Review

Mechanisms of endothelial dysfunction in obesity

Angelo Avogaro
*
, Saula Vigili de Kreutzenberg
Metabolic DiseasesDepartment of Clinical and Experimental Medicine, University of Padova, School of Medicine,
Via Giustiniani 2, 35128 Padova, Italy
Received 18 January 2005; received in revised form 12 April 2005; accepted 12 April 2005
Available online 27 June 2005
Abstract
Obesity is a chronic disease, whose incidence is alarmingly growing, affecting not only adults but also children and
adolescents. It is associated with severe metabolic abnormalities and increased cardiovascular morbidity and mortality. Adipose
tissue secretes a great number of hormones and cytokines that not only regulate substrate metabolism but may deeply and
negatively influence endothelial physiology, a condition which may lead to the formation of the atherosclerotic plaque. In this
review, the physiology of the endothelium is summarised and the mechanisms by which obesity, through the secretory products
of adipose tissue, influences endothelial function are explained. A short description of methodological approaches to diagnose
endothelial dysfunction is presented. The possible pathogenetic links between obesity and cardiovascular disease, mediated by
oxidative stress, inflammation and endothelial dysfunction are described as well.
D 2005 Elsevier B.V. All rights reserved.
Keywords: Endothelium; Endothelial dysfunction; Adipose tissue; Obesity
Contents
1. Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.1. Obesity and cardiovascular disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
1.2. The physiologic role of endothelium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.3. Adipose tissue, adipokines and vascular endothelium . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.4. Adipose tissue, subclinical inflammation and endothelium . . . . . . . . . . . . . . . . . . . . . . . . . 14
2. Obesity, oxidative stress and endothelial dysfunction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3. The endothelium beyond NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
3.1. Obesity, free fatty acids and endothelium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
0009-8981/$ - see front matter D 2005 Elsevier B.V. All rights reserved.
doi:10.1016/j.cccn.2005.04.020
* Corresponding author. Tel.: +39 49 8212178; fax: +39 49 8754179.
E-mail address: angelo.avogaro@unipd.it (A. Avogaro).
Clinica Chimica Acta 360 (2005) 926
www.elsevier.com/locate/clinchim
4. Assessing the endothelial function in vivo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
4.1. Obesity and endothelial dysfunction: evidence from adult human studies . . . . . . . . . . . . . . . . . 19
4.2. Obesity and endothelial dysfunction: evidence from children and adolescent studies . . . . . . . . . . . 20
5. Weight loss, caloric restriction and endothelium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
6. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
1. Introduction
For centuries, obesity has been frequently
regarded as a condition of healthiness and beauty.
Unfortunately, the positive anthropological and so-
ciological considerations toward obesity are the
wrong sides of the coin because obesity is a serious
health problem, especially in countries where econ-
omy is growing fast. As defined by Bray, obesity is
a chronic disease in the same sense as hypertension
and atherosclerosis [1]. Obesity predisposes to dia-
betes mellitus and to metabolic syndrome, condi-
tions in which the distinct metabolic defect is
insulin resistance; this abnormality contributes
greatly to the pathophysiology of the metabolic
abnormalities and their associated morbidity [2,3].
There is now substantial evidence that the regional
distribution of fat is important: excessive accumu-
lation of fat in the upper bodys region, or central
obesity, is a better predictor of morbidity than
excess fat in the lower body [4]. Thus, it is well
established that obesity, in particular central obesity,
appears to be the depot most associated with insulin
resistance.
Obesity predisposes to diseases due to increased
fat cell mass, such as diabetes, non-alcoholic fatty
liver disease, cardiovascular disease and cancer, and
to diseases due to increased fat mass, such as oste-
oarthritis and sleep apnea. Obesity is associated with
premature death, i.e., obese people have an in-
creased years of life lost: non-smoking women
with a body mass index (BMI) N25 kg/m
2
at age
of 40 lose 3.3 years, while men 3.1 years; if the
BMI is N30 kg/m
2
, women lose 7.1 years and men
5.8 [5]. As recently shown, the BMI is an important
and independent predictor of mortality and, most
importantly, a higher level of physical activity
does not appear to negate the risk associated with
adiposity [6].
1.1. Obesity and cardiovascular disease
The cause of increased morbidity and mortality, in
obese people, is that all the major risk factors for
coronary artery disease coexist, and this condition pre-
disposes to premature cardiovascular disease (CVD).
Obesity is indeed a component of the metabolic syn-
drome, a constellation of metabolic risk factors that
consist of serum elevations of triglycerides, low levels
of high-density lipoprotein, elevated blood pressure,
elevated glucose associated with insulin resistance, a
prothrombotic state and a proinflammatory state [7].
The metabolic hallmark of the metabolic syndrome is
the presence of insulin resistance, i.e., a decreased
sensitivity or responsiveness of peripheral tissues to
the metabolic action of insulin. Insulin resistance per se
and all the components of the metabolic syndrome are
associated with altered functions of the endothelium,
which ultimately lead to CVD. It appears that obesity is
indeed associated with an excess of CVD.
