered. In some cases, skinfolds or estimates of percentage body fat or fat mass were used. b Maternal or paternal effect indicates whether transmission through mother or father alters heritability.
vary from person to person, such that there may be several major obesity genes in the entire population. However, no major obesity genes have been identiﬁed in any population.
III. GENE–ENVIRONMENT INTERACTIONS Why some people in modern societies become obese, despite considerable effort and expense to avoid this condition, whereas others stay lean without such effort, appears to have a genetic basis . The chronic overfeeding studies by Sims and colleagues beginning in the 1960s showed interindividual differences in weight gain [3, 4]. More recently, Bouchard and colleagues determined the response to changes in energy balance by submitting pairs of monozygotic twins either to positive energy balance induced by overeating or to negative energy balance induced by exercise training. During 100 days of overfeeding by 1000 kcal/day, signiﬁcant intrapair resemblance was observed for changes in body composition and was particularly striking for changes in regional fat distribution and amount of visceral fat, with six times as much variance among as within twin pairs . During long-term energy deﬁcit induced by exercise training, intrapair resemblance was observed for changes in body weight, fat mass, percent fat, and abdominal visceral fat . One explanation for these differences is that some twin pairs were found to be better oxidizers of lipid, as evidenced by reduced respiratory quotient, during submaximal work than were other twin pairs . An important component of the interindividual difference in response to overeating may be individual differences in spontaneous physical activity or ‘‘ﬁdgeting’’ [7, 8]. A large portion of the variability in total daily energy expenditure, independent of lean body mass, is due to ﬁdgeting, which varies by more the sevenfold among subjects , is a familial trait, and is a predictor of future weight gain . In a very elegant study of the fate of excess energy during overfeeding, Levine et al.  again demonstrated the consid-
erable interindividual variation in susceptibility to weight gain. Two-thirds of the increases in total daily energy expenditure in nonobese subjects overfed by 1000 kcal/day for 8 weeks was due to increased spontaneous physical activity associated with ﬁdgeting, maintenance of posture, and other daily activities of life independent of volitional exercise .
IV. THE OBESITY GENE MAP A genetic map is a representation of the distribution of a set of genetic loci or markers. (For a discussion of genetic maps, see .) The three types of genetic maps are linkage, chromosomal, and physical maps. Genetic maps provide many kinds of information, from overall chromosomal views to more detailed molecular information, but all genetic maps place items (usually genes or clones) in an order, from top to bottom or left to right. The Human Obesity Gene Map  incorporates information from all three types of maps—linkage, chromosomal, and physical. The map and its associated summary provide an overview of the data reported in peer-reviewed journals on human obesity genes and markers as well as published evidence from rodent obesity models. Five types of data were used to generate the map, all of which are represented in Fig. 1: (1) single-gene obesity mutations, e.g., POMC; (2) Mendelian disorders exhibiting obesity as a clinical feature, e.g., ALMS1; (3) quantitative trait loci (QTLs)2 identiﬁed in linkage studies in animals, e.g., Mob 6 and Pfat1, and in humans; (4) linkage studies of candidate genes in humans, e.g., ACP1; and (5) association studies of candidate genes, e.g., also ACP1. The most up-to-date compilation of obesity gene information, covering all 22 autoso2 A quantitative trait is one that varies over a continuous range, such as body weight and height, and is generally controlled by more than one gene. A quantitative trait locus (QTL) is a chromosomal region in which alleles are linked to variation of a quantitative trait.
Genetics of Human Obesity
V. SINGLE-GENE OBESITY IN HUMANS
FIGURE 1 Chromosome 2 demonstrates each of the types of putative obesity loci found in the Human Obesity Gene Map. Mutation of the POMC gene causes single-gene obesity in humans. Mutations of ALMS and BBS5 cause the rare Mendelian syndromes, Alstrom syndrome and Bardet-Beidl-5 syndrome. IRS1, the insulin receptor substrate-1, is a candidate gene for type 2 diabetes, obesity, and hyperinsulinemia in humans. D2S165 is an anonymous marker linked to obesity in humans and Obq3 is a QTL linked to adiposity in a mouse model. [Reprinted with permission from Chagnon, Y. C., Pe´russe, L., Weisnagel, S. J., Rankinen, T., and Bouchard, C. (2000). The Human Obesity Gene Map: The 1999 update. Obes. Res. 8, 89–117.]
mal chromosomes as well as the X and Y chromosomes, is available in the Human Obesity Gene Map, published each January in the journal Obesity Research. The same information is available on-line at http://www.obesity.chair.ulaval. ca/genes.html. The current update  of the map includes many obesity-related phenotypes, including body mass index, percent body fat, fat mass, skinfolds, abdominal fat, macronutrient intake, metabolic rate, energy expenditure, and fat-free mass.
