Short Communication
Circulating Interleukin-6 in Relation to
Adiposity, Insulin Action, and Insulin Secretion
Barbora Vozarova, Christian Weyer, Kristin Hanson, P. Antonio Tataranni, Clifton Bogardus,
and Richard E. Pratley
Abstract
VOZAROVA, BARBORA, CHRISTIAN WEYER, KRISTIN
HANSON, P. ANTONIO TATARANNI, CLIFTON
BOGARDUS, AND RICHARD E. PRATLEY. Circulating
interleukin-6 in relation to adiposity, insulin action, and
insulin secretion. Obes Res. 2001;9:414 – 417.
Objective: Plasma concentrations of interleukin-6 (IL-6), a
proinflammatory cytokine produced and released in part by
adipose tissue, are elevated in people with obesity and type
2 diabetes. Because recent studies suggest that markers of
inflammation predict the development of type 2 diabetes,
we examined whether circulating plasma IL-6 concentra-
tions were related to direct measures of insulin resistance
and insulin secretory dysfunction in Pima Indians, a popu-
lation with high rates of obesity and type 2 diabetes.
Research Methods and Procedures: Fasting plasma IL-6
concentrations (enzyme-linked immunosorbent assay),
body composition (DXA), insulin action (M; hyperinsuline-
mic euglycemic clamp), and acute insulin secretory re-
sponses to glucose (25 g intravenous glucose tolerance test)
were measured in 58 Pima Indians without diabetes (24
women, 34 men).
Results: Fasting plasma IL-6 concentrations were positively
correlated with percentage of body fat (r ⫽ 0.26, p ⫽ 0.049)
and negatively correlated with M (r ⫽ ⫺0.28, p ⫽ 0.031),
but were not related to acute insulin response (r ⫽ 0.13, p ⫽
0.339). After adjusting for percentage of body fat, plasma
IL-6 was not related to M (partial r ⫽ ⫺0.23, p ⫽ 0.089).
Discussion: Fasting plasma IL-6 concentrations are posi-
tively related to adiposity and negatively related to insulin
action in Pima Indians. The relationship between IL-6 and
insulin action seems to be mediated through adiposity.
Submitted for publication December 8, 2000.
Accepted for publication in final form April 20, 2001.
Clinical Diabetes and Nutrition Section, National Institute of Diabetes and Digestive and
Kidney Diseases, National Institutes of Health, Phoenix, Arizona.
Address correspondence to Barbora Vozarova, Clinical Diabetes and Nutrition Section,
National Institutes of Health, 4212 N 16th Street. Room 5– 41, Phoenix, AZ 85016. E-mail:
bvozarov@mail.nih.gov
Copyright © 2001 NAASO
414 OBESITY RESEARCH Vol. 9 No. 7 July 2001
Key words: inflammation, insulin resistance, cytokines,
adipose tissue
Introduction
In recent years, a number of studies have indicated that
several humoral markers of inflammation are elevated in
people with obesity and type 2 diabetes (1,2). Based on
these and other findings, it has been proposed that long-term
activation of the innate immune system may be involved in
the development of insulin resistance and type 2 diabetes.
One possible explanation for elevated inflammatory
markers in obesity is that adipose tissue secretes a number
of proinflammatory cytokines, including tumor necrosis
factor-␣ (TNF-␣) and interleukin-6 (IL-6) (1). Although
immune cells, fibroblasts, endothelial cells, and monocytes
have traditionally been regarded as the major sources of
circulating IL-6 (3), a recent study in which adipose tissue
veins were selectively catheterized has indicated that a
considerable proportion of circulating IL-6 is derived from
adipose tissue (4). Circulating IL-6 levels have been re-
ported to be elevated in obese people (3,5) and in people
with type 2 diabetes (6) and to correlate with indirect
measures of adiposity and insulin resistance, such as body
mass index (BMI), waist-to-hip ratio (5,7), and fasting in-
sulin concentrations (7). However, to our knowledge, no
study has examined the relationship between circulating
IL-6 levels and direct measures of adiposity, insulin action,
and insulin secretion. Thus, it is unclear whether the asso-
ciation between insulin resistance and markers of inflam-
mation is independent of obesity.
The aim of the present study was to examine the rela-
tionship between fasting plasma IL-6 concentrations and
direct measures of adiposity, insulin action, and insulin
secretion in Pima Indians without diabetes, a population that
has one of the highest prevalence rates of obesity, insulin
resistance, and type 2 diabetes in the world (8,9).
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IL-6, Obesity, and Insulin Resistance, Vozarova et al.