The Framingham Study showed in 2005 men and
2521 women that the 28-year age-adjusted rate (per
100) of coronary heart disease (CHD) was 26.3 for a
mean BMI of 21.6 kg/m
2
and 42.2 for a mean BMI of
31 in men, and 19.5 for a BMI of 20.4 and 28.8 for a
BMI of 32.3 in women, respectively [8]. The Gothen-
burg Study, in a 12-year incidence period, showed, in
a multivariate analysis, that the waist hip ratio (WHR)
was the strongest predictor [9] of myocardial infarc-
tion in 1462 women [9]. In 1990, the Nurses Health
Study, during an 8-year observation, clearly showed in
a population of 121700 females that obesity is a
determinant of CHD; after control far cigarette smok-
ing, which is essential to assess the true effect of
obesity, even mild-to-moderate overweight increased
the risk of CHD [10]. This study showed a relative
risk of 3.3 for a BMI of N29 kg/m
2
when compared to
a BMI b21; a negative effect of obesity remained
appreciable after a multivariate correction for hyper-
A. Avogaro, S.V. de Kreutzenberg / Clinica Chimica Acta 360 (2005) 926 10
tension, diabetes and high cholesterol levels. Similar-
ly, the Honolulu Heart Program demonstrated over a
20-year observation period that a mean subscapular
skinfold thickness of 27.2 mm increased the risk of
developing CHD in Japanese American [11]. The
Rochester Coronary Heart Disease project suggested
that both weight and BMI are mildly associated with
angina [12]. The Paris Prospective Study has shown
that increased BMI, along with resting heart rate,
systolic or diastolic blood pressure, tobacco consump-
tion, diabetes, cholesterol and parental history of sud-
den death, was an independent predictor of sudden
death during follow-up [13].
The interaction between CHD and obesity has been
confirmed by the PROCAM Study [14].
The association between obesity and CHD
becomes more robust when the distribution of fat is
considered. Several studies have confirmed that the
abdominal adiposity is an independent risk for CHD
[1517]. The relationship between obesity and CHD
is operative not only in the elderly population but also
in children and adolescents [18,19].
Obesity is also a risk factor for cerebrovascular
disease, although its negative role appears more clearly
in women than in men [20]. The ARIC(Atherosclerosis
Risk in Communities) Study found that, in diabetic
patients, the relative risk for ischemic stroke was 1.74
for a 0.11 increment of WHR [21].
Finally, obesity appears to be an independent pre-
dictor of peripheral vascular disease (PVD) [22].
Therefore, from the available data, obesity is a signif-
icant predictor of CVD: this condition begins when
the risk factors, which coexist in obese people, induce
the endothelial dysfunction, which appears when the
endothelium loses its physiological properties, i.e., the
tendency to promote vasodilation, fibrinolysis and
antiaggregation.
1.2. The physiologic role of endothelium
Vascular endothelial cells play a major role in
maintaining cardiovascular homeostasis in health. In
addition to providing a physical barrier between the
vessel wall and lumen, the endothelium secretes a
number of mediators that regulate platelet aggrega-
tion, coagulation, fibrinolysis and vessel tone. Endo-
thelial cells secrete an array of mediators, which can
alternatively mediate either vasoconstriction, such as
endothelin-1 and thromboxane A2, or vasodilation
such as nitric oxide (NO), prostacyclin and endothe-
lium-derived hyperpolarizing factor (EDHF) (Fig. 1)
[23]. NO is the major contributor to endothelium-
dependent relaxation in conduit arteries, whereas the
contribution of EDHF predominates in smaller resis-
tance vessels [24]. l-Arginine, the physiologic pre-
cursor of NO, is carried within the endothelial cells by
facilitated transport mediated by the y+ system carrier
[25]. Intracellular l-arginine concentrations in endo-
thelial cells range between 0.1 and 0.8 mM; within the
cells, l-arginine can be converted to l-citrulline and
NO, or to l-ornithine and urea. Evidence suggests that
there is a complex compartmentalization of l-arginine
within endothelial cells: one compartment is accessi-
ble to NOS; in another compartment, the recycling of
l-citrulline to l-arginine takes place and, in an addi-
tional compartment, l-arginine derives from protein
breakdown [26]. The conversion of l-arginine to NO
is catalysed by a family of enzymes, the NO synthases
(NOS). Three NOS isoforms have been identified:
endothelial NOS (eNOS), neuronal NOS (nNOS)
and inducible or inflammatory NOS (iNOS) [27].
