Atherosclerosis 211 (2010) 353–360

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Atherosclerosis
journal homepage: www.elsevier.com/locate/atherosclerosis

Review

Abnormal hepatic apolipoprotein B metabolism in type 2 diabetes

Bruno Vergès ∗
Service Endocrinologie, Diabétologie et Maladies Métaboliques, Dijon University Hospital, France

a r t i c l e i n f o a b s t r a c t

Article history: Increased Very Low Density Lipoprotein (VLDL) production is a major feature of diabetic dyslipidemia
Received 23 December 2009 with consequences on the metabolism of other lipoproteins such as Low Density Lipoproteins (LDL)
Received in revised form 20 January 2010 and High Density Lipoproteins (HDL). More precisely, we observe, in patients with type 2 diabetes, an
Accepted 21 January 2010
increased production of VLDL1 particles that is potentially detrimental by generating atherogenic rem-
Available online 29 January 2010
nants, small dense LDL particles and triglyceride-rich HDL particles. Several pathophysiological factors
are responsible for increased VLDL production, in type 2 diabetes. Among those, insulin resistance plays
Keywords:
an important role. Indeed, defective activation of PI3-kinase, secondary to insulin resistance, is associated
Diabetes
Type 2
with a reduction of apoB degradation in the hepatocytes, a rise in MTP expression (by increasing nuclear
VLDL transcription factors Fox01 and Foxa2) and an increased activity of phospholipase D1 and ARF-1, which
Triglycerides are involved in VLDL1 formation. Moreover, peripheral insulin resistance is responsible for increased
Lipogenesis lipolysis of adipose tissue leading to augmented portal flux of FFA to the liver and, as a consequence, acti-
Insulin vation of VLDL production. In addition, increased de novo lipogenesis is observed in type 2 diabetes. This
is secondary to increased activation of SREBP-1c (Sterol Regulatory Element-Binding Protein-1c), mainly
by Endoplasmic Reticulum stress, and of ChREBP (Carbohydrate Responsive Element Binding Protein),
mainly by hyperglycemia. Furthermore, decreased plasma adiponectin observed in type 2 diabetes, may
also play a role in increased VLDL production by decreasing liver AMP-kinase activation and by increasing
plasma FFA levels as a consequence of reduced muscle FFA oxidation.
© 2010 Elsevier Ireland Ltd. All rights reserved.

Contents

1. Apolipopoprotein B and VLDL assembly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353

2. The role of insulin on hepatic VLDL production . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 354
3. Hepatic VLDL production is increased in type 2 diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 355
3.1. Pathophysiology of increased hepatic VLDL production in type 2 diabetes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356
3.1.1. Insulin resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356
3.1.2. De novo lipogenesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 356
3.1.3. Adiponectin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 358

Diabetic dyslipidemia plays an important role in the increased teins (HDL) [3]. Augmented VLDL production, observed in type
cardiovascular risk observed in patients with type 2 diabetes [1,2]. 2 diabetes, is the result of significant modification of hepatic
It includes quantitative, qualitative and kinetic lipid abnormali- metabolism of both liver lipids and apolipoprotein B (apoB), mainly
ties, which are potentially atherogenic. Increased Very Low Density due to insulin resistance. After a brief review on normal apoB and
Lipoprotein (VLDL) production is a major feature of diabetic dyslipi- VLDL assembly in the liver, then on the role of insulin on hepatic
demia with consequences on the metabolism of other lipoproteins VLDL production, we will present the main pathophysiological fac-
such as Low Density Lipoproteins (LDL) and High Density Lipopro- tors responsible for increased VLDL production in type 2 diabetes.

1. Apolipopoprotein B and VLDL assembly

∗ Service Endocrinologie, Diabétologie et Maladies Métaboliques, Hôpital du
Bocage, 2 Bd Maréchal de Lattre de Tassigny, F-21000 Dijon, France.
VLDL is a lipoprotein produced and secreted by the liver. It con-
Tel.: +33 03 80 29 34 53; fax: +33 03 80 29 35 19. sists of a core of neutral lipids (mostly triglycerides) surrounded
E-mail address: bruno.verges@chu-dijon.fr. by a monolayer of amphipathic lipids (phospholipids, unesterified