Research Methods and Procedures for 100 minutes at a constant rate of 40 mU/m2 of body
surface area per minute (low dose, M-low), followed by a
Subjects
second 100-minute infusion at a rate of 400 mU/m2 per
A total of 58 Pima Indians, 24 women and 34 men, were
minute (high dose, M-high). These infusions achieved
included in this analysis (Table 1). All were participants in
steady state plasma insulin concentrations of 147 ⫾ 42
an ongoing longitudinal study of the pathogenesis of type 2
diabetes, were between 20 and 50 years of age, did not have ␮U/mL and 2681 ⫾ 1410 ␮U/mL (mean ⫾ SD), respec-
tively. Plasma glucose concentrations were maintained at
diabetes according to a 75-g oral glucose tolerance test
⬃100 mg/dL with a variable infusion of a 20% glucose
(World Health Organization criteria), were nonsmokers at
solution. The rate of total insulin-stimulated glucose dis-
the time of the study, and were healthy according to a
posal (M) was calculated for the last 40 minutes of the
physical examination and routine laboratory tests. No sub-
low-dose (M-low) and high-dose (M-high) insulin infu-
ject had clinical or laboratory signs of acute infection,
sions. M-low was also corrected for the rate of endogenous
dyslipidemia, hypertension, and/or a personal history of
glucose output (measured by a primed [30 ␮Ci], continuous
hypertension, dyslipidemia, atherosclerotic disease, autoim-
[0.3 ␮Ci/min] 3-3H-glucose infusion) (9). M-values were
mune disease, or other conditions known to be associated
adjusted for the steady state plasma glucose and insulin
with altered plasma IL-6 concentrations. The Tribal Council
concentrations as previously described (10) and were nor-
of the Gila River Indian Community and the Institutional
malized to estimated metabolic body size (estimated meta-
Review Board of the National Institute of Diabetes and
Digestive and Kidney Diseases approved the protocol bolic body size ⫽ fat free mass ⫹ 17.7 kg).
and all subjects provided written informed consent Insulin secretion was measured in response to a 25-g
before participation. intravenous glucose tolerance test and the acute insulin
response (AIR) calculated as the average incremental
Methods plasma insulin concentration from the third to the fifth
Subjects were admitted to the National Institutes of minute after the glucose bolus (9). Because even mildly
Health Clinical Research Unit in Phoenix, Arizona, for 8 to
10 days for testing. While in the unit, subjects were fed a
Table 1. Physical and metabolic characteristics of the
weight-maintaining diet (50%, 30%, and 20% of daily cal- study population
ories provided as carbohydrate, fat, and protein, respec-
tively) and abstained from strenuous exercise. Mean ⴞ SD Range
Body composition was estimated by total body DXA
(DPX-L; Lunar Radiation Corp., Madison, WI) with calcu- Age (y) 30 ⫾ 7 18–43
lations of percentage of body fat, fat mass, and fat free mass Body weight (kg) 89.9 ⫾ 20.3 51.5–147.7
as previously described (9). Waist and thigh circumferences Body mass index (kg/m2) 32.5 ⫾ 6.5 20.0–51.2
were measured at the umbilicus in the supine and the gluteal Body fat (%) 32 ⫾ 8 13–47
fold in the standing positions. The waist-to-thigh ratio was Fat mass (kg) 29.7 ⫾ 11.8 8.7–59.1
calculated as an index of body fat distribution. Fat-free mass (kg) 60.2 ⫾ 12.0 38.8–91.8
A 2-hour 75-g oral glucose tolerance test was performed Waist (inches) 41 ⫾ 6 31–58
after a 12-hour overnight fast (9) to exclude subjects with Waist-to-thigh ratio 1.62 ⫾ 0.15 1.32–2.02
diabetes. Baseline blood samples were drawn for determi- Fasting glucose (mg/dL) 84 ⫾ 8 72–112
nation of glucose, insulin, and IL-6 concentrations using
Fasting insulin (␮U/mL) 38 ⫾ 16 12–90
prechilled syringes and prechilled glass tubes. Plasma glu-
2-hour glucose (mg/dL) 122 ⫾ 29 58–178
cose concentrations were determined by the glucose oxidase
method (Beckman Instruments, Fullerton, CA) and plasma M-low
insulin concentrations by an automated immunoassay (Ac- (mg/kg EMBS per minute) 2.9 ⫾ 1.2 1.6–7.8
cess; Beckman Instruments). IL-6 concentrations were mea- M-high
sured by a two-antibody enzyme-linked immunosorbent (mg/kg EMBS per minute) 8.3 ⫾ 2.1 4.9–13
assay using bioptin-strepavidin-peroxidase detection (Cyto- Acute insulin response
kine Core Laboratory, Baltimore, MD; normal range 1.6 to (␮U/mL) 218 ⫾ 137 28–628
100 pg/mL, coefficient of variation 10.6% at 1.6 pg/mL and Fasting plasma IL-6 (pg/mL) 2.6 ⫾ 1.5 0.4–7.1
1.4% at 100 pg/mL).
Insulin action was assessed at physiological and supra- M-low, insulin-stimulated glucose disposal during low-dose insu-
physiological insulin concentrations during a two-step hy- lin infusion; M-high, insulin-stimulated glucose disposal during
perinsulinemic euglycemic glucose clamp as previously de- high-dose insulin infusion; EMBS, estimated metabolic body size
scribed (9). Briefly, after an overnight fast, a primed (fat free mass ⫹ 17.7 kg).
continuous intravenous insulin infusion was administered

