大脑与心脏代谢健康:需要精准生活方式医学方法的微妙平衡。

IF 4.2 2区 医学 Q1 ENDOCRINOLOGY & METABOLISM Obesity Pub Date : 2024-09-24 DOI:10.1002/oby.24119
Jean-Pierre Després, Natalie Alméras
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引用次数: 0

摘要

抑郁症是发病的一个主要原因,对生活质量有重大影响,同时还会影响缺勤率、工作效率和医疗成本[(1)]。2023 年,24% 的成年女性和 11% 的成年男性因抑郁症状而接受治疗[(2)]。此外,三十多年来的心脏代谢成像(计算机断层扫描 [CT] 或磁共振成像 [MRI])研究也提供了大量证据,证明在相同体重指数(BMI)下,个体的身体成分和区域脂肪组织分布存在很大差异[(4)]。例如,内脏脂肪组织(VAT)是与胰岛素抵抗和增加 2 型糖尿病和心血管疾病风险的代谢综合征特征最密切相关的身体脂肪区,这一点现已得到公认[(5)]。我们还了解到,过多的腹腔脂肪是皮下脂肪组织相对无法膨胀并充当代谢汇的标志,导致脂肪不仅沉积在腹腔,而且还沉积在心脏、肝脏、肾脏、胰腺和骨骼肌等通常较瘦的组织中,这种现象被称为异位脂肪沉积。安德森(Andersson)等人利用获得英国生物库(UK Biobank)成像数据(n = 40,174)的机会,回顾性地研究了AD(选择性5-羟色胺再摄取抑制剂和三环类抗抑郁药)使用者与性别、年龄和体重指数匹配的非使用者相比,是否会在体内脂肪分布和肌肉组成方面出现差异[(6)]。作者在报告中指出,与对照组相比,选择性 5-羟色胺再摄取抑制剂使用者的增值脂肪水平较高,肌肉体积较小,脂肪浸润较多。随着时间的推移,在体重指数的增加方面也发现了性别差异(女性和男性)。虽然发现三环类抗抑郁药使用者罹患心血管疾病(男性)和 2 型糖尿病的风险增加,但无法确定肌肉成分的变化对这种风险增加的具体影响。Andersson 等人的论文探讨了一个重要的话题,因为据报道,一些抗抑郁药物会诱发体重增加,不同类别和特定分子的药物之间存在差异。该论文还很好地证明了体重的变化(或无变化)有时可能会误导追踪对心脏代谢健康有重大影响的身体成分的临床相关变化。该论文提供了来自几项相关探索性分析的大量数据,进一步证明了长期监测体重不足以监测心脏代谢健康的变化,尤其是在接受这些药物治疗的患者中。然而,一些研究的局限性也应得到强调。与其他在英国生物库队列中进行的子分析相反,作者无法使用加速度测量数据来更好地评估各组的体力活动水平。另一个限制因素是无法检查整体饮食质量和热量摄入的潜在变化。最后,由于没有心血管代谢健康的中间指标,作者假设与某些药物相关的肌肉质量下降和脂肪浸润增加有助于增加心血管代谢健康是推测性的。尽管肌少症显然对肥胖患者不利,但在控制了内脏脂肪(以及肝脏和心脏脂肪增加)后,这一现象在多大程度上独立地增加了该队列中的心脏代谢风险,这是作者无法妥善解决的问题。有一点是肯定的:在当今时代,由于许多药物并不是体重中性的,我们显然需要比 BMI 更好的工具来评估临床实践中的脂肪表型,尤其是评估对哪种治疗的反应。此外,由于已知行为会调节与任何特定脂肪表型(无论是否由药物引起)相关的风险[(4)],因此应在所有患者中获取 "生活方式生命体征",如整体饮食质量、体力活动水平、睡眠质量、心肺功能和腹部脂肪的人体测量指标[(7, 8)]。Andersson等人的这一有趣分析应为在这一需要改善心血管代谢健康、心理健康和生活质量的高发人群中进一步开展精准生活方式医学研究铺平道路。
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Brain versus cardiometabolic health: a delicate balance in need of precision lifestyle medicine approaches

Depression is a major cause of morbidity and has major consequences on quality of life, impacting absenteeism, productivity at work, and health care costs [(1)]. In 2023, 24% of adult women and 11% of adult men were treated for depressive symptoms [(2)]. Because some antidepressants (AD) are known to have an impact on body weight [(3)], the balance between managing mental health versus limiting adiposity-related cardiometabolic risk remains an important dilemma in clinical practice.

