GENOMICS, TYPE 2 DIABETES AND OBESITY

Preceptor : Dr. Ayaskant Singh Dr. R. K. Dalai

(Asso. Prof. PG Dept. Of Medicine )

Introduction
Genetics is the study of a single or few genes and their phenotypic effects .

After the completion of the human genome

project ,the term genomics was coined which is the study of all the genes in the genome and their interactions.1 The sequence of the human genome is complete.

Less than 2% of human genome encodes for

protein ,mere 20,000-25,000 genes code for

protein.1

 The recent progress in genomics is that ,on average any two individuals share greater than 99.5% of their DNA sequences .

Thus the remarkable diversity n humans is

encoded in 0.5% of DNA .1

Diabetes

Mellitus

(DM)

refers

to

group

of

common

metabolic

disorders

that

share

the

phenotype of hyperglycemia.2

Several distinct

types of Diabetes Mellitus

exist and are caused by a complex interaction of genetics and environmental factors.2

Type 2 Diabetes Mellitus has a strong genetic

component. The concordance of Type 2 Diabetes Mellitus in identical twins is between 70% and 90%.2 If both parents have Type 2 Diabetes Mellitus

,the increased risk approaches 40 % .2

 Insulin resistance is present in many non diabetic first degree relatives of individuals of Type 2 Diabetes Mellitus. The disease is polygenic and multifactorial since addition to genetic susceptibility , environmental factors (obesity ,nutrition and physical activity )modulate the phenotype.

The increasing prevalence of Type 2 Diabetes

Mellitus is linked to rising rates of obesity.3 The prevalence of obesity and overweight continues to rise worldwide, causing serious personal health problems .3

 By current estimates, 70% of adults in USA and >60% of adults in UK are overweight, and about half of these are obese.4 It is well established that rapid globalization of the the westernized present-day lifestyle is fuelling this emerging obesity epidemic. Yet, not everyone in obesogenic environment

develops obesity, highlighting the multi-factorial

nature of the condition . Family and twin studies show that genetic factors contribute 40% - 70% to the individual variation in common obesity.5 inter-

 For the last 15 years, candidate gene and genome-wide linkage studies have been the two main genetic epidemiological approaches to identify genetic loci for common traits, yet progress has been slow and success limited. The genome-wide association approach, which has become available in recent years, has

dramatically
discoveries

changed
for

the

pace

of

gene

common

disease,

including

obesity and diabetes .6

Discovery Of Susceptible Genes

Discovery Of Susceptible Genes

Family Linkage Studies

Candidate Gene Studies

Genome Wide Association Studies

Family Linkage Studies

Definition : An approach to susceptibility-gene discovery that relies on matching family-level patterns of segregation of the disease of interest with genetic markers of known location.

These

proved

effective

in

identifying

genes

responsible for extreme forms of early-onset disease segregating as single-gene (mendelian) disorders.

 Genes underlying several distinct, familial forms of non-autoimmune diabetes of with the including young, and maturity-onset mitochondrial diabetes diabetes

deafness,

neonatal diabetes.7 Similar approaches revealed mutations in genes responsible for rare forms of severe childhood

obesity, including the genes encoding leptin, the

leptin receptor, and propiomelanocortin.8

Candidate Gene Studies

Definition : An discovery approach that to susceptibility-variant on genetic analysis focuses

restricted to one or more candidate genes genes that have typically been selected on the basis of a perceived match between their known

or

presumed

functions

and

the

biologic

characteristics of the disease in question.

 Common

coding

variants

in

PPARG

and

KCNJ11 (each of which encodes a protein that acts as a target for classes of therapeutic agents widely used in diabetes management) were shown to have modest effects on the risk of Type 2 diabetes.9,10 Resequencing of the gene encoding the

melanocortin-4 receptor (MC4R) resulted in the

identification of low-frequency coding variants that explain approximately 2 to 3% of cases of severe obesity.11

Genome Wide Association Studies

Definition : Genome Wide Association Studies (GWAS) also known as Whole Genome Association Studies is an examination of all or

most of the genes ( The Genome ) of different

individuals of a particular species to see how many of the genes vary from individual to individual. Different variations are then associated with different traits or diseases.