0021-9150/$ – see front matter © 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.atherosclerosis.2010.01.028
354 B. Vergès / Atherosclerosis 211 (2010) 353–360
cholesterol) whose surface is bound to a structural protein, apoB
(apoB100).
The first step of VLDL assembly takes place in the rough endo-
plasmic reticulum (ER). ApoB, which is associated with the ER
membrane, is co-translationally and post-translationally lipidated
by the microsomal transfer protein (MTP), forming a pre-VLDL
[4–6] (Fig. 1). MTP plays a critical role in VLDL assembly, which
requires its normal activity. Indeed, mutation of the gene encoding
MTP is responsible for abetalipoproteinemia, a condition in which
VLDL formation does not occur [7]. During the second step, pre-
VLDL is further lipidated to form VLDL2 , late in the ER compartment
[8]. VLDL2 exits the ER compartment by Sar 1 (a GTPase)/COP II
(coatomere Protein II) vesicles which fuse to form the ER-Golgi
intermediate compartment ERGIC [9]. ERGIC fuses with the cis
side of the Golgi apparatus. In the Golgi apparatus, VLDL2 is con-
verted to larger VLDL1 by addition of lipids (Fig. 1). The formation
of VLDL1 depends on different factors such as ADP ribosylation
factor 1 (ARF-1), Phospholipase D1 and ERK2 (extracellular signal-
regulated kinase 2). ARF-1 plays an important role in the membrane
trafficking between the ER and the Golgi apparatus [10,11]. Phos-
pholipase D1 and ERK2 increase the formation of cytosolic lipid
droplets which can deliver lipids into the Golgi apparatus and, thus,
promote the conversion of VLDL2 to VLDL1 [12]. Moreover, in vitro
studies have shown that ARF-1 was responsible for the activation
of phospholipase D1 [10,13]. The secretion of VLDL1 is determined
by the availability of fatty acids and triglycerides. Thus, in the pres-
ence of large amounts of free fatty acids (FFA) and triglycerides
the formation of VLDL1 will be increased [11]. Normally, in healthy
individuals, the majority of VLDL particles secreted by the liver are
VLDL2 , small and triglyceride-poor, whereas the production of large
triglyceride-rich VLDL1 is minor. The increase of VLDL1 production
by the liver, observed in some conditions such as insulin resis-
tance and type 2 diabetes, is potentially detrimental by generating
atherogenic remnants, small dense LDL particles and triglyceride-
rich HDL particles.
In the ER, in the absence of adequate core lipids and/or MTP,
partially translocated apoB is exposed to the cytosol and sub-
jected to degradation [14]. ApoB degradation occurs mainly via
the ubiquitin–proteasome system [15] (Fig. 1). In the cytosol,
apoB becomes conjugated with ubiquitin which targets the apoB
protein to subsequent proteasomal degradation. However, a non-
proteasomal pathway may also be involved in apoB degradation
[16]. Many studies support the concept that hepatic apoB secretion
is metabolically regulated. This regulation involves mainly co- and
post-translational mechanisms such as ER translocation or protein
degradation [17]. MTP reduces apoB degradation by downregu-
lating the ubiquitin–proteasome-mediated degradation pathway
[18].
2. The role of insulin on hepatic VLDL production
Insulin plays a central role in the regulation of lipid metabolism
[19]. In adipose tissue, insulin inhibits the hormone-sensitive
lipase. Thus, insulin has an anti-lipolytic action, promoting stor-
age of triglycerides in the adipocytes and reducing release of FFA
from adipose tissue into the circulation.
Furthermore, insulin directly inhibits VLDL production from
the liver. Acute incubation of HepG2 cells, rat hepatocytes and
human hepatocytes with insulin suppress apoB secretion and
synthesis [20–23]. Similarly, insulin has been shown to reduce
VLDL–triglycerides secretion by cultured hepatocytes [20,24]. In
animal studies, insulin, in vivo, has been shown to suppress hepatic
VLDL-apoB and VLDL-TG production [25]. This suppressive effect
of insulin on VLDL secretion has been confirmed in humans. In nor-
mal subjects, it has been shown that insulin induces a 67% decrease
of VLDL–triglyceride production and a 52% decrease of VLDL-apoB
production [26,27]. Insulin reduces VLDL production not only by
diminishing circulating FFA (due to its anti-lipolytic effect), which
are substrates for VLDL, but also by a direct inhibitory effect in
hepatocytes [27]. Malmström et al. have shown, in healthy men,
that insulin suppresses the total production rate of VLDL-apoB by
decreasing the production of large triglyceride-rich VLDL1 parti-
cles, independently of its effects on FFA [27]. In the same study,
they found that acute lowering of FFA, using acipimox, induces
a shift toward production of smaller and denser VLDL2 particles
without any significant change of the overall production rate of
VLDL particles [27]. These data support that insulin has a direct
suppressive effect on the production of VLDL-apoB in the liver,
independent of the availability of FFA. The inhibition of hepatic
VLDL production by the liver is essential in the post-prandial period.
It prevents exaggerated hypertriglyceridemia after feeding that
might occur if both intestinal and hepatic TG-rich lipoproteins
were secreted simultaneously and competed for common clearance
pathway.
The precise mechanisms involved in the direct inhibitory effect
of insulin on VLDL production are not totally known. Several data
indicate that the phosphatidylinositol 3-kinase (PI3K) pathway
may be involved. Insulin signaling involves a cascade of events ini-
tiated by the binding of insulin to its cell surface receptor. This is
followed by receptor autophosphorylation and activation of recep-
tor tyrosine kinase activity leading to tyrosine phosphorylation of
insulin receptor substrates (IRSs), such as IRS1 and IRS2 [28,29]
(Fig. 2). Tyrosine phosphorylation of IRS1 and IRS2 leads to activate
the PI3K which, once activated, induces the transformation of phos-
phatidylinositol 4,5-biphosphate (PIP2) into phosphatidylinositol
(3,4,5)-trisphosphate (PIP3), leading to promote the activation of
Akt, a ser/thr kinase implicated as an effector of metabolic actions
of insulin [30]. Insulin has been shown to suppress apoB expression
and to promote apoB degradation in cultured HepG2 cells, rat hep-
atocytes and perfused rat livers [20,21,31,32]. It has been reported
that treatment of hepatocytes with wortmannin, a PI3K inhibitor
abolished insulin inhibition of apoB secretion, suggesting that the
insulin effect on the apoB pathway involves activation of PI3K [33].
This has been confirmed by Chirieac et al. in vivo in mice [34]. In
vitro studies, using HepG2 cells, have shown that insulin-induced
reduction of apoB expression may be due to a decrease in the rate
of apoB RNA translation [35]. The main effect of insulin on hep-
atic apoB seems to be promotion of its degradation [36,37]. Indeed,
some data indicate that PI3K/Akt activation by insulin promotes
the inactivation of a protein phosphatase, PTP 1B [36]. This inacti-
vation of PTP 1B is associated with increased expression of ER60,
a cysteine protease associated with the ER, which promotes apoB
degradation [37] (Fig. 2). Insulin has been shown to negatively reg-
ulate MTP gene in human liver cells [38–40]. MTP production, in
HepG2 cells, is inhibited by insulin and stimulated by the tran-
scription factor forkhead box O1 (FoxO1) [41]. In the absence of
insulin, FoxO1 resides in the nucleus and binds to its target genes,
whose MTP gene is one of them. In response to insulin, FoxO1
is phosphorylated through the PI3K/Akt pathway, resulting in its
nuclear exclusion and inhibition of MTP gene expression [41,42].
In addition, some data indicate that the forkhead box A2 (Foxa2)
contributes to the regulation of MTP expression. Foxa2, in complex
with its co-activator Peroxisome Proliferator-Activated Receptor
␥ Coactivator-1␤ (PGC-1␤), stimulates hepatic mRNA expression,
contributing to increased hepatic VLDL secretion [43]. It has been
shown that insulin inhibits this process by inactivating Foxa2 via
PI3K/Akt-induced promotion of its phosphorylation and its disas-
sociation from PGC-1␤ [44] (Fig. 2).
Moreover, some data indicate that insulin could inactivate two
factors involved in the formation of VLDL1 , phospholipase D1 and
ARF-1 [45]. Indeed, both phospholipase D1 and ARF-1 are stimu-
 B. Vergès / Atherosclerosis 211 (2010) 353–360 355