These enzymes have a ~50% sequence homology,
and catalyse the NADPH and O
2
-dependent oxidation
of l-arginine to NO and citrulline. NOS are flavo-
haem enzymes that are active only as dimers. The
dimerization activates the enzyme by sequestering
iron, generating high-affinity binding sites for argi-
nine and the essential cofactor tetrahydrobiopterin
(BH4), and allowing electron transfer from the reduc-
tase-domain flavins to the oxygenase-domain haem
[28]. Activity is also dependent on bound calmodulin.
In addition, eNOS activity can also be regulated by
post-translational modifications: these modifications
occur through the phosphorylation of Ser1179,
which increases the activity of the enzyme [27]. Sev-
eral kinases can phosphorylate this site, including
protein kinase A, protein kinase C and serine/threo-
nine kinase Akt. Myristoylation and palmitoylation
maintain the localization of eNOS to caveolae, dis-
crete microdomains of the plasma membrane, where
eNOS is bound to caveolin which keeps the enzyme
inactive [29]. Activation of endothelial acetylcholine
receptors activates phospholipase C (PLC) that cata-
lyzes the production of inositol 1,4,5-triphosphate
(IP
3
) and diacylglycerol (DAG) from phosphatidyli-
nositol 4,5-biphosphate (PIP
2
). The IP
3
-induced in-
A. Avogaro, S.V. de Kreutzenberg / Clinica Chimica Acta 360 (2005) 926 11
crease in intracellular Ca
2+
activates calmodulin that
binds to eNOS, which dissociates from caveolin and
translocates to the cytoplasm. Phosphorylation of
eNOS by protein kinase A (PKA) inactivates the
enzyme, which then relocates to the membrane caveo-
lin. It has been shown that insulin has vasodilatory
properties: this effect takes place because this hor-
mone can stimulate NO synthesis, in vivo through
the activation of post-receptor pathways, that involve
phosphatidylinositol-3 kinase (PI
3
K) and Akt [30,31].
In insulin-resistant states, such as in obesity, the
alterations of insulin post-receptor pathways impair
not only metabolic, but also vascular effects of the
hormone.
NO-sensitive guanylyl cyclase (NO sensitive GC)
is the most important receptor for the signalling mol-
ecule NO [32]. The latter stimulates cyclic guanosin
monophosphate (cGMP) production by activating sol-
uble GC, perhaps by binding to the heme moiety of
the enzyme. cGMP mediates most of its intracellular
effects through the activation of specific cGMP-de-
pendent protein kinases (PKG). Several families of
phosphodiesterases (PDE-I-VI) act as regulatory
switches by catalyzing the degradation of cGMP to
guanosine-5V-monophosphate (5V-GMP). The NO/
cGMP signalling cascade is crucial in the cardiovas-
cular system, where it controls smooth muscle relax-
ation, and inhibition of platelet aggregation; cyclic
nucleotide PDEs hydrolyze cGMP and thus terminate
their action [33]. Of note, it has been recently reported
that, in obese leptin deficient mice, NO-cGMP signal-
ing pathway is significantly altered in ventricular
myocytes [34].
NO has several important effects on the vascula-
ture. First, it maintains basal tone by relaxing vascu-
lar smooth muscle cells; it also inhibits platelet
adhesion, activation, secretion and aggregation and
promotes platelet disaggregation [35]. In addition to
these effects, endothelial-derived NO inhibits leuko-
cyte adhesion to the endothelium and inhibits smooth
muscle cell migration and proliferation: therefore,
NO is a powerful inhibitor of all these mechanisms
L-Arginine
NO
NO
eNOS Endothelial cell
Basal Membrane
+ L-Citrullin
Shear Stress Agonist
Ca
++
Ca
++
stretch operated Ca2+
channels G-protein CP
SGCi
SGCa
GTP cGMP
NO
+
+
Vascular Smooth Muscle
Cell

Ca
++
Agonist
G-protein CP
Ca
++
EDHF PGI
2
ATP cAMP
Ca
++
Relaxation
K
IR
K
IR
Hyperpolarization
Fig. 1. Vasodilatating mediators produced by endothelial cells. Several stimuli (shear stress or agonists) can induce the synthesis of NO, EDHF
or PGI
2
, which, in turn, determine vasorelaxation of underneath vascular smooth muscle cells. ATP=adenosine triphosphate, Ca=calcium,
cAMP=cyclic adenosine monophosphate, EDHF=endothelium-derived hyperpolarizing factor, cGMP=cyclic guanosine monophosphate,
GTP=guanosine triphosphate, G-protein CP=G-protein carrier protein, NO=nitric oxide, eNOS=endothelial nitric oxide synthase, PGI
2
=
prostacyclin, SGCi =soluble guanylyl cyclase inactivated, SGCa=soluble guanylyl cyclase activated, K
IR
=inwardly rectifying potassium
channels.
A. Avogaro, S.V. de Kreutzenberg / Clinica Chimica Acta 360 (2005) 926 12
that ultimately lead to neointimal proliferation and
atherosclerosis.