Cloning of the rodent obesity genes,3 Lepob, Leprdb, Cpefat, Tub, and Ay, between 1992 and 1996 led to an explosion of knowledge, summarized below, of the genetic causes of obesity. In addition to severe obesity, most of these models are characterized by insulin resistance and infertility. The function of only one of these rodent obesity genes, Tub, remains unknown. The human gene, TUB,4 located at 11p15.5, encodes a novel protein of unknown function, the C terminus of which is highly conserved across species. Recent papers provide hints of Tub function. One reports that Tub codes for a protein that functions in intracellular signaling by insulin . The other shows that Tub binds to DNA and may thus inﬂuence transcription . To date, no studies implicate TUB in human obesity or insulin resistance. Obesity in these rodent models exhibits Mendelian segregation, indicating that the obesity is inherited as a singlegene mutation. With one exception, these mutations result in the loss of gene or protein function and are expressed only when both copies of the gene in an individual are defective. Therefore, obesity due to these mutations in humans would not be common. Although most human obesity is not believed to be due to a single-gene defect but exhibits a complex, non-Mendelian inheritance, these genes are of great interest, since subtle mutations may contribute to common forms of obesity. Also, study of these genes has identiﬁed many new pathways for investigation of the physiology of obesity and provided many therapeutic targets for new antiobesity drugs . As of early 2000, ﬁve genes have been shown to cause spontaneous Mendelian obesity in humans: leptin (gene abbreviation, LEP), leptin receptor (LEPR), proopiomelanocortin (POMC), melanocortin-4 receptor (MC4R), and proprotein convertase subtilisin/kexin type 1 (PCSK1) (Table 2).
A. Leptin Deﬁciency Cloning and characterization of the mouse Lepob gene identiﬁed its protein product, leptin, a hormone that is secreted from adipose tissue  and to a lesser extent from placenta  and gastric epithelium . Leptin circulates in the blood , crosses the blood–brain barrier , and binds to its receptor in the hypothalamus to regulate food intake and energy expenditure. Thus, leptin functions as an afferent signal in a negative feedback loop to maintain constancy of body fat stores. Because leptin is expressed in, and secreted from, adipose tissue, circulating levels of leptin closely 3 The designations Lepob, Leprdb, and Cpefat represent mutations of the genes coding for leptin, the leptin receptor, and carboxypeptidase E that occur in the obese mouse, the diabetes mouse, and the fat mouse, respectively. 4 Capital letters, e.g., TUB, indicate the human gene, whereas lowercase letters, e.g., Tub, indicate the mouse gene.
TABLE 2 Protein product Autosomal recessive inheritance Leptin
C. Genetic Influence on Nutritional Health
Genes Known to Cause Spontaneous Mendelian Obesity in Humans Gene abbreviation LEP
Leptin receptor Proopiomelanocortin
Proprotein convertase subtilisin/kexin type 1
Autosomal dominant inheritance Melanocortin-4 receptor
match the total amount of fat stores  and decrease with weight loss . Peripheral or central administration of leptin reduces food intake and body fat in several mouse models of obesity (those with a functional leptin receptor), while preserving lean tissue mass, although relatively high doses are required in certain models [18, 22–24]. A recent clinical trial indicates that the same is true for both lean and obese humans treated with recombinant leptin . Leptin clearly has a broader physiological role than just the regulation of body fat stores. Leptin deﬁciency results in many of the abnormalities seen in starvation, including reduced body temperature, reduced activity, decreased immune function, and infertility. Leptin levels, for equivalent body fat mass, are higher in women than in men . In prepubertal females, leptin levels are highly correlated with body fat, and the increase in serum leptin is associated with a younger age of menarche . Leptin reverses the starvation-induced suppression of T cells even in the presence of continued energy deﬁcit . For a review of the physiological role of leptin see Friedman and Halaas . Known mutations in leptin (Table 2) causing spontaneous massive obesity in humans are autosomal recessive and are rare in the population5. However, two highly consanguineous families were identiﬁed that carry mutations in LEP. Two severely obese children of one family have very low serum leptin levels despite massive obesity . One of the children weighed 86 kg at the age of 8 years, with 57% body fat. The other child weighed 29 kg at the age of 2 years. Both children had normal birth weight but were markedly hyper-
5 If an allele is rare and if two copies (homozygosity) of a mutation are required for the phenotype to be expressed, then homozygotes are usually found only in highly consanguineous (inbred) families.
Phenotype Severe hyperphagia and massive obesity beginning in early childhood Infertility due to hypothalamic-pituitary hormone insufﬁciency in adults Same phenotype as leptin deﬁciency Moderate obesity in early childhood Adrenal insufﬁciency, red hair Extreme childhood obesity Abnormal glucose homeostasis, hypogonadotropic gonadism, hypocortisolism, elevated proinsulin and POMC Severe hyperphagia, massive obesity from early childhood
Reference     
[40, 41, 42]
phagic and gained weight rapidly in the early postnatal period. Four massively obese members of another family are homozygous for a different mutation in LEP and have very low leptin levels. Three of these individuals are adults: The females have primary amenorrhea and the male never entered puberty. Seven obese members of this pedigree, presumably also carrying the mutation in LEP, died of infectious diseases during childhood (no normal weight family members have died). All others in the family are either heterozygous for the mutation or homozygous for the wild-type allele and have normal body weight and serum leptin levels [30, 31]. Recombinant leptin therapy in doses sufﬁcient to raise serum concentrations of leptin to the normal range in a 9-year-old girl with congenital leptin deﬁciency corrected many aspects of the obese phenotype. Over a 12-month period, this patient, with a baseline weight of 94 kg, lost 16 kg, primarily as fat mass .