Fig. 1. VLDL assembly and secretion. First step: in the rough endoplasmic reticulum (ER), apoB is lipidated by the Microsomal transfer Protein (MTP), leading to the formation
of pre-VLDL, then VLDL2 by further lipidation. VLDL2 exits the ER compartment by Sar 1/COP II vesicles, which are directed to the Golgi apparatus. ADP ribosylation factor 1
(ARF-1) is involved in VLDL2 trafficking between the ER and the Golgi apparatus. Second step: in the Golgi apparatus, VLDL2 is converted to larger VLDL1 by addition of lipids.
This step is promoted by Phospholipase D1 and ERK2. FA: fatty acid, FFA: free fatty acid, apoB: apolipoprotein B, VLDL: very low density lipoprotein, TG: triglycerides, ER:
endoplasmic reticulum, MTP: microsomal transfer protein, ARF-1: ADP ribosylation factor 1, ERK2: extracellular signal-regulated kinase 2.

lated by PIP2 [46–48]. Insulin by stimulating PI3K promotes the
generation of PIP3 from PIP2 leading to decrease PIP2 concentra-
tion and thus to down regulate both phospholipase D1 and ARF-1
[49] (Fig. 2). This is in accordance with a study performed in cul-
tured rat hepatocytes, which has shown that insulin inhibits the
maturation phase of VLDL assembly via PI3K [50]. However, this
putative inhibition of phospholipase D1 and ARF-1 by insulin is
a matter of controversy because in vitro studies have found that
insulin activates phospholipase D1 in adipocytes [51].
3. Hepatic VLDL production is increased in type 2 diabetes
In vivo kinetic studies performed in patients with type 2 dia-
betes have shown an augmented production of both VLDL-apoB