Endothelium contributes to the regulation of
blood pressure and blood flow by releasing not
only NO but also several other compounds, which
contribute both to vasodilation and vasoconstriction.
Endothelium produces a less well-characterized com-
pound known as EDHF that promotes vascular smooth
muscle relaxation and vasodilation by activating ATP-
sensitive potassium channels, smooth muscle sodium
potassium ATPase or both. The exact nature of EDHF
however remains elusive. Among the more recent
candidates to explain endothelium-dependent hyper-
polarization, gap junction, epoxyeicosatrienoic acids
(EETs), potassium ions and hydrogen peroxide are the
major contenders [36].
1.3. Adipose tissue, adipokines and vascular
endothelium
Adipose tissue is a secretory factory: it can produce
a significant amount of compounds able to affect
endothelial function, the most important being leptin,
resistin, tumor necrosis factor (TNF) a, interleukin
(IL) 6, monocyte chemoattractant protein (MCP)-1,
plasminogen activator inhibitor (PAI)-1, adiponectin
and the proteins of the reninangiotensin system [37].
The proteins of the reninangiotensin system and PAI-
1 will not be discussed in this review. Recent evidence
indicates that there is a strong interaction between the
secretory proteins of adipocytes, called adipokines,
and endothelium; thus, it appears that the ability of
adipokines to directly affect vascular homeostasis may
represent an important mechanistic basis of cardiovas-
cular disease in patients with obesity [38,39]. In this
review, we will consider recent findings on the effect
of leptin, resistin, adiponectin, IL-6 and TNFa on
endothelium.
Leptin is a 167-amino acid protein expressed mainly
by adipocytes and released in the blood in proportion to
the size of adipose tissue; leptin action in the CNS
promotes weight loss by decreasing food intake and
increasing energy expenditure. Recent studies have
shown that leptin has a broad range of effects on
vascular homeostasis [40]. Leptin can exert a pressor
effect through the activation of sympathetic nervous
system: this effect is probably due to a central neural
action of this hormone because intracerebroventricular
administration of leptin mimics the effects of systemic
administration [41]. Leptin also affects endothelial
function. In vitro studies have shown that leptin causes
oxidative stress in cultured endothelial cells by increas-
ing the generation of reactive oxygen species (ROS)
[42]. Leptin also has been shown to stimulate the
secretion of proinflammatory cytokines (e.g., tumor
necrosis factor a, interleukin-6) that are known not
only to promote hypertension but also to affect the
endothelial function [43,44].
However, it has been recently shown that leptin
may have direct vascular effects that tend to decrease
arterial pressure. Lembo et al. and Vecchione et al.
have shown that vasorelaxation evoked by leptin is
heterogeneous and related to a predominant role of the
EDHF mechanisms [45,46]; this vasodilatory effect,
independent from NO, has also been confirmed by
Matsuda et al. in human coronary arteries [47]. How-
ever, other groups have demonstrated that leptin can
induce vasodilation through the stimulation of NO
[48,49]. Interestingly, Mastronardi et al. have hypoth-
esized that the leptin-induced release of NO is not
only determined by a direct effect on vascular endo-
thelium, but also by an indirect effect on adipocytes:
these cells, under leptin control, may indeed have a
major role in NO release by activating NO synthase
[50].
Resistin is a recently discovered adipokine that has
been suggested to play a role in the development of
insulin resistance and obesity [51]. Resistin appears to
be produced during adipogenesis and inhibits glucose
uptake in skeletal muscle cells in animal models.
Verma et al. have shown that endothelial cells, incu-
bated with human recombinant resistin, resulted in an
increase in endothelin-1 release, with no change in
NO production [52]. Additionally, they found that
resistin-treated cells showed increased expression of
vascular cellular adhesion molecules (VCAM)-1 and
MCP-1. These data suggest that resistin directly acti-
vates endothelial cells by promoting endothelin-1 re-
lease and upregulating adhesion molecules. However,
further studies are needed to determine the biological
significance of resistin vascular effects in vivo in
humans.
More consistent appear the data so far gathered on
the effect of adiponectin on vascular endothelium.
Adiponectin, a 30-kDa polypeptide highly and specif-
ically expressed in differentiated adipocytes, circu-
A. Avogaro, S.V. de Kreutzenberg / Clinica Chimica Acta 360 (2005) 926 13
lates at high levels in the bloodstream [53]. A strong
and consistent inverse association between adiponec-
tin and both insulin resistance and inflammatory states
has been established [54]. Within the vascular wall,
adiponectin has several effects that are mediated via
increased phosphorylation of the insulin receptor, ac-
tivation of AMP activated protein kinase (AMPK) and
modulation of the nuclear factor nB pathway [55]. In
vitro studies have shown that it inhibits monocyte
adhesion by decreasing expression of adhesion mole-
cules, inhibits macrophage transformation to foam
cells and decreases proliferation of migrating smooth
muscle cells in response to growth factors. Adiponec-
tin has also the ability to stimulate the production of
NO; Chen et al. found that directly stimulates produc-
tion of NO in endothelial cells, using phosphatidyli-
nositol 3-kinase-dependent pathways involving
phosphorylation of eNOS at Ser1179 by AMPK
[56]. Moreover, adiponectin can also induce angio-
genesis by promoting cross-talk between AMP-acti-
vated protein kinase and Akt signalling within
endothelial cells [57,58].