OBESITY RESEARCH Vol. 9 No. 7 July 2001 415

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IL-6, Obesity, and Insulin Resistance, Vozarova et al.

elevated glucose concentrations can secondarily affect in-

sulin secretion, only data from the 44 subjects with normal
glucose tolerance were included when analyzing the corre-
lation between IL-6 and AIR.

Statistical Analyses
Statistical analyses were performed using the software of
the SAS Institute (Cary, NC). Log-transformed values of M
and IL-6 were used for all statistical analyses to achieve
normal distributions. The relationships between fasting IL-6
concentrations and anthropometric and metabolic variables
were assessed by simple linear regression models. Partial
correlation analyses and multiple linear regression models
were used to examine the relationship between IL-6, per-
centage of body fat, and insulin action, and to assess the
effect of gender and glucose tolerance on IL-6.

Results
The anthropometric and metabolic characteristics of the
study population are summarized in Table 1.
The mean fasting plasma IL-6 concentration did not
differ between men and women (2.5 ⫾ 0.2 vs. 2.7 ⫾ 0.3,
p ⫽ 0.57) or between individuals with normal and impaired
glucose tolerance (2.6 ⫾ 0.2 vs. 2.5 ⫾ 0.5, p ⫽ 0.98), before
or after adjusting for percentage of body fat.
Fasting plasma IL-6 concentrations were positively cor-
related with percentage of body fat (r ⫽ 0.26, p ⫽ 0.049;
Figure 1A), body weight (r ⫽ 0.26, p ⫽ 0.047), BMI (r ⫽
0.35, p ⫽ 0.008), fat mass (r ⫽ 0.32, p ⫽ 0.015), waist
(r ⫽ 0.32, p ⫽ 0.014) and thigh circumference (r ⫽ 0.28,
p ⫽ 0.037), but not with the waist-to-thigh ratio (r ⫽ 0.17,
p ⫽ 0.189).
Fasting plasma IL-6 concentrations were negatively cor-
related with the rate of insulin-stimulated glucose disposal
(M) as assessed during the low-dose insulin infusion (M-
low) (r ⫽ ⫺0.28, p ⫽ 0.031; Figure 1B), but not with M
during high-dose insulin infusion (M-high, r ⫽ ⫺0.04, p ⫽
0.769), fasting plasma insulin concentrations (r ⫽ 0.17,
p ⫽ 0.208), AIR (n ⫽ 44, r ⫽ 0.13, p ⫽ 0.33), or fasting
(r ⫽ 0.20, p ⫽ 0.127) or 2-hour glucose concentrations (r ⫽
0.003, p ⫽ 0.983). The relationship between fasting plasma
IL-6 concentration and M-low was no longer significant
after adjustment for percentage of body fat in partial corre-
lation analyses (partial r ⫽ ⫺0.23, p ⫽ 0.089).
Discussion
In the present study, we examined the relationships be-
tween fasting plasma IL-6 concentration and direct mea-
sures of adiposity, insulin action, and insulin secretion in
Pima Indians. We found that fasting plasma IL-6 concen-
trations were positively related to adiposity and negatively
related to insulin action but were not related to insulin
Figure 1. Relationship between the fasting plasma IL-6 concen-
tration and percentage of body fat (A) and insulin action (B) in 58
Pima Indians without diabetes. EMBS, estimated metabolic body
size (fat free mass ⫹ 7.7 kg). After excluding a lean subject (body
fat of 13%) with high plasma IL-6 concentration (7.1 pg/mL),
correlation between IL-6 and percentage of body fat became
stronger (r ⫽ 0.33, p ⫽ 0.01). After adjusting for percentage of body
fat, IL-6 was not correlated to insulin action (r ⫽ ⫺0.22, p ⫽ 0.1).
secretion. However, after adjustment for adiposity, there
was no correlation between IL-6 and insulin action.
Our finding of a positive relationship between IL-6 con-
centration and percentage of body fat (Figure 1A), fat mass,
and waist circumference confirms results from previous
studies in other populations, which indicate that plasma
IL-6 concentrations are elevated in obesity (4,5,7). In those
studies, plasma IL-6 concentrations seem to be more closely
related to BMI and percentage of body fat than in the
present study in Pima Indians (4,7). This could in part be
due to differences in subject selection. Two previous stud-
ies, for instance, included subjects with sleep disorders (5)
and type 2 diabetes (7), conditions known to be associated
with elevated IL-6 concentrations. A weaker relationship
between IL-6 and BMI has recently been reported in urban

416 OBESITY RESEARCH Vol. 9 No. 7 July 2001


IL-6, Obesity, and Insulin Resistance, Vozarova et al.
Indians living in India (11) suggesting that ethnicity may
also affect the relationship between IL-6 and obesity.
Previous studies have shown that several humoral mark-
ers of inflammation such as TNF-␣, C-reactive protein, and
complement C3 are inversely correlated with insulin action,
independently of adiposity (1,12,13). These findings are
consistent with the hypothesis that low-grade inflammation
may have a pathogenic role in the development of insulin
resistance and type 2 diabetes (14). Although there is lim-
ited experimental evidence suggesting that IL-6 may be
involved in the pathogenesis of decreased insulin sensitivity
(15), a positive association between plasma IL-6 concentra-
tions and fasting insulin concentrations, an index of insulin
resistance, has recently been reported (7). These results
must be interpreted with caution, however, given that sub-
jects with type 2 diabetes were included in that study and
that type 2 diabetes is known to be associated with elevated
IL-6 concentrations (2,6). In the present study, we show that
plasma IL-6 concentrations are inversely related to the rate
of insulin-stimulated glucose disposal (M-low), a direct
measure of insulin action, in subjects without diabetes (Fig-
ure 1B). However, after adjustment for obesity, M-low was
not related to plasma IL-6 concentrations. The lack of a
statistically significant association between M-low and
plasma IL-6 concentration after adjusting for obesity is most
likely due to the fact that adipose tissue secretes IL-6 or
other factors (such as TNF-␣ or complement C3) that affect
insulin action.
In summary, fasting plasma IL-6 concentrations are pos-
itively related to adiposity and negatively related to insulin
action in Pima Indians. The relationship between IL-6 and
insulin action seems to be mediated via adiposity.
Acknowledgments
The authors thank members of the Gila River Indian
Community for their participation. We also acknowledge
Mr. Mike Milner, Ms. Carol Massengill, the nurses of the
Clinical Research Unit as well as the staff of the metabolic
kitchen for their care of the patients in the studies, and the
Clinical Diabetes and Nutrition Section technical staff. No
outside funding/support was provided for this study.
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