Fig. 2. Direct role of insulin on hepatic VLDL production. (1) Insulin promotes apoB degradation: insulin, through PI3K/Akt activation, inactivates a protein phosphatase, PTP
1B. This PTP 1B inactivation induces increased expression of a cysteine protease ER60, which promotes apoB degradation. (2) Insulin decreases MTP expression: insulin, through
PI3K/Akt activation, inactivates FoxO1 and Foxa2 by phosphorylation. Because FoxO1 and Foxa2 are transcription factors stimulating MTP expression, their inactivation lead to
reduced MTP expression. (3) Insulin inactivates phospholipase D1 and ARF-1: insulin by activating PI3K, is responsible for a decrease in PIP2, an activator of both phospholipase
D1 and ARF-1. Thus, this insulin-induced PIP2 decrease leads to reduce the activity of phospholipase D1 and ARF-1, two factors involved in the formation of VLDL1 . IRS1:
insulin receptor Substrate 1, IRS2: insulin receptor Substrate 2, PI3K: phosphatidylinositol 3-kinase, PIP2: phosphatidylinositol biphosphate, PIP3: phosphatidylinositol
triphosphate, PTP 1B: protein phosphatase 1B, FoxO1: transcription factor forkhead box O1, Foxa2: transcription factor forkhead box A2, MTP: microsomal transfer protein,
ARF-1: ADP ribosylation factor 1, PLD1: phospholipase D1.
356 B. Vergès / Atherosclerosis 211 (2010) 353–360
and VLDL-TG [52–54]. More precisely, it has been shown that type
2 diabetes is associated with increased production of VLDL1 but
not VLDL2 particles [55,56]. Similar increase in VLDL or VLDL1 pro-
duction has been observed in obese non-diabetic insulin-resistant
individuals arguing for a critical role of insulin resistance in
the pathophysiology of VLDL overproduction, in type 2 diabetes
[57–59].
VLDL-apoB hepatic secretion has been shown to be positively
and significantly correlated with visceral adipose tissue area mea-
sured by magnetic resonance imaging [60]. This has been confirmed
by Adiels et al., who found a significant correlation between intra-
abdominal fat and both VLDL1 -apoB and VLDL1 -TG production rates
[61]. However, in multivariate analysis, VLDL1 -apoB and VLDL1 -TG
production rates were significantly associated with liver fat deter-
mined by proton magnetic resonance spectroscopy but no more
with intra-abdominal fat [61]. This reflects the known association
between intra-abdominal visceral fat and liver fat content [45]. The
increased fat content observed in insulin resistance and type 2 dia-
betes is the result of different factors such as increased FFA flux to
the liver, increased FFA uptake by the liver, decreased fatty acid oxi-
dation and de novo lipogenesis (see below). The exact relationship
between increased liver fat and VLDL overproduction is not clear.
As discussed below, several mechanisms are supposed to play a
role in the pathophysiology of increased hepatic VLDL production,
in type 2 diabetes, such as insulin resistance, de novo lipogenesis
and reduced plasma adiponectin level.
3.1. Pathophysiology of increased hepatic VLDL production in
type 2 diabetes
3.1.1. Insulin resistance
A large body of evidence strongly suggests that insulin resis-
tance plays an important role in the pathophysiology of VLDL
overproduction by the liver, in patients with type 2 diabetes.
Insulin resistance is associated with reduction of the inhibitory
effect of insulin on the hormone-sensitive lipase in the adipose
tissue leading to increase its lipolysis [3,19,45,62]. As a conse-
quence, patients with type 2 diabetes show increased plasma levels
of FFA and augmented FFA flux to the liver [63]. Using stable iso-
tope labelling of FFA both intravenously and orally, Hodson et al.
have shown that, in insulin-resistant individuals, the post-prandial
source of fatty acids for VLDL-TG production was mainly derived
from splanchnic sources [64]. These data suggest that insulin resis-
tance is associated with an increased lipolysis of intra-abdominal
visceral fat leading to an augmented flux of visceral FFA to the
liver. It has been shown that increased FFA delivery to the liver
stimulates synthesis of triglycerides in hepatocytes [65]. Indeed,
the chronically increased flux of FFA to the liver increases the
cytosolic triglyceride storage pool and promotes VLDL production
by reducing post-translational degradation of apoB and increasing
MTP expression [66,67]. The cytosolic triglyceride pool has been
shown to be correlated with VLDL secretion [68,65]. Numerous
studies with culture liver cells indicate that FFA availability in hep-
atocytes targets newly synthesized apoB for assembly with lipids
and secretion, rather than degradation [14,69]. In humans, Lewis
et al. have shown that an acute increase in plasma FFA, induced by