B. Leptin Receptor Deﬁciency Leptin acts through the leptin receptor, a single-transmembrane-domain receptor of the cytokine-receptor family . The leptin receptor is found in many tissues in several alternatively spliced forms, raising the possibility that leptin affects many tissues in addition to the hypothalamus . For additional discussion of the leptin receptor, see . An autosomal recessive mutation in the human leptin receptor gene (LEPR) that results in a truncated leptin receptor was discovered in homozygosity in a consanguineous family. Three of nine siblings had severe hyperphagia and developed early morbid obesity despite normal birth weight . Individuals homozygous for this mutation have no pubertal development and their secretion of growth hormone
Genetics of Human Obesity
and thyrotropin is reduced. This phenotype is similar to that seen in individuals with mutation of the leptin gene.
C. Proopiomelanocortin Deﬁciency Sequential cleavage of the precursor protein proopiomelanocortin (POMC) generates the melanocortin peptides adrenocorticotrophin (ACTH), the melanocyte-stimulating hormones (␣- and ␤-MSH), and the opioid-receptor ligand betaendorphin. ␣-MSH plays a central role in the regulation of food intake by the activation of the brain melanocortin-4 receptor (Section V. E) . The dual role of ␣-MSH in regulating food intake and inﬂuencing hair pigmentation predicts that the phenotype associated with a defect in POMC function would include obesity, alteration in pigmentation, and ACTH deﬁciency. The observations of these symptoms in two probands6 led to the identiﬁcation of three separate mutations within their POMC genes  (Fig. 2, see color plate at the back of the book). One individual is a compound heterozygote7 for two mutations that interfere with appropriate synthesis of ACTH and ␣-MSH. The other patient is homozygous for a mutation that abolishes POMC translation. These ﬁndings deﬁne a new monogenic endocrine disorder resulting in early-onset obesity, adrenal insufﬁciency, and red hair pigmentation.
D. Proprotein Convertase Subtilisin/Kexin Type 1 Deﬁciency A wide variety of hormones, enzymes, and receptors are initially synthesized as large inactive precursors. To release the active hormone, enzyme, or receptor, these precursors must undergo limited proteolysis by speciﬁc convertases. Examples are the conversion of proinsulin to insulin by the combined actions of proprotein convertase 1 and 2 and the clipping of POMC by proprotein convertase 1. A recessive mutation of carboxypeptidase E, an enzyme active in the processing and sorting of prohormones, causes obesity in the Cpefat mouse. A mutation in a homologous enzyme was found in a woman with extreme childhood obesity, abnormal glucose homeostasis, hypogonadotrophic hypogonadism, hypocortisolism, and elevated proinsulin and proopiomelanocortin concentrations but a very low insulin level . This woman is a compound heterozygote for mutations in proprotein convertase subtilisin/kexin type 1 (PCSK1; also known as prohormone convertase-1), which acts proximally to carboxypeptidase E in the pathway of post-translational processing of prohormones and neuropeptides. Since the proband and the fat mouse share similar phenotypes, it can be inferred that molecular defects in prohormone conversion represent a generic mechanism for obesity. 6 A proband is the index case, the person through whom the pedigree (family) was acertained. 7 A compound heterozygote would have two different mutations in the gene, one on each chromosome.
FIGURE 2 Photo of 5-year-old-boy with early-onset obesity, adrenal insufﬁciency, and red hair caused by mutation of the POMC gene. This patient had early hypoglycemia and hyponatriaemia due to ACTH deﬁciency. Birth weight was normal but, due to hyperphagia, obesity was apparent by 5 months of age. (See color plate.) [Reprinted with permission from Krude, H., Biebermann, H., Luck, W., Horn, R., Brabant, G., and Gru¨ters, A. (1998). Severe earlyonset obesity, adrenal insufﬁciency and red hair pigmentation caused by POMC mutations in humans. Nature Genet. 19, 155–157.]
E. Mutation in the Melanocortin-4 Receptor Gene The agouti protein, identiﬁed in the yellow obese (Ay) mouse, inhibits binding of ␣-MSH to melanocortin receptors, including Mc4r, which is located in the hypothalamus, and Mc1r, which is located in the skin. Obesity and yellow coat color in the Ay mouse result from expressing agouti in all tissues, not just in skin, which is the normal condition. The melanocortin-4 receptor, a G-protein-coupled receptor, is highly expressed in the hypothalamus, a region of the brain intimately involved in appetite regulation. It is a receptor for ␣-MSH, a product of the POMC gene (Section V. C), which inhibits feeding. Inactivation of Mc4r by gene targeting in mice results in a maturity-onset obesity syndrome associated with hyperphagia and impaired glucose tolerance . Mc4r-deﬁcient mice do not respond to a ␣-MSH-like agonist, suggesting that ␣-MSH inhibits feeding primarily by activating Mc4r . Mice heterozygous for a null Mc4r allele exhibit phenotypes intermediate to that seen in wildtype and homozygous littermates .