Thus, adiponectin has strong antiatherogenic prop-
erties, which have been confirmed also in vivo, in
humans. Ouchi et al. have analyzed the endothelial
function in 202 hypertensive patients, and found that
plasma adiponectin level was highly correlated with
the vasodilator response to reactive hyperemia, a NO-
mediated phenomenon [59]. They also found that, in
adiponectin-KO mice, the endothelial function in re-
sponse to acetylcholine was significantly reduced in
adiponectin-KO mice compared with WT mice; con-
versely, hypoadiponectinemia is associated with a
blunted endothelial function and coronary artery dis-
ease [60]. Interestingly, it has been recently shown
that the action of adiponectin on vascular endothelium
in humans appears to be independent of its link with
insulin sensitivity [61].
MCP-1 is a chemokine that recruits monocytes to
sites of inflammation, is expressed and secreted by
adipose tissue [62]. MCP-1 expression in obese mice
expressed 10- to 100-fold more MCP-1 mRNA than
the liver, suggesting that the adipose tissue may be a
major source of the increased plasma levels of MCP-
1 observed in these animals [63]. The pathological
role of MCP-1 expression in adipose tissue is not
understood. MCP-1 has a direct angiogenic effect on
endothelial cells [64]: it was recently observed that
MCP-1 accelerates wound healing, a process that
depends on blood vessel growth [65]. Despite a
growing number of information, yet MCP-1 effect
on endothelial function in human obesity has to be
completely undisclosed.
1.4. Adipose tissue, subclinical inflammation and
endothelium
A growing body of evidence implicates adipose
tissue in general, and visceral adiposity in particular,
as key regulators of inflammation. Adipose tissue
secretes proinflammatory cytokines such as TNFa
and IL-6, which seem to play a major role in affecting
both endothelial function and glucose metabolism
[66]. Growing evidence has pointed to a causative
relationship between inflammation and insulin resis-
tance. TNFa mediates insulin resistance as a result of
obesity in many rodent obesity models [67]. Recently,
MCP-1 was also shown to impair adipocyte insulin
sensitivity [63]. Most importantly, recent articles dem-
onstrated that macrophage infiltration into adipose
tissue in obesity could be integral to these inflamma-
tory changes [68,69]. Both studies address the possi-
bility that some inflammatory responses took place
outside adipocytes in macrophages infiltrating the
expanding adipose tissue. Still, critical questions in-
clude the mechanisms by which the inflammatory
response is triggered and maintained in obesity: are
adipocytes themselves the antigens? Or the inflamma-
tory response takes place without the classic antigen
antibody reaction? Or it is the physical damage to the
endothelium produced by the several risk factors for
CVD? Whatever the initial stimulus, proinflammatory
cytokines negatively affect the endothelium. TNFa, a
26-kDa transmembrane protein that is cleaved into a
17-kDa biologically active protein that exerts its
effects via type I and type II TNFa receptors, not
only induces insulin resistance but deeply affects
endothelial function. TNFa stimulates nuclear tran-
scription factor-kappa B (NF-nB) activation; NF-nB
plays a critical role in mediating inflammatory
responses and apoptosis: it also regulates the expres-
sion of growth factors, proinflammatory cytokines and
adhesion molecules [70]. Many products of the genes
regulated by NF-nB also, in turn, activate NF-nB
(e.g., TNFa). Through this activation, TNFa induces
oxidative stress, which exacerbates pathological pro-
A. Avogaro, S.V. de Kreutzenberg / Clinica Chimica Acta 360 (2005) 926 14
cesses leading to endothelial dysfunction, and athero-
genesis. Exaggerated production of TNFa has been
shown to increase the activity of inducible NOS, i.e.,
the enzyme which produced NO in large amount and
which is cardiotoxic and promotes apoptosis [71]. It
has also been recently shown that TNFa mediates the
increased endothelial permeability by activating
NADPH oxidase [72]. Finally, TNFa inhibits tran-
scriptional, as well as post-transcriptional, eNOS
gene expression an effect this that can account for
the endothelial dysfunction [73]. Aljada et al. [74]
have clearly demonstrated that TNFa inhibits insu-
lin-induced increase in e-NOS expression in human
aortic endothelial cells. Through this mechanism,
TNFa may contribute to the inability of insulin to
cause vasodilatation in obesity and in type 2 diabetes
mellitus.
IL-6 is another cytokine associated with obesity
and insulin resistance [75]. IL-6 circulates in multiple
glycosylated forms ranging from 22 to 27 kDa in size.