intralipid and heparin infusion, stimulates VLDL-apoB production
[70].
In addition, the inhibitory effect of insulin on hepatic VLDL pro-
duction is significantly reduced in condition of insulin resistance
such as type 2 diabetes. Hepatocytes from insulin-resistant obese
Zucker rats have been found to be resistant to the inhibitory effect of
insulin on VLDL production [71,72]. The inability of insulin to effec-
tively inhibit VLDL secretion (and more precisely VLDL1 secretion)
has been demonstrated, in vivo, in patients with type 2 diabetes
[26,55]. Furthermore, it has been shown that failure of insulin to
suppress VLDL1 production was associated with high liver fat [73].
Several mechanisms seem to be involved in the overproduction of
hepatic VLDL in relation to the reduction of the inhibitory effect of
insulin.
First, insulin resistance is associated with reduction of apoB
degradation in the hepatocytes, leading to increased apoB pool
available for VLDL assembly (Fig. 3). Studies performed in Syr-
ian golden hamsters, a model for insulin resistance, have shown
reduced apoB degradation associated with increased VLDL assem-
bly and secretion [37]. Furthermore, using the same animal model,
it has been demonstrated that hepatic VLDL production was asso-
ciated with attenuated insulin signaling (reduction of PI3K activity
and Akt specific phosphorylation) leading to increased expression
of Protein-tyrosine Phosphatase 1B PTP-1B [37]. Increased PTB-1B
is associated with suppression of ER60, a protease associated with
the ER, which promotes apoB degradation via a non-proteasomal
pathway [74]. Thus, insulin resistance is associated with reduced
apoB degradation leading to increased apoB availability for VLDL
assembly and secretion. In addition, increased FFA level in hep-
atocytes, reduces post-translational degradation of apoB. Indeed,
FFA in cell cultures, have been shown to cause a decrease in
ER-associated ubiquitin–proteasome dependent apoB degradation
[75].
Second, MTP expression is increased in insulin-resistant states
and type 2 diabetes. Animal models of type 2 diabetes show
increased activity of MTP and augmented MTP mRNA [76]. The pro-
motion region of the MTP gene has an insulin response element,
which is negatively regulated by insulin [38,39,77]. In insulin-
resistant animals, MTP mRNA levels are significantly upregulated
[76,78]. In condition of insulin resistance, the reduced activation of
PI3K leads to increase FoxO1, which is normally inhibited by acti-
vated PI3K. This increase in FoxO1 is responsible for augmented
transcription of the MTP gene [41] (Fig. 3). Furthermore, a reduc-
tion of the insulin-induced inactivation of Foxa2 might also play
a role in the increased MTP expression, in insulin-resistant states
and type 2 diabetes [44]. However, the significance of this potential
mechanism in the pathogenesis of hypertriglyceridemia remains to
be determined.
Third, it has been suggested that insulin resistance could be
responsible for increased activity of two factors involved in the for-
mation of VLDL1 , phospholipase D1 and ARF-1 [45,50]. In condition
of insulin resistance, impaired insulin signaling is responsible for
reduced PI3K activity leading to increased PIP2, because of dimin-
ished transformation of PIP2 to PIP3. This increase in PIP2 may
activate both phospholipase D1 and ARF-1, since PIP2 has been
shown to be a potent activator of these two factors [46–48]. How-
ever, this hypothesis needs confirmation.
3.1.2. De novo lipogenesis
Several studies have shown increased lipogenesis in individ-
uals with obesity and insulin resistance [79–81]. An increased
activity of key enzymes of lipogenesis (Acetyl CoA Carboxylase,
Fatty Acid Synthase, Stearoyl CoA Desaturase) has been reported in
Psammomys obesus gerbils, an animal model for human nutrition-
induced obesity and type 2 diabetes [82]. Increased de novo
lipogenesis has been shown in individuals with abdominal obesity
or type 2 diabetes [80,83]. This increased de novo lipogenesis is sec-
ondary to augmented expression of both Carbohydrate Responsive
Element Binding Protein (ChREBP) and Sterol Regulatory Element-
Binding Protein-1c (SREBP-1c), in insulin resistance and type 2
diabetes. Both of these transcription factors activate genes required
for de novo lipogenesis in liver (Fig. 3).
Activation of ChREBP by glucose (from 5.5 to 27.5 mmol/l) has
been shown to bind to the promoter region of many lipogenic
enzymes (Acetyl CoA Carboxylase, Fatty Acid Synthase, Stearoyl
CoA Desaturase) and, thus, to increase their expression [84,85].
 B. Vergès / Atherosclerosis 211 (2010) 353–360 357