 GWAS

have been the most important and the associated wide Type 2 Diabetes ,large

most successful contributors in finding novel, reproducibly In genome Mellitus variants. association studies cohorts of patients with or without the disease are examined across the entire genome for

genetic

variants

or

single

DNA
or

mutations(single-nucleotide the disease .

polymorphisms

SNP ) ;that are overexpressed in patients with

 This identifies the regions of the genome that contain a variant gene or genes that confer disease

susceptibility
As of December 2010, over 1200 human GWAS have been examined for 200 diseases and found almost

4000 SNP associations .12

The first demonstration that unbiased discovery efforts could reveal new insights into the

pathogenesis

of Type

Diabetes

resulted

from

identification of the association between type 2 diabetes and variants within TCF7L2 (encoding

transcription

factor

7like

2,

protein

not

previously identified as a biologic candidate).13

 After the publication of the first Genome Wide Association Studies in 2007 revealed 6 new associations :14
CDKAL1, CDKN2A, and CDKN2B (which encode putative or known regulators of cyclin-dependent kinases) HHEX (which is transcribed into a homeobox protein implicated in beta-cell development) SLC30A8 and IGF2B2

Typically each copy of a susceptibility allele at one of these loci is associated with a 15 to 20% increase in the risk of diabetes.15-16

 The

current

total

of

approximately

40

confirmed type 2 diabetes loci also includes variants in or near :

WFS1 (Wolframin) Hepatocyte nuclear factors HNF1A and HNF1B (genes that also harbour rare mutations responsible for monogenic forms of diabetes) The melatonin-receptor gene MTNR1B (which highlights the link between circadian and metabolic regulation) IRS1 (encoding insulin-receptor substrate 1), one of a
17-18

limited number of type 2 diabetes loci with a primary

effect on insulin action rather than on secretion.

Genomic Locations of Proven Signals of Non autoimmune Forms of Diabetes.

McCarthy MI. N Engl J Med 2010;363:2339-2350.

McCarthy MI. N Engl J Med 2010;363:2339-2350

 Genome Wide Association Studies of populationbased samples to examine the full range of BMI values have identified approximately 30 loci influencing BMI and the risk of obesity. The first study was a genome-wide association study for Type 2 diabetes , identifying a cluster of SNPs in the first intron of FTO that were

significantly associated with Type 2 diabetes.

After adjusting for BMI, the association with Type 2 diabetes that was the completely abolished, 2 diabetes
19-20

suggesting

FTOType

association was mediated through BMI.

 Another newly identified locus was mapped at 188 kb downstream of MC4R, an established biological candidate.21 For the third wave of discoveries included :
1.Neuronal growth regulator 1 (NEGR1), 2.Transmembrane protein 18 (TMEM18), 3. SH2B adaptor protein 1 (SH2B1), 4. Potassium channel tetramerization domain containing 15 (KCTD15), 5.Near glucosamine-6-phosphate deaminase 2 (GNPDA2), and 6. In mitochondrial carrier homologue 2 (MTCH2)

Genomic Locations of Proven Signals of Body-Mass Genomic Locations of Proven Signals of Body-Mass Index (BMI), Obesity, and Related Index (BMI), Obesity, and Related Phenotypes. Phenotypes.

McCarthy MI. N Engl J Med 2010;363:2339-2350.