C. Genetic Influence on Nutritional Health
In screening children that were severely obese from an early age, mutations in MC4R resulting in haploinsufﬁciency8 as well as several missense9 mutations were identiﬁed [40–43]. The functional signiﬁcance of the missense mutations  is uncertain. The haploinsufﬁciency mutations were present in the heterozygous state, and other members of each family were obese in a pattern consistent with autosomal dominant inheritance. Adrenal function is not impaired in the MC4R-deﬁcient subjects. Sexual development and fertility are normal. Affected subjects are tall, similar to the increased linear growth that occurs in heterozygous Mc4r-deﬁcient mice. Female haploinsufﬁciency carriers are heavier then male carriers in their families, a pattern also seen in Mc4r-deﬁcient mice. These data are strong evidence for dominantly inherited obesity, not associated with infertility, due to haploinsufﬁciency mutations in MC4R.
VI. SINGLE-GENE MUTATIONS RESULTING IN ADIPOSE TISSUE ATROPHY The lipodystrophies are characterized by the absence or reduction of subcutaneous adipose tissue. Patients with familial partial lipodystrophy (FPLD) are born with normal fat distribution, but close to puberty, they experience regional adipose tissue atrophy that is often associated with insulin resistance, diabetes, and hyperlipidemia. The gene coding FPLD was mapped to 1q21. 2-q21. 3 and found to be LMNA, which codes for a polypeptide, lamin A, found in the nuclear lamina of the cell. Three different amino acid substitutions at one position in the lamin A polypeptide that result in heritable partial lipodystrophy were identiﬁed in a dozen families [44, 45]. Different mutations in LMNA result in speciﬁc muscular dystrophy and cardiomyopathy disorders as well.
VII. RARE GENETIC SYNDROMES WITH OBESITY AS A PROMINENT FEATURE There are at least 26 rare Mendelian syndromes, in which obesity is a prominent clinical feature, described in the On8 Haploinsufﬁciency occurs when a gene, or a group of genes, is present in too few copies or too many copies. In autosomes (all but the X and Y chromosomes) one copy of each gene is inherited from each parent. The presence of extra chromosomal material or lack of chromosomal material alters gene dosage, causing abnormalities in gene function. 9 A missense mutation is one that changes amino acid sequence, but does not produce a stop codon (nonsense mutation). 10 The Online Mendelian Inheritance in Man (OMIM)  database is available at http://www3.ncbi.nlm.nih.gov/omim/. This database is a catalog of human genes and genetic disorders authored and edited by Dr. Victor A. McKusick and his colleagues at Johns Hopkins and elsewhere, and developed for the World Wide Web by the National Center for Biotechnology Information (NCBI).
line Mendelian Interitance in Man (OMIM) database10 . Among the better known of these syndromes are the PraderWilli syndrome, the Bardet-Biedl syndromes, and Alstrom syndrome. Currently, the pathophysiologic mechanisms leading to obesity in these syndromes are not known. The identiﬁcation of the underlying genes will likely help deﬁne the mechanisms controlling appetite, satiety, and obesity. The characteristic features of these syndromes were recently reviewed . With an incidence of about 1 in 25, 000 births, the most common of the Mendelian syndromes is the Prader-Willi syndrome, which results from a microdeletion of paternal chromosome 15q11-q13 or, more rarely, as a result of maternal disomy11 of chromosome 15. In addition to obesity, the Prader-Willi syndrome is characterized by hypotonic musculature, mental retardation, hypogonadism, short stature, and small hands and feet (for review, see [48, 49]). Aberrant behavior, including hyperphagia and aggressive food seeking, makes management of these patients difﬁcult. Autosomal recessive Mendelian obesity syndromes include the Bardet-Biedl syndromes (BBS1–BBS5) and the Alstrom syndrome (ALMS1). The Bardet-Biedl syndromes are associated with variants on chromosomes 11q13 (BBS1), 16q21 (BBS2), 3p13-p12 (BBS3), 15q22. 3–23 (BBS4), and 2q31 (BBS5). The Bardet-Biedl syndromes are all characterized by mental retardation, pigmentary retinopathy, polydactyly, obesity, and hypogonadism. It is, therefore, apparent that mutation in at least ﬁve separate genes can result in the same phenotype. The gene on chromosome 16 coding for BBS2 may predispose males carrying only one copy of the gene to obesity and may explain approximately 3% of severely overweight males . Of interest, BBS2 parents of both sexes were signiﬁcantly taller than U. S. individuals of comparable age . In addition to obesity, Alstrom syndrome is characterized by retinitis pigmentosa leading to blindness, insulin resistance, diabetes, and deafness, but does not involve mental retardation or polydactyly (for review, see [51, 52]). Onset of obesity is usually between 2 and 10 years of age and can range from mild to severe. The gene for Alstrom syndrome (ALMS1) was narrowed down to a small region on chromosome 2p13-p12 .
VIII. EVIDENCE FROM LINKAGE STUDIES OF OBESITY PHENOTYPES A. Mapping of Loci in Animals Animal models have been very important in the dissection of complex traits . Quantitative trait locus mapping is a method for mapping Mendelian factors that underlie complex traits, in virtually any animal model, by using genetic Maternal disomy is inheritance of an extra maternal chromosome or part thereof. 11
CHAPTER 12 linkage maps12 (for discussion, see [10, 54]). As of October 1999, 98 animal QTLs were linked variously to body weight, body fat, energy expenditure, food intake, leptin levels, or weight gain . A number of these QTLs identiﬁed in separate crossbreeding experiments of different strains are overlapping and it is likely that the same underlying gene is responsible for these overlapping QTLs. Many of these QTLs have pleiotropic effects.13
B. From Mouse to Human QTLs are valuable for identifying candidate genes to be further evaluated by gene targeting experiments in mice or by linkage studies or association studies of the candidate genes in humans. Because of the evolutionary relationship between mice and humans, many ancestral chromosomal segments have been retained where the same genes occur in the same order within discrete regions of chromosome (homology)14 . These regions of homology may include many hundreds to thousands of genes in the same orders, although some regions of homology are made more complex by chromosomal rearrangements within the region of homology. Because regions of homology between mouse and human chromosomes are well deﬁned, the identiﬁcation of a gene in the mouse frequently gives the chromosomal location of the same gene in the human. This relationship was used to map a gene for obesity to human chromosome 20 . To test whether an obesity QTL on mouse chromosome 2 contributes to human obesity, linkage analysis between markers located within the homologous region on chromosome 20 and measures of obesity was performed in a large study of more than 150 French Canadian families; a locus on 20q13 that contributes to body fat and fasting insulin was found . This locus was later conﬁrmed in a second population group . A polymorphism within this region in the candidate gene, adenosine deaminase (ADA), was recently associated with obesity in a population of subjects with non-insulindependent diabetes (NIDDM)  (Section IX.B).
C. Linkage Studies in Humans Linkage studies in humans are conducted with large extended families or with nuclear families. A conceptually 12 A locus is any segment of DNA that is measurable in genetic analysis. A locus may be within a gene or may be an alternative DNA sequence of no known function. A linkage map represents a set of loci on a single chromosome in which all members of the set are linked either directly or indirectly with all other members of the set. Linkage in humans refers to the cosegregation of a genetic marker and a trait together in families. 13 Pleiotropy means that one gene has a primary effect on more than one phenotype. 14 The Davis Human/Mouse Homology Map is a table comparing genes in homologous segments of DNA from human and mouse sources, sorted by position in each genome. A total of 1793 loci are presented, most of which are genes, in 201 homology groupings . Current homology data are available at http://www.ncbi.nlm.nih.gov/Homology/.
Genetics of Human Obesity
simple and practical method is the nonparametric sib-pair linkage method that provides statistical evidence of linkage between a quantitative phenotype and a genetic marker [1, 59]. The method is based on the concept that siblings who share a greater number of alleles (1 or 2) identical by descent15 at a linked marker locus should also share more alleles at the phenotypic locus of interest and should be phenotypically more similar than siblings who share fewer marker alleles (0 or 1). The method has been expanded to use data from multiple markers, allowing higher resolution mapping . Linkage studies do not identify any speciﬁc gene but are useful in identifying candidate genes for further study. A number of whole genome scans and linkage studies covering smaller chromosomal regions, published as of October 1999, identiﬁed 56 QTLs for various measures of adiposity, respiratory quotient, metabolic rate, and plasma leptin levels in humans (for details, see ). Many of these chromosomal loci contain candidate genes for obesity, including genes known to cause single-gene obesity (Section V). Linkage studies suggest that the LEP gene or a gene very near it on 7q31. 3 contributes to obesity in several different populations although the monogenic syndrome of leptin deﬁciency is rare [61–65]. One group linked both the LEPR  and MC4R  genes to multigenic obesity-related phenotypes in French Canadians. Candidate genes ﬁrst identiﬁed through linkage studies include the adrenergic receptors [68, 69], UCP2/UCP3 , and ADA .
IX. ASSOCIATION STUDIES OF CANDIDATE GENES FOR OBESITY AND OBESITY-RELATED INSULIN RESISTANCE AND HYPERLIPIDEMIA Association studies examine the correlation of a genetic variant (polymorphism) within a gene with the phenotype of interest. It is assumed that variants within a gene’s coding region alter gene function, although proof of that requires gene-targeting experiments in cell or animal models. Association studies are generally carried out in unrelated individuals and are frequently designed as case-control studies. Although case-control studies remain a powerful tool in some areas, they are less powerful for genetic studies due to methodological issues that complicate analyses in complex populations such as those found in the United States. Therefore, most association studies are now conducted in isolated populations, such as occur in Finland and Quebec. A positional candidate gene is identiﬁed both by its location in a 15 Identical by descent is in contrast to identical by state. Two siblings sharing the same allele are identical by descent if you know that it is the same allele inherited from the same parent. They are identical by state if they have the same allele, but you do not know if they are derived from the same parental haplotype.
C. Genetic Influence on Nutritional Health
chromosomal region that has signiﬁcant linkage to obesity in family studies and because its biological functions are generally consistent with a role in body weight regulation. Forty candidate genes have been associated with varying degrees of conﬁdence with obesity phenotypes to date . The complete physical map of the human genome should be available by 2003 providing many new candidate genes for investigation.
A. Role of Single-Gene Obesity in Common Forms of Human Obesity Several of the genes causing spontaneous massive obesity in humans have been implicated in polygenic obesity using association studies. The LEP gene is associated with body weight, weight loss, or leptin levels [71–73]. The LEPR gene is associated with obesity in three studies, including one of severe obesity in children [66, 74, 75]. Populations from the Paciﬁc Island of Nauru have some of the highest rates of obesity and NIDDM in the world. In Nauruan males, speciﬁc combinations of alleles in the LEP and LEPR genes are associated with increased risk for development of insulin resistance . POMC is associated with variation in leptin levels . MC4R is associated with fat mass in one study . These data suggest that mutations of the genes causing Mendelian obesity also contribute to common (polygenic) obesity in humans.
B. Candidate Genes with Variants Causing Altered Function A number of other genes, with variants that may alter gene product function, are believed to contribute to common obesity and its comorbidities. Obesity frequently clusters with insulin resistance, hyperlipidemia, and hypertension . This clustering might arise by any of several mechanisms: Obesity might promote comorbidities, comorbidities might promote obesity, or some genes might promote development of both obesity and its comorbidities. Several association studies have reported evidence for genes that inﬂuence obesity and one or more comorbidities. However, the demonstration that these variants result in single-gene obesity in any case remains to be established. The more promising candidates are described in Table 3. Peroxisome-proliferator-activated receptor ␥ (PPAR␥) is a member of the nuclear hormone receptor subfamily of transcription factors that includes T3 and vitamin D3 receptors. PPARs regulate expression of genes involved in, among other things, lipid metabolism and energy balance (for review, see ). Due to combined effects on both fat and muscle, activation of PPAR␥ improves insulin sensitivity and glucose metabolism, and decreases blood triglyceride levels. Three association studies have implicated PPAR␥ in obesity and insulin resistance phenotypes. Four of 121 obese
German subjects had a missense mutation in the PPAR␥ gene compared to none in 237 normal weight individuals . All of the subjects with the mutant allele were severely obese. The mutant gene was then overexpressed in mouse ﬁbroblasts, which led to the accelerated differentiation of the cells into adipocytes with greater accumulation of triglyceride than seen with the wild-type PPAR␥ gene . A different mutation of the PPAR␥ gene was identiﬁed in Finnish populations and was found to be associated with lower body mass index (BMI), lower fasting insulin levels, and greater insulin sensitivity . The ␤-2-adrenergic receptor (ADR␤2) is a major lipolytic receptor in human adipose tissue, and, thus, plays a signiﬁcant role in lipid mobilization. Several polymorphisms have been identiﬁed and their frequencies compared between lean and obese subjects. These variants were associated with body mass index and blood triglycerides in both Swedish and Japanese populations [82–84]. Swedish women with two copies of a common polymorphism, Glu27, were about 10 times more likely to be obese than those with the wildtype ADR␤2 gene, with approximately 20 kg excess body fat and a 50% increase in fat cell size . Another variant of the ADR␤2 gene, Gly16, was associated with improved adipocyte ADR␤2 function. Thus, genetic variability in the human ADR␤2 gene may be a signiﬁcant contributor to human obesity. The ␤-3-adrenergic receptor (ADR␤3) is expressed in adipose tissue and is involved in the regulation of lipolysis and thermogenesis. Disruption of the Adr␤3 gene in mice results in moderate obesity . This potential relevance to human obesity led to an initial positive report in 1995 of an association between ADR␤3 and obesity  followed by numerous studies with conﬂicting results (for review, see ). A paired sibling design that aimed to detect effects of the variant by accounting for background genes examined 45 nondiabetic sibling-pairs discordant for the variant who were identical by descent at another marker that is known to be associated with obesity in this population. Presence of the variant was signiﬁcantly associated with increases in BMI, fat mass, and waist circumference . However, a metaanalysis16 combining 23 studies and 7399 subjects concluded that the ADR␤3 gene variant is not signiﬁcantly associated with BMI . The possible association of the variant with diabetes phenotypes was not examined in the meta-analysis. Thus, whether the ADR␤3 gene contributes to obesity or diabetes phenotypes is still subject to debate. Adenosine deaminase (ADA) was identiﬁed as a positional candidate gene for obesity by linkage studies in both mice and humans . ADA is an ␣-adrenergic agonist with potent lipolytic and vasodilator effects that regulates both 16 Meta-analysis is a statistical tool for pooling data from many studies into a single analysis, thus greatly increasing the statistical power of the analysis.
CHAPTER 12 TABLE 3 Protein product
Genetics of Human Obesity
Genes Associated with Obesity and Comorbidities in Humans Gene abbreviation
Peroxisome-proliferator-activated receptor ␥
Uncoupling protein 2
Uncoupling protein 3
Fatty acid-binding protein 2
Apolipoprotein B-100 Lipoprotein lipase
lipolysis and insulin sensitivity in human adipose tissue. Thus, variants in the ADA gene could theoretically explain the effects of this locus on both energy balance and insulin levels. A recent association study of ADA reported that one ADA variant was more commonly observed in subjects with NIDDM who were obese . Uncoupling proteins 2 and 3 (UCP2/UCP3) are structurally related to UCP1, a mitochondrial protein found in brown fat that plays an important role in generating heat and burning calories without the production of adenosine triphosphate. UCP1 is critical in the maintenance of body temperature of newborn humans, but is unlikely to be significantly involved in weight regulation because brown fat is normally atrophied in adult humans. UCP2 and UCP3 are recently identiﬁed genes [89, 90] located very near each other on chromosome 11 that, like UCP1, encode mitochondrial transmembrane carrier proteins. UCP2 is widely expressed in human tissues, whereas UCP3 is expressed only in skeletal muscle. In a large French Canadian study, UCP2 and UCP3 were linked with resting metabolic rate, BMI, percentage of body fat, and fat mass . Several groups have, therefore, examined polymorphisms within the coding
Phenotypes associated with different variants Severe obesity Lower BMI, lower fasting insulin, greater insulin sensitivity Higher BMI and excess body fat, increased subcutaneous fat, higher blood triglycerides Obesity, greater susceptibility to weight gain and diabetes phenotypes Increased BMI, fat mass and waist circumference No association with BMI Obesity in subjects with non-insulin-dependent diabetes Metabolic rate during sleep BMI, fasting serum leptin Obesity, reduced capacity to oxidize fat, elevated respiratory quotient Hyperinsulinemia Increased abdominal fat Increased insulin response to dexamethasone, increased BMI Insulin resistance, increased fat oxidation Obesity, elevated triglycerides Insulin resistance, greater intra-abdominal fat NIDDM Obesity, elevated fasting insulin Visceral obesity, dense LDL Obesity, hypertriglyceridemia
Reference   [82, 83, 84]                [108, 109] 
regions of both UCP2 and UCP3. Polymorphisms in UCP2 were associated with metabolic rate during sleep in older, but not younger, Pima Indians . A stronger association between a UCP2 exon variant and body mass index was found in South Indian subjects . The same variant was not associated with obesity in a British population, but was correlated with fasting serum leptin concentrations in the presence of extreme obesity . Two other studies failed to ﬁnd a relationship between UCP2 variants and energy expenditure, obesity, or insulin resistance [93, 94]. To determine whether UCP3 mutations could contribute to human obesity, the nucleotide sequence of coding exons was determined in obese and/or diabetic Africans, African-Americans, and Caucasians. A mutation and two missense polymorphisms in the UCP3 gene were identiﬁed in two severely obese probands of African descent . The gene variants were not found in the Caucasian population. The variants were transmitted in a Mendelian fashion; however, they were not consistently associated with obesity in other family members. Individuals who carried one copy of the exon 6-splice polymorphism were found to have only 50% the capacity to oxidize fat and had elevated respiratory quotients
C. Genetic Influence on Nutritional Health
(RQs), even though they were not obese. These data indicate that UCP3 could alter the availability in the cell of fatty acids for oxidation, promoting fat storage. High RQ and low fat oxidation were previously identiﬁed risk factors for future weight gain in Pima Indians  and African-Americans . Thus, UCP3 is a potentially important obesity gene in certain population groups. Animal models of obesity demonstrate the importance of glucocorticoid receptor (GRL) activity in the etiology and maintenance of the obese state. In humans, glucocorticoid excess (i.e., Cushing syndrome) results in central fat distribution. The GRL gene was weakly linked with BMI in a study of French obese families . Therefore, polymorphisms of GRL were examined for association with obesity. A variant of the BC1I polymorphism of GRL was associated with increased abdominal fat measured by computerized tomography in middle-aged Canadians  and hyperinsulinemia in British Caucasian women . In an elderly population in the Netherlands, 6% carried a polymorphism resulting in altered sensitivity to glucocorticoids . Although healthy, these subjects had higher BMI and higher insulin response to dexamethasone suppression . Intestinal fatty acid-binding protein 2 (FABP2) is thought to facilitate the uptake, intracellular metabolism, and/or transport of long-chain fatty acids. Linkage between measures of insulin action and a region on chromosome 4q near the FABP2 locus was found in Pima Indians of Arizona . Therefore, an Ala54Thr polymorphism in FABP2 was examined in Pima Indians and in an isolated population of native Canadians. The variant was associated with insulin resistance and increased fat oxidation rate in Pima Indians  and obesity and higher fasting plasma triglyceride levels in the Canadians . The variant was also associated with insulin resistance and greater intra-abdominal fat in Japanese men . Lipoprotein function has been associated with several obesity phenotypes. Apolipoprotein D is a protein component of high-density lipoprotein (HDL). Variants of APOD were associated with obesity, elevated fasting insulin , and NIDDM . Apolipoprotein B is the main apolipoprotein of chylomicrons and low-density lipoproteins (LDLs) and occurs in two main forms, apoB–48 and apoB–100. A polymorphism of the APOB-100 gene was associated with abdominal fat and LDL particle size in obese hyperinsulinemic men [108, 109]. Lipoprotein lipase (LPL) deﬁciency reduces clearance of chylomicrons and other triglyceride-rich lipoproteins. LPL polymorphisms are associated with BMI and hypertriglyceridemia .