Fig. 3. Pathophysiology of increased hepatic VLDL production in type 2 diabetes (summary). (1) Insulin resistance is responsible for: (a) reduction of apoB degradation leading
to increased apoB levels in hepatocytes (decreased PI3K activation is associated with a decrease in ER60, a cysteine protease in charge of apoB degradation), (b) increased
MTP expression (decreased PI3K activation augments FoxO1 and Foxa2, transcription factors upregulating MTP), and (c) increased activity of two factors involved in the
formation of VLDL1 , phospholipase D1 and ARF-1 (reduced PI3K activation leads to increase PIP2, which activates both phospholipase D1 and ARF-1).(•) Moreover, peripheral
insulin resistance is responsible for increased levels of FFA, which activate VLDL production. (2) Increased de novo lipogenesis is observed in type 2 diabetes. This is secondary
to: (a ) Increased activation of SREBP-1c (by ER stress, by hyperinsulinemia?) (b ) Increased activation ChREBP (by hyperglycemia). (3) Reduced plasma adiponectin level may
promote VLDL production: (a ) By increasing plasma FFA levels as a consequence of reduced muscle FFA oxidation. (b ) By decreasing AMP-kinase activation in the liver. This
reduced AMP-kinase activation promotes de novo lipogenesis. FA: fatty acid, FFA: free fatty acid, apoB: apolipoprotein B, VLDL: very low density lipoprotein, TG: triglycerides,
ER: endoplasmic reticulum, MTP: microsomal transfer protein, ARF-1: ADP ribosylation factor 1, ERK2: extracellular signal-regulated kinase 2, SREBP-1c: sterol regulatory
element-binding protein-1c, ChREBP: carbohydrate responsive element binding protein.

This activation of ChREBP by glucose is independent of insulin [85].
We may hypothesize that hyperglycemia, in patients with type 2
diabetes, may activate ChREBP leading to increased de novo lipo-
genesis.
In addition, in obese insulin-resistant ob/ob mice, a liver over-
expression of SREBP-1c is observed [86,87]. A similar increase in
SREBP-1c expression has also been reported in insulin-resistant
P. obesus gerbils [82]. The SREBP-1c precursor is retained in the
ER through tight association with SCAP (SREBP Cleavage Activated
Protein) and the Insig protein. Under appropriate signal (ER stress,
for example), the SREBP-1c/SCAP complex is dissociated from the
Insig protein and migrates from the ER to the Golgi apparatus where
two proteases (S1P, S2P) sequentially cleave the precursor protein,
releasing the mature form of SREBP-1c in the cytoplasm before its
transfer to the nucleus where it binds to specific response elements
on the promoter of its target genes [88]. The increase in SREBP-
1c expression, observed in insulin resistance and type 2 diabetes,
could be related to augmented ER stress [88]. ER stress is an adap-
tative response that is elucidated by the accumulation of unfolded
or misfolded proteins in the ER lumen [88]. Increased ER stress
has been described in the liver of insulin-resistant mice and has
been shown to be associated with augmented liver lipogenesis [89].
Increased ER stress in insulin resistance and type 2 diabetes may
be promoted by increased hepatic FFA and hepatocyte lipid content
[90,91].
It has been shown in mice that lipid-induced ER stress influ-
enced hepatic apoB secretion in a parabolic manner [90]. Indeed,
experimental data show that mild ER-stress secondary to increased
FA delivery is associated with increased hepatic secretion of
apoB100 [69,90], when greater ER-stress is accompanied with
increased proteasomal and non-proteasomal apoB degradation
leading to reduced apoB100 secretion [90]. It has been proposed
that, in response to lipid overload into the liver, increased VLDL
production in insulin-resistant states may be a safeguarding mech-
anism for protecting against the development of steatosis. This
view raises an important question: why the liver cannot totally
rid of excessive lipids and avoid steatosis by enhancing VLDL
secretion in the face of lipid excess such as in type 2 diabetes?
A part of the answer could be that significant lipid-induced ER
stress leads to reduced apoB100 and VLDL secretion [90]. However,
in patients with type 2 diabetes the exact relationship between
lipid-induced ER stress and VLDL apoB production remains to be
clarified.
In addition, increased activation of Liver X receptors (LXR) may
also play a role in augmented lipogenesis. LXR, which play a crit-
ical role in cholesterol homeostasis and bile metabolism, is also
known to upregulate SREBP-1c expression and administration of
LXR agonists to mice results in elevated hepatic fatty acid synthe-
sis and steatosis [92,93]. Furthermore, it has been reported that LXR
upregulate not only SREBP-1c but also ChREBP [94]. Interestingly,
it has been shown that glucose binds and stimulates the transcrip-
tional activity of LXR and induces expression of LXR target genes
including fatty acid synthesis genes [95]. Thus, LXR activation by
hyperglycemia could also be involved in the increased de novo
lipogenesis observed in patients with type 2 diabetes.
Moreover, some data suggest that IRS2 activation down regu-
late SREBP-1c and specific inhibition of IRS2 in mice, which mimics
insulin resistance has been shown to be associated with increased
SREBP-1c expression [96,29].
During the recent years, Peroxisome Proliferator-Activated
Receptor ␥ Coactivator-1␤ (PGC-1␤) has been shown to play a
role in lipogenesis [97]. Indeed, PGC-1␤ activates the expression of
genes involved in lipogenesis (such as FAS and SCD-1) via direct co-
activation of SREBP-1c [97,98]. In rats with fructose-induced insulin
resistance, PGC-1␤ has been shown to play a role in the augmented
hepatic lipogenesis [98]. However, the potential role of PGC-1␤ in
358 B. Vergès / Atherosclerosis 211 (2010) 353–360
the pathogenesis of increased hepatic lipogenesis in humans with
type 2 diabetes is still unknown.
Furthermore, hyperinsulinemia, observed in insulin resistance
and type 2 diabetes, has been supposed to be responsible for
increased SREBP-1c expression, because insulin stimulates SREBP-
1c transcription. One may find contradictory that in a situation of
hepatic insulin resistance, such as type 2 diabetes, insulin may still
be able to stimulate lipogenesis. Data in humans do not support
this hypothesis. Indeed, insulin treatment, in patients with type
2 diabetes, resulting in systemic hyperinsulinemia was found to
decrease liver fat content and not to increase it [99,100]. However,
in animal models, insulin has been shown to stimulate lipogenesis
through SREBP-1c, even in insulin-resistant liver [101]. Recently,
Han et al. reported reduced lipogenesis and VLDL secretion in a
mice model deficient for LDL-receptor, expressing low level of
insulin receptor in the liver and no insulin receptors in periph-
eral tissues [102]. They also showed that adenovirus-mediated
hepatic overexpresssion of Akt, in this animal model, increased
lipogenesis and that knockdown of 90% of insulin receptors in
insulin-resistant ob/ob mice induced a significant decrease in
VLDL–triglyceride secretion [102]. These data indicate that hyper-
insulinemia might play a role in increased hepatic lipogenesis
in type 2 diabetes. Interestingly, in insulin-resistant, lipoatrophic
mouse models, Shimomura et al. [87] showed that there are 2
independent hepatic insulin-signaling pathways. One pathway,
controlled by insulin receptor Substrate 2, is responsible for glu-