McCarthy MI. N Engl J Med 2010;363:2339-2350

Implcations of genomics in Etiopathogenesis Of Type 2 DM

 Analysis of Type 2 Diabetes Mellitus associated variants in healthy populations has clearly demonstrated that most of the Type 2 Diabetes Mellitus susceptibility signals so far examined ( notably CDKAL1, the signals near KCNJ11, TCF7L2, HNF1B, CDKN2A/B, IGF2BP2,

HHEX/IDE, JAZF1 and SLC30A8 ) have a

predominant effect on insulin secretion, with

only FTO ( which acts primarily through an effect on BMI and risk of obesity ) and IRS1 and PPARG shown to influence insulin action.
22

 Both HHEX and TCF7L2 are implicated in the regulation process in of Wnt-signalling, Type 2 highlighting Mellitus dysfunction of its pathway in the islet as a key Diabetes development.23 The associated signal in SLC30A8 clearly points the finger at disturbances in Zinc transport

within insulin secretory granules.24

 Perhaps most informative is the evidence incriminating

abnormalities in cell cycle regulation.

Genes thought to be involved in this process

signals close to CDKAL1, CDKN2A/B, CDKN1C [KCNQ1]).25

are the
and

CDC123

In

rodents,

CDKA2a

over

expression

compromises

maintenance of beta-cell mass and recapitulates the Type 2 Diabetes Mellitus phenotype. Further studies at these loci may provide valuable clues to which aspects of the regulation of beta-cell mass (development, regeneration or senescence) are central to the development of diabetes.

Pathways to Type 2 Diabetes Implicated by Identified Common Variant Associations

McCarthy MI. N Engl J Med 2010;363:2339-2350

Tcf7l2 : The Biggest Story In Diabetes Genomics.

It is a novel type 2 diabetes-susceptibility gene (encoding the transcription factor, TCF7L2 [7like 2]) Studies in Dutch
26

and Indian

27samples

have

confirmed

the

powerful

effect

of

TCF7L2

variation on type 2 diabetes-risk ,nearly twofold increase of risk

The largest effect size for Type 2 Diabetes

Mellitus identified to date resides within the TCF7L2 on Chromosome 10.

 TCF7L2 has now been shown to modulate pancreatic islet function.14 At this early stage, precious little is known about the normal role of TCF7L2 . The gene seems to be widely expressed and the transcription factor product is known to be

involved in the Wnt signalling cascade which

may lead to impairment of insulin secretion .28

 Several of the genes implicated in Type 2 Diabetes Mellitus-susceptibility appear to have effects on other common disease traits . Thus, variation in CDKAL1 has been implicated

in inflammatory bowel disease as well as Type 2

Diabetes Mellitus .29 In the case of HNF1B, alleles at the same variant have opposing effects on predisposition to Type 2 Diabetes Mellitus and prostate cancer, an inverse relationship which is consistent with the epidemiological data .30

Implications For Etiology Of Obesity

 New insights based on animal and humans studies have begun to accumulate, in particular on the biology of the FTO gene. FTO is a member of the non-haeme dioxygenase superfamily that encodes a 2-oxoglutaratedependent nucleic acid demethylase and catalyses the demethylation of 3-methylthymine

in single-stranded DNA.31
Studies in rodents indicated that FTO mRNA expression is abundant in the brain, specially in the hypothalamic nuclei governing energy balance, and dependent on the energy state.

 Studies in humans have supported a central neuronal role for FTO as its risk-alleles have been associated with increased appetite and energy intake, and reduced satiety. A recent study in mice, however, has challenged the neuronal hypothesis and has provided strong evidence for a peripheral role of FTO.

Fischer et al. found that the loss of FTO in mice

leads to a significant reduction in adipose tissue and lean body mass, which is a consequence of increased energy expenditure and systemic sympathetic activation.32

 The near-MC4R locus, identified in the second wave of genome-wide association studies is an obvious candidate gene given its role in monogenic early-onset obesity. The physiological role in relation to obesity risk is not or poorly understood.

 For rest of the loci discovered , the physiological

role in relation to obesity risk is not or poorly understood . Yet two loci contain genes with a strong candidacy.