X. CLINICAL IMPLICATIONS OF THE DISCOVERY OF OBESITY GENES The recent discoveries of human obesity genes have broad implications for clinical practice. Most human obesity genes
have only been identiﬁed in the last few years. For most of the obesity gene mutations there is no information on the physiological impacts of these mutations, except for obesity. Thus, methods for their diagnosis and the implications of their discovery for treatment have not been discussed in depth. The discovery of human obesity genes will inﬂuence several areas of clinical practice including diagnosis and therapy.
A. Diagnosis of Obesity Disorders 2000 Until recently, only the rare Mendelian (single-gene) mutations, such as Prader-Willi and Bardet-Biedl syndromes, caused known heritable obesity (Section VII) . These disorders are easily recognized, both by a wide spectrum of phenotypes and by the use of cytogenetics assays that are widely available. However, the new molecular Mendelian obesity disorders (Section V) are not so easily diagnosed, because obesity is often the only apparent phenotype and molecular assays for known obesity gene mutations are currently not practical. It has been estimated that 2–7% of morbidly obese patients have mutations in MC4R [40–43], 3% have mutations in PPAR␥ [80, 111], and an unknown, but smaller, percent have mutations in other obesity genes, including POMC . Thus, only about 1 in 10 morbidly obese patients has a known mutation that explains the obesity, and molecular assays for the currently known Mendelian obesities would be negative in the majority of morbidly obese patients. Also, there are several known distinct mutations in each of these genes. Thus, no clinical laboratories yet provide diagnosis of these mutations, rather they have only been diagnosed by research laboratories, which are not licensed to provide patient information. However, inability to make speciﬁc molecular diagnosis does not mean that one cannot identify people with increased risk for genetic obesity, and this may inﬂuence choices or approaches to treatment. Several criteria can be used to estimate individual risks for genetic obesity. At the present time, due to the lack of data, these estimates do not produce any quantitative values revealing individual risk that obesity is genetic. 1. The earlier the age of onset and the more extreme the obesity, the more likely that there is a genetic basis for the obesity. Extreme trait values are more likely to be genetic for many complex diseases, simply because extremes tend to result from the actions of severe mutations or from mutations in genes that have larger effects . Children with single-gene obesity are normal weight at birth but severe early hyperphagia, often associated with aggressive food-seeking behavior, results in rapid weight gain, usually beginning in the ﬁrst year of life. 2. Prader-Willi, Bardet-Biedl, and other Mendelian syndromes can be diagnosed by a variety of characteristic
CHAPTER 12 phenotypes as well as by cytogenetic assays. Thus, one should rule out these diagnoses by phenotype determination and by absence of characteristic chromosomal abnormalities. 3. A strong family history of obesity is consistent with the presence of an obesity gene shared among family members. 4. POMC defects can cause red hair and obesity , although most red hair results from mutations in melanocortin receptor-1 (MC1R) , which does not inﬂuence obesity. Thus, red hair is only informative when red hair and obesity cosegregate within a family. 5. At present, few diagnostic tools are available for the medical evaluation of patients suspected of having Mendelian obesity. The only screening tests available are for endocrine abnormalities. Leptin should be measured. Very low or very high serum leptin levels will indicate mutation in LEP or LEPR, respectively. A subset of obese individuals has inappropriately low leptin levels for their fat mass, suggesting a less severe defect in leptin regulation . ACTH and proinsulin should be measured to indicate defects in POMC or in prohormone processing.
B. Implications of Obesity Genes for Obesity Treatment The recent discovery of human obesity genes may have broad future implications for diet, behavioral, and drug therapy of genetically obese humans, and perhaps of all obese people. The identiﬁcation and characterization of gene products associated with obesity have provided novel pathways that can be targeted for pharmaceutical intervention. A signiﬁcant new drug is the hormone leptin, which, as of this writing, is still in clinical trials. However, an early study suggests that exogenous leptin induces weight loss even in some obese subjects with elevated endogenous serum leptin levels . Leptin therapy may, therefore, be effective even for obese individuals without defects in leptin production. Another potential drug target identiﬁed by the cloning of obesity genes is the melanocortin receptor. Development of safe and effective drugs such as an ␣-MSH-like agonist for the melanocortin receptor to inhibit food intake or stimulators of the expression of UCP2 or UCP3 to enhance energy expenditure are certainly goals of the pharmaceutical industry . Patients with monogenic obesity will probably be more difﬁcult to treat than those with polygenic obesity, because individuals with monogenic obesity will likely have strong food-seeking behavior and may have physiological resistance to fat loss. Certainly, the primary therapy for individuals with documented leptin deﬁciency is recombinant leptin. Speciﬁc pharmaceutical treatment of other single-gene obesities will have to await development of drugs targeted further along the pathway of the mutated gene. Meanwhile, lifestyle
Genetics of Human Obesity
changes that may promote weight loss and improve metabolic ﬁtness and quality of life should be recommended. Drugs should also be considered, but whether currently available drug therapies, such as appetite suppressants (phentermine or sibutramine) or inhibitors of fat absorption (orlistat), are more or less effective in individuals with single-gene obesity than those with polygenic obesity is unknown. However, as with any severe obesity, when lifestyle changes and pharmaceutical approaches are inadequate to ameliorate morbidity, surgical treatment of the obesity may be necessary (see Chapter 31).
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