coneogenesis and is insulin-resistant (lacking proper inhibition of
gluconeogenesis by insulin, thus causing hyperglycemia), whereas
the other insulin-signaling pathway, controlled by the transcription
factor SREBP-1c, remains insulin-sensitive and leads to increased
amounts of mRNA for the key enzymes of lipogenesis. With the
increased quantity of insulin present in insulin resistance, the
insulin-sensitive signaling pathway (SREBP-1c) is indeed stimu-
lated and leads to increased lipogenesis. This mixed pattern of
hepatic insulin resistance and sensitivity might be the molecular
foundation for the association between dyslipidemia and type 2
diabetes.
Moreover, some data indicate that AMP-kinase activity is
reduced in individuals with type 2 diabetes, likely due to dimin-
ished plasma levels of adiponectin, an AMP-kinase activator
[103–105]. AMP-kinase is known to be a cellular energy sensor
which switches on catabolic pathways producing ATP (such as fatty
acid oxidation) and switches off energy-consuming biosynthesis
pathway (such as lipogenesis). Thus, AMP-kinase activation leads
to inactivate enzymes involved in lipogenesis (Acetyl CoA Carboxy-
lase, Fatty Acid Synthase) and to reduce the expression of SREBP-1c
[104]. Therefore, reduced AMP-kinase activity, observed in type 2
diabetes, might also play a role in the increased de novo lipogenesis.
In addition, patients with type 2 diabetes show reduced fatty acid
oxidation, which automatically increases the availability of fatty
acids for triglyceride synthesis.
3.1.3. Adiponectin
Adiponectin is a peptide predominantly synthesized in the adi-
pose tissue, that plays an important role in carbohydrate and lipid
metabolism [106,107]. Adiponectin signaling pathways comprise 2
known receptors, adipoR1 and adipoR2 [108]. It has been suggested
that adipoR1 may exert its biological effects through AMP-kinase
pathway whereas adipoR2 may exert them through the peroxisome
proliferator-activated alpha (PPAR␣) pathway [109]. The activa-
tion of adiponectin receptors lead to increased FFA oxidation and
glucose uptake and to reduced neoglucogenesis and inflammation
[109,110]. Both functional and genetic data on adiponectin suggest
that reduced adiponectin activity plays a causal role in the devel-
opment of insulin resistance, type 2 diabetes and atherosclerosis
[109,111]. Plasma adiponectin levels are reduced in individuals
with abdominal obesity, metabolic syndrome and/or type 2 dia-
betes [112]. Moreover, it has been found that expression of adipoR1
and adipoR2 is decreased in animal models of obesity and type
2 diabetes [113,114] as in individuals with a family history of
type 2 diabetes [115]. Reduced plasma level of adiponectin may
also play a role in the increased VLDL production observed in
type 2 diabetes. Indeed, adiponectin, by activating AMP-kinase,
increases FFA oxidation in both muscles and liver [116,117]. It
has been shown that adiponectin decreases triglyceride content
in muscle and liver in obese mice [118]. Thus, diminished cir-
culating adiponectin is responsible for reduction of muscle FFA
oxidation and, as a consequence, for increased plasma FFA levels
and augmented liver fat, that will promote hepatic VLDL pro-
duction. In addition, hypoadiponectinemia decreases AMP-kinase
activation in the liver, which may increase de novo lipogene-
sis by enhancing SREBP-1c expression and activating enzymes
involved in lipogenesis (Acetyl CoA Carboxylase, Fatty Acid Syn-
thase) (Fig. 3). Furthermore, adiponectin also activates the PPAR␣
pathway. PPAR␣ activation, by fibrates, has been shown to decrease
VLDL–triglyceride secretion in both rats and humans [119,120] and
in vitro data suggest that PPAR␣ activation reduces the availability
of triglycerides for VLDL assembly [121]. Thus we may also hypoth-
esise that decreased adiponectin activity could be responsible for
increased VLDL production via reduction of PPAR␣ activation. How-
ever, we still do not know the precise part of the peripheral action of
adiponectin (via augmented FFA oxidation ion peripheral tissues)
and of its direct action on the liver (via AMP-kinase and PPAR␣
activation).
In summary, increased hepatic VLDL (and more precisely VLDL1 )
production is a major feature of diabetic dyslipidemia. The pre-
cise mechanisms responsible for this VLDL overproduction are not
totally understood but some factors are likely to play a role such as
increased FFA flux to the liver, reduction of the direct inhibitory
effect of insulin on VLDL production, enhanced de novo lipoge-
nesis and decreased plasma adiponectin level. Indeed, peripheral
insulin resistance is responsible for increased lipolysis of adipose
tissue leading to augmented FFA delivery to the liver that may
activate VLDL production. In the hepatocytes, defective activa-
tion of PI3-kinase, secondary to insulin resistance, is associated
with a reduction of apoB degradation, a rise in MTP expression
(by increasing nuclear transcription factors Fox01 and Foxa2) and
an increased activity of phospholipase D1 and ARF-1, which are
involved in VLDL1 formation. In addition, augmented de novo lipo-
genesis is observed in type 2 diabetes, secondary to increased
activation of SREBP-1c, potentially by ER stress and of ChREBP
by hyperglycemia. Furthermore, decreased plasma adiponectin,
observed in type 2 diabetes, may also play a role in increased
VLDL production by decreasing liver AMP-kinase activation and by
increasing plasma FFA levels as a consequence of reduced mus-
cle FFA oxidation. However many questions remain unsolved such
as the exact relationship between increased fat content and VLDL
overproduction and secretion, the clear role of ER stress on VLDL
production and the precise consequences of hypoadiponectine-
mia.
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