Furthermore, we have substantial evidence from more than three decades of cardiometabolic imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) studies demonstrating that, for the same body mass index (BMI), there are considerable individual differences in body composition and regional adipose tissue distribution [(4)]. For instance, it is now well established that visceral adipose tissue (VAT) is the body fat compartment most closely associated with insulin resistance and features of the metabolic syndrome that increase risk of type 2 diabetes and cardiovascular disease [(5)]. We also understand that excess VAT is a marker of the relative inability of subcutaneous adipose tissue to expand and act as a metabolic sink, leading to deposition of fat not only in the abdominal cavity but also in usually lean tissues such as the heart, liver, kidney, pancreas, and skeletal muscle, a phenomenon referred to as ectopic fat deposition.

Andersson et al. took the opportunity of having access to the now-famous UK Biobank imaging data (n = 40,174) to retrospectively examine whether AD (selective serotonin reuptake inhibitors and tricyclic antidepressants) users would display differences in body fat distribution and muscle composition compared with sex-, age-, and BMI-matched nonusers [(6)]. The authors report that selective serotonin reuptake inhibitor users had higher levels of VAT and less muscle volume combined with greater fat infiltration than control individuals. Sex differences were also found in BMI gained over time (women > men). Although an increased risk of cardiovascular disease (men) and type 2 diabetes was found among tricyclic antidepressant users, the specific contribution of changes in muscle composition to such increased risks could not be determined with certainty.

The paper by Andersson et al. addresses an important topic because some AD medications have been reported to induce weight gain, with differences observed among classes and specific molecules. The paper also nicely demonstrates that changes (or lack of changes) in body weight could sometimes be misleading in order to track clinically relevant variations in body composition with significant consequences on cardiometabolic health.

This paper presents a large amount of data from several relevant exploratory analyses providing additional evidence that monitoring body weight over time is not sufficient to monitor changes in cardiometabolic health, especially among patients treated with these drugs. However, some study limitations should be highlighted. Contrary to other subanalyses conducted in the UK Biobank cohort, the authors could not use accelerometry data to better evaluate the level of physical activity across the groups. Another limitation is the inability to examine potential changes in overall diet quality and caloric intake. Finally, because intermediate markers of cardiometabolic health were not available, the assumption made by the authors that the decreased muscle mass and increased fat infiltration associated with some of these drugs contributed to increasing cardiometabolic health is speculative. Although sarcopenia is clearly detrimental to people living with obesity, to what extent this phenomenon independently contributed to cardiometabolic risk in this cohort after control for visceral adiposity (and increased liver and heart fat) is a question that could not be properly addressed by the authors.

One thing is certain: in this day and age, because many pharmacological agents are not weight-neutral, we are clearly in need of better tools than BMI to assess adiposity phenotypes in clinical practice, particularly to evaluate the response to whichever treatment. Furthermore, because behaviors are known to modulate the risk associated with any given adiposity phenotype (drug-induced or not) [(4)], “lifestyle vital signs” such as overall diet quality, level of physical activity, quality of sleep, cardiorespiratory fitness, and anthropometric markers of abdominal adiposity should be obtained in all patients [(7, 8)]. This interesting analysis by Andersson et al. should pave the way to further precision lifestyle medicine studies conducted in this prevalent patient population in need of solutions to improve not only their cardiometabolic health but also their mental health and quality of life.

The authors declared no conflict of interest.

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来源期刊
Obesity
Obesity 医学-内分泌学与代谢
CiteScore
11.70
自引率
1.40%
发文量
261
审稿时长
2-4 weeks
期刊介绍: Obesity is the official journal of The Obesity Society and is the premier source of information for increasing knowledge, fostering translational research from basic to population science, and promoting better treatment for people with obesity. Obesity publishes important peer-reviewed research and cutting-edge reviews, commentaries, and public health and medical developments.
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