SH2B1

is

implicated

in

leptin

signaling and Sh2b1-null mice are obese.32

The BDNF locus is a strong prior candidate and one of the SNPs in this locus is the nonsynonymous Val66Met that has previously been examined in candidate gene studies of eating

behavior and BMI .33

From Genes To Clinical Practice

Despite the growing number of loci discovered, the contribution of genetic discoveries to the clinical management of diabetes and obesity

remains limited to the small proportion of cases

with monogenic forms of disease.

 The obstacles faced are : 1. The first is the modest effect size of the implicated variants. The common variants with the greatest effects on the risk of type 2 diabetes (TCF7L2 in Europeans, KCNQ1 in Asians) result in lifetime prevalence rates that are, in persons carrying two copies of

the risk allele, roughly double those seen in

persons with none. The association signal at FTO accounts for less than 0.5% of the overall variance in BMI, equivalent to a difference of 2 to 3 kg.

Most other variants associated with type 2 diabetes and BMI have effects considerably smaller than these. In contrast, have far the mutations underlying clinical monogenic forms of diabetes and obesity more dramatic consequences.

2. A

second

obstacle

to

the

translation

of

variants implicated in multifactorial forms of diabetes and obesity relates to the speed with which risk-allele discovery has led to an improved understanding of the biologic basis of disease. Most alleles implicated in monogenic and syndromic forms of diabetes

and obesity alter the coding sequence and

therefore have dramatic and largely predictable effects on the function of the gene.

In

multifactorial

disease,

however,

most

susceptibility variants lie outside the coding regions of genes (Introns) and are assumed to influence transcript regulation rather than gene function. Characterization of the downstream consequences of these non-coding variants is

difficult, given our rudimentary knowledge of

the mechanics of gene regulation.

Targetted Treatment And Prevention

In the long term of course, we can expect novel insight into Type 2 Diabetes pathogenesis generated by genetic discoveries to feed forward

into drug development.

Proof of principle is provided by the observation that two of the proven Type 2 Diabetes susceptible signals lie in genes ( PPARG, KCNJ11 ) whose protein products are already the targets of established and effective therapeutic agents.

 Recommended therapies for the various subtypes of

diabetes differ as in the table below :

McCarthy MI. N Engl J Med 2010;363:2339-2350.

In monogenic forms of diabetes, genetic testing already drives the choice of therapy. For example, in patients who have maturityonset diabetes of the young due to mutations in the gene encoding glucokinase (GCK), the hyperglycaemia is mild and stable, the risk of complications is low, and dietary management

is often sufficient.34

In contrast, in patients who have maturityonset diabetes of the young due to mutations in HNF1A, the disease follows a more aggressive course, with a greater risk of severe complications, but is particularly responsive to the hypoglycaemic effects of sulfonylureas.
35

 Most children with neonatal diabetes have mutations in KCNJ11 or ABCC8, adjacent genes that jointly encode the beta-cell ATP-sensitive potassium channel that mediates glucosestimulated insulin secretion and is the target of sulfonylureas. In such children, treatment with sulfonylureas has proved more effective and

convenient than the lifelong insulin therapy

previously considered the default option. In children with severe obesity due to profound leptin deficiency, exogenous leptin therapy is lifesaving.36

 As yet, there are insufficient genetic data to

support management decisions for common

forms of type 2 diabetes and obesity Although the TCF7L2 genotype is associated with variation in the response to sulfonylurea treatment, the effect is too modest to guide the

care of individual patients .37

Conclusion
The advent of Genome Wide Association Studies has led to an explosion in confirmed signals; not just for Type 2 Diabetes Mellitus but also for obesity. These discoveries provide unique sight into the

pathogenesis of Type 2 Diabetes Mellitus and

Obesity. An improved understanding of the fundamental disease mechanisms advances will and lead to future risk therapeutic prediction. improved

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