ore than 1.9 billion adults are overweight or obese, representing over one third of the worldwide adult population 1. The biggest health and economic burden of obesity is the large number of obesity-related co-morbidities. In addition to type 2 diabetes and cardiovascular disease, obesity is associated with an increased risk of cancer and infections 2-4. Indeed, up to 49% of certain types of cancer are now attributed to obesity 3 , and weight loss through bariatric surgery can reverse cancer risk 5. Potential mechanisms for the increased risk of cancer associated with obesity include overproduction of hormones (for example, oestrogens), adipokines (for example, leptin), and insulin, which favor cell proliferation and tumor growth 6,7. Peroxisome proliferator-activated receptors (PPARs) are transcriptional regulators of cellular metabolism. It has recently been shown that obesity induces a PPAR-driven lipid metabolism program in metastatic tumor cells, which enhances metastasis and tumor cell survival 8. In intestinal stem cells, obesitydriven PPAR signaling enhances stemness and tumor progression 9. However, despite the increasing attention to the role of the immune system and inflammation in obesity-driven insulin resistance, the impact of obesity-induced dysfunction on immunosurveillance and cancer risk is not well understood. Natural killer (NK) cells have crucial roles in protective immunity against tumors and viral infections 10. NK cells kill their targets through the directed secretion of lytic granules, which contain pore-forming perforin and apoptosis-inducing granzymes 11-13. Cellular metabolism has a critical role in the function of immune cells. NK cells switch the balance of the core metabolic program from oxidative phosphorylation (OXPHOS) to glycolysis to meet the increased energy required to kill tumor cells 14,15 , although the steps in the killing process that require this metabolic activation are unknown. Humans and mice with obesity display numerical and functional defects in NK cells and have an increased risk of cancer and infections. As obesity is a state of altered metabolism, we investigated the effect of obesity on the cellular metabolism, gene expression, and function of NK cells, and its contribution to cancer development. Our data show that NK cell uptake of lipids from the environment in human obesity interfered with their cellular bioenergetics, inducing 'metabolic paralysis'. Lipid-induced metabolic defects caused NK cell incompetence by inhibiting trafficking of the cytotoxic machinery, leading to loss of antitumor functions in vitro and in vivo. Our data suggest that obesity targets immunometabolic pathways and that this may be partly responsible for the increased cancer and infection risks in obesity, and suggest that metabolic reprogramming may improve innate immunosurveillance in obesity. Results Obesity induces lipid metabolism in NK cells. To better understand the effects of obesity on NK cells, we examined mouse models of diet-induced obesity. We performed transcriptional a...

Abstract-Adipose tissue (AT) can accumulate macrophages and secrete several inflammatory mediators. Despite its pivotal role in the progression of chronic inflammatory processes such as atherosclerosis, the adaptive role of immunity in obesity remains poorly explored. Visceral AT of diet-induced obese C57BL/6 mice had higher numbers of both CD4 ϩ and CD8 ϩ T cells than lean controls, monitored by flow cytometry. When stimulated in vitro, T cells from obese AT produced more interferon (IFN)␥ than those from controls. AT from obese animals also had more cells expressing I-A b , a mouse class II histocompatibility marker implicated in antigen presentation, as determined by immunostaining. Differentiated 3T3-L1 cells stimulated with recombinant IFN␥ or T-helper 1-derived supernatant produced several chemokines and their mRNAs. Obese IFN␥-deficient animals had significantly reduced AT expression of mRNAencoding inflammatory genes such as tumor necrosis factor-␣ and monocyte chemoattractant protein-1, decreased AT inflammatory cell accumulation, and better glucose tolerance than control animals consuming the same diet. Obese mice doubly deficient for IFN␥ receptor and apolipoprotein (Apo)E on a mixed 129SvEv/C57BL/6 (129/B6) genetic background, despite exhibiting similar AT mRNA levels of tumor necrosis factor-␣ and monocyte chemoattractant protein-1 as 129/B6-ApoE Ϫ/Ϫ controls, had decreased expression of important T cell-related genes, such as IFN␥-inducible protein-10 and I-A b , and lower plasma triglycerides and glucose. These results indicate a role for T cells and IFN␥, a prototypical T-helper 1 cytokine, in regulation of the inflammatory response that accompanies obesity.

IMPORTANCE Emerging data support bariatric surgery as a therapeutic strategy for management of type 2 diabetes mellitus. OBJECTIVE To test the feasibility of methods to conduct a larger multisite trial to determine the long-term effect of Roux-en-Y gastric bypass (RYGB) surgery compared with an intensive diabetes medical and weight management (Weight Achievement and Intensive Treatment [Why WAIT]) program for type 2 diabetes. DESIGN, SETTING, AND PARTICIPANTS A 1-year pragmatic randomized clinical trial was conducted in an academic medical institution. Participants included persons aged 21 to 65 years with type 2 diabetes diagnosed more than 1 year before the study; their body mass index was 30 to 42 (calculated as weight in kilograms divided by height in meters squared) and hemoglobin A1c (HbA1c) was greater than or equal to 6.5%. All participants were receiving antihyperglycemic medications. INTERVENTIONS RYGB (n = 19) or Why WAIT (n = 19) including 12 weekly multidisciplinary group lifestyle, medical, and educational sessions with monthly follow-up thereafter. MAIN OUTCOMES AND MEASURES Proportion of patients with fasting plasma glucose levels less than 126 mg/dL and HbA1c less than 6.5%, measures of cardiometabolic health, and patient-reported outcomes. RESULTS At 1 year, the proportion of patients achieving HbA1c below 6.5% and fasting glucose below 126 mg/dL was higher following RYGB than Why WAIT (58% vs 16%, respectively; P = .03). Other outcomes, including HbA1c, weight, waist circumference, fat mass, lean mass, blood pressure, and triglyceride levels, decreased and high-density lipoprotein cholesterol increased more after RYGB compared with Why WAIT. Improvement in cardiovascular risk scores was greater in the surgical group. At baseline the participants exhibited moderately low self-reported quality-of-life scores reflected by Short Form-36 total, physical health, and mental health, as well as high Impact of Weight on Quality of Life–Lite and Problem Areas in Diabetes health status scores. At 1 year, improvements in Short Form-36 physical and mental health scores and Problem Areas in Diabetes scores did not differ significantly between groups. The Impact of Weight on Quality of Life–Lite score improved more with RYGB and correlated with greater weight loss compared with Why WAIT. CONCLUSIONS AND RELEVANCE In obese patients with type 2 diabetes, RYGB produces greater weight loss and sustained improvements in HbA1c and cardiometabolic risk factors compared with medical management, with emergent differences over 1 year. Both treatments improve general quality-of-life measures, but RYGB provides greater improvement in the effect of weight on quality of life. These differences may help inform therapeutic decisions for diabetes and weight loss strategies in obese patients with type 2 diabetes until larger randomized trials are performed.

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