IL-6 and IL-6 receptor are expressed by adipocytes
and adipose tissue matrix. IL-6 circulates at high
levels in the bloodstream and as much as one third
of circulating IL-6 originates from adipose tissue [37].
It has been shown that plasma IL-6 concentrations
predict the development of cardiovascular disease
[76].
IL-6 negatively affects endothelial function; it is an
important mediator of increased endothelial perme-
ability via alterations in the ultrastructural distribution
of tight junctions and morphologic changes in cell
shape. Protein kinase C (PKC) has been shown to
be a critical intracellular messenger in these IL-6-
mediated changes [77]. It has also been shown that
IL-6 can induce endothelial dysfunction by upregulat-
ing the angiotensin II receptor AT1: this effect may
contribute also to reverberate the oxidative stress
caused by pro-inflammatory cytokine in obesity [78].
Yudkin et al. have shown that an increased plasma
C reactive protein (CRP) concentration, a marker of a
low level of chronic inflammation, is related to the
metabolic syndrome [79]. Another study reported an
independent association between waist girth and CRP
levels; since abdominal fat depot is a source of IL-6
which potently stimulates CRP synthesis by the liver,
abdominal obesity is an important factor that helps to
explain the inflammatory reaction in obesity [80].
This hypothesis has been substantiated by the group
of Despres and colleagues who found a significant
relationships between plasma CRP levels and all in-
dices of adiposity, such as BMI, total body fat mass
and waist girth [81]. An increased concentration of
CRP is important since recent studies suggest that
CRP, besides being a marker of inflammation, may
also directly contribute to endothelial dysfunction
[82]. Exposure of endothelial cells to CRP decreases
endothelial NO production and downregulates eNOS
expression due to decreased eNOS mRNA stability
[83]. Thus, it appears that an increased cytokine pro-
duction, arising from expanded abdominal fat, could
be responsible, not only for the metabolic abnormal-
ities associated with the insulin resistance syndrome,
but also for the increased CVD risk observed in
abdominally obese patients.
2. Obesity, oxidative stress and endothelial
dysfunction
Oxidation reactions are crucial in all the events
that lead to atherogenesis, including endothelial dys-
function. The effects of oxygen-derived free radicals
(ROS) on vascular function depend critically on the
amounts produced: when formed in low amounts
they can act as intracellular second messengers,
modulating the responses as growth of vascular
smooth muscle cells and fibroblasts [84]. Higher
amounts of ROS can cause widespread cellular tox-
icity. Virtually all types of vascular cells produce
ROS, which can regulate several general classes of
genes, including adhesion molecules and chemotactic
factors, antioxidant enzymes and vasoactive sub-
stances. Upregulation of adhesion molecules and
chemotactic molecules by oxidant-sensitive mechan-
isms is of particular relevance to endothelial dys-
function since these molecules promote adhesion and
migration of monocytes into the vessel wall [85]. In
endothelium exposed to agents that damage the vas-
culature, there is stimulation of several enzymes that
can produce ROS: the enzymes of the mitochondrial
electron transport chain, xanthine oxidase, cycloox-
ygenases, lipoxygenases, myeloperoxidases, cyto-
chrome P450 monooxygenase, uncoupled NOS,
heme oxygenases, peroxidases and NAD(P)H oxi-
dases. ROS can be produced intracellularly, extracel-
lularly or in specific intracellular compartments.
A. Avogaro, S.V. de Kreutzenberg / Clinica Chimica Acta 360 (2005) 926 15
Among these enzymes, nicotinamide adenine dinu-
cleotide/NADPH oxidase is relevant since it is a
major vascular source of ROS (Fig. 2) [86]. There
is evidence that strong correlations exist among
NADPH oxidase activity, atherosclerotic risk factors
and endothelial dysfunction [87]. We have recently
shown that circulating lymphomonocytes from type
2 diabetic patients are sites of important oxidative
stress, that the NADPH oxidase gene expression is
increased and that this increase is dependent upon
metabolic control [88,89]. Interestingly, NADPH ac-
tivity is increased not only by factors that damage
vascular endothelium but possibly by insulin itself
[90] and by macronutrients as well. A challenge with
glucose, for example, results in a significant increase
in ROS generation, in normal subjects, with a spe-
cific increment in the expression of p47
phox
, the key
protein component of NADPH oxidase [91]. More-
over, it has been recently shown that fat accumula-
tion correlates with systemic oxidative stress in
humans and mice [92]. Production of ROS increased
selectively in adipose tissue of obese mice and was
associated with an augmented expression of NADPH
oxidase and decreased expression of antioxidative
enzymes [93]. Moreover, in cultured adipocytes, it
has been shown that elevated levels of fatty acids
increased oxidative stress via NADPH oxidase. This
increased oxidative stress causes dysregulated pro-
duction of adipocytokines (fat-derived hormones),
including adiponectin, PAI-1, IL-6 and MCP-1. In
humans, an increase in reactive oxygen species-in-
duced damage in lipids, proteins and amino acids has
been demonstrated in obese patients by Dandona et
al. [94]. In particular, lipid peroxidation, through the
production of bioactive iso-eicosanoids, could ampli-
fy and sustain not only a low-grade systemic inflam-
mation, but also platelet activation, as demonstrated
by Dav ` et al. [95] in women with android obesity.
The increased oxidative stress enhances nitric oxide
destruction, thereby reducing its biological effects.
Other factors associated with obesity and insulin
resistance such as free fatty acids and low concen-
trations of high-density lipoprotein also increase ox-
idative stress, contributing to reduced nitric oxide
bioavailability [96]. In particular, an increased oxi-
dative stress seems to be the main mechanism
through which insulin resistance causes endothelial
dysfunction. It has been hypothesised that insulin-
resistance per se, independent of hyperglycaemia,
can contribute to ROS production [97,98]. Another
Redox regulation
of NF-B
Expression of
inflammatory genes
(VCAM-1, ICAM-1, E-
selectin, MCP-1, Leptin
TNF,)
BH
4
L-Citrulline
L-Arg
O
2
Xantine oxydase
NAD(P)H oxidase

SOD
OH
.
Haber-Weiss
& Fenton
reactions
Peroxynitrous acid
Oxidative
injury
Toxic free radicals
ONOO
-

GSH
O
2
NO
O
2
.-
GSNO
eNOS
H
2
O
2
The Physiology and the Pathophysiology of eNOS
ADMA
TNF
Leptin
Adiponectin
Leptin
CRP
IL-6
Fig. 2. Reactive oxygen species (ROS) generation. ROS can be generated intracellularly and extracellularly by several enzymes. eNOS
uncoupling contributes to ROS production. Cytokines secreted by adipose tissue can augment oxidative injury (see text). l-arg=l-arginine,
BH
4
=tetrahydrobiopterin, TNFa=tumor necrosis factor a, CRP=C reactive protein, eNOS=endothelial nitric oxide synthase, ADMA=asym-
metric dimethylarginine, GSNO=S-nitroglutathione, GSH=reduced glutathione, ONOO

=peroxynitrite, SOD=superoxide dismutase, IL-

6=interleukin 6, NF-nB=nuclear factor kappa B, VCAM=vascular cell adhesion molecule, ICAM=intracellular adhesion molecule, MCP-
1=monocyte chemoattractant protein 1, NAD(P)H=nicotinamide adenine dinucleotide (phosphate) oxidase, 8 means inhibition.
A. Avogaro, S.V. de Kreutzenberg / Clinica Chimica Acta 360 (2005) 926 16
source of free radicals species is the so-called
uncoupled eNOS, a condition in which this enzyme
is deprived of l-arginine or tetrahydrobiopterin
(BH4), an important cofactor for a normal eNOS
activity, leading to the generation of O
2

and H
2
O
2
in lieu of NO. Uncoupling occurs in endothelial
dysfunction, engendering decreased NO bioavailabil-
ity, increased O
2

production and formation of per-

oxynitrite (ONOO

), a key mediator of lipid

peroxidation and foam cell formation in atheroscle-
rotic lesions [99]. It has been recently shown that the
gene encoding eNOS is expressed at higher levels in
obese women [100]. It can be hypothesized that a
non-physiologic increase in the activity of this en-
zyme may lead to an increased oxidative stress due
to a state of uncoupled eNOS.
Importantly, vascular superoxide levels and NO
activity are determined by the rate of superoxide
degradation. The major oxygen free radical-degrading
enzyme system is superoxide dismutase. The extra-
cellular form of superoxide dismutase is located be-
tween endothelium and vascular smooth muscle cells.
It has been shown both experimentally and clinically
that obesity is associated with a decreased anti oxidant
machinery: this condition renders patients more prone
to oxidative stress [101,102].
Finally, NO production can be inhibited by endog-
enous inhibitors. Asymmetric dimethyl arginine
(ADMA) is an endogenous competitive inhibitor of
the binding of l-arginine to eNOS, and therefore may
play a role in dysregulation of the l-arginine/NO
pathway [103]. An increased production of TNF-a
has been shown to inhibit ADMA breakdown [104]:
this may represent an important mechanism by which
obesity could alter NO biology as shown in elderly
high-risk men in whom a strong relationship was
found between BMI and plasma levels of ADMA
indicating a link to endothelial dysfunction in over-
weight subjects [105]. Collectively, these data suggest
that increased oxidative stress in accumulated fat
plays a major role in inducing endothelial dysfunction
in human obesity.
3. The endothelium beyond NO
Endothelium contributes to the regulation of
blood pressure and blood flow by releasing not
only NO but also several other compounds which
contribute both to vasodilation and vasoconstriction.
Endothelium produces a less well-characterized com-
pound known as EDHF that promotes vascular
smooth muscle relaxation and vasodilation by acti-
vating ATP-sensitive potassium channels, smooth
muscle sodiumpotassium ATPase or both [36].
The exact nature of EDHF however remains specu-
lative. There is evidence that EDHF-mediated
responses are initiated by an increase in the intracel-
lular endothelial [Ca
2
+
] and the consequent activation
of endothelial small conductance Ca
2
+
sensitive po-
tassium channels and intermediate-conductance Ca
2+
sensitive potassium channels, which elicit the hyper-
polarization of the endothelial cells [106]. In some
tissues, the hyperpolarization of the endothelial cells
might be regulated by the activation of cytochrome
P450 and the resulting generation of epoxyeicosa-
trienoic acids. The endothelial hyperpolarization is
then spread to the adjacent smooth muscle cells
through myo-endothelial gap junctions [36].
Important experimental evidence suggests that,
while NO-mediated relaxation is enhanced with
increases in vessel size, EDHF is the more prominent
vasodilator in smaller vessels: this introduces an im-
portant concept, i.e., the presence of a heterogeneous
vascular relaxation in vessels of different sizes: small
arteries contribute to vascular resistance and may
exhibit mechanisms of endothelium-dependent relax-
ation different from those in large arteries.
Endothelium produces also contracting factors
such as endothelin-1 (ET-1), the most potent vasocon-
strictor identified to date, and contracting factors such
as endothelium-derived contracting factors (EDCF)
[107]. This EDCF has been shown to be produced
in excess from the carotid artery of obese mice [108].
Traupe et al. found that obesity augments prostanoid-
dependent vasoconstriction and markedly increases
vascular thromboxane receptor gene expression [109].
A further hypothesis that could explain the altered
endothelial function in obesity is that in this clinical
condition the endothelium itself produces vasocon-
stricting compounds in excess, leading to a situation
of increased vascular reactivity. In this context, the
same group has found that, in obese C57Bl6/J mice,
obesity increases endothelium-dependent vasocon-
striction in the absence of endothelial nitric oxide,
and that this effect can be completely prevented by
A. Avogaro, S.V. de Kreutzenberg / Clinica Chimica Acta 360 (2005) 926 17
chronic endothelin receptors A blockade, suggesting
that endothelin modulates increased endothelium-de-
pendent vasoconstriction in obesity [110].
3.1. Obesity, free fatty acids and endothelium
Central obesity is associated with increased plasma
levels and turnover of free fatty acids (FFA). Recent
data have shown that exposure to pathophysiological
concentrations of FFAs may impair endothelial func-
tion as measured by agonist stimulated and flow-
mediated vasodilatation [111,112].
When FFA are exogenously raised in humans there
is also an increase in blood pressure; elevation of FFA
represents a critical crossroad between hemodynamic
and metabolic abnormalities [113]. These substrates
can impair endothelial function both in vitro and in
vivo: experimental data show that oleic acid inhibits
the constitutive nitric oxide (NO) synthase in cultured
bovine pulmonary artery endothelial cells [114].
Steinberg et al. and our group have shown that in-
creased FFA availability might affect insulin-mediated
vasodilation, in humans [111]. We reported that, in
conditions associated with marked plasma FFA con-
centration, as occurs after insulin withdrawal in type 1
diabetic subjects, a significant alteration in NO-medi-
ated vasodilation develops [112]. FFA alter some
important intracellular signal transduction pathways:
they could affect ion transport, e.g., Na/K ATPase, Na
and K channels, and Ca currents. They could also
enhance a1 adrenoceptor-mediated vascular reactivity
through a cyclooxygenase sensitive mechanism; in
vascular smooth-muscle cells, oleic and linoleic
acids increase PKC and extracellular signal-regulated
kinase which negatively affect both vascular tone and
cell growth [115]. Activation of PKC leads to activa-
tion of NADPH oxidase and to generation of reactive
oxygen species, which are associated with activation
of ERK, transcription factors, and decreased endothe-
lial function. Thus, elevated FFA not only interfere
with intermediary metabolism but also negatively af-
fect vascular biology, and specifically the l-arginine/
NO pathway and endothelial-mediated vascular relax-
ation. We also found that the elevation of FFA leads to
an impairment of NO-independent mechanisms medi-
ated by a reduced potassium-mediated vasodilation
[116]. This action may have potential relevant impli-
cations for obese patients: in these patients elevated
FFA levels could prevent a normal vasodilatory ca-
pacity in the small forearm vessels where the coupling
between blood flow and metabolism takes place. An-
other possible mechanism that could impair vasodila-
tion in obese patients is the reduction of prostacyclin
(PGI2) induced by elevated FFA levels. In fact, an
increase in fatty acids concentration causes a dose-
dependent inhibition of PGI2 synthesis by rat aortic
rings in vitro, with an effect consistently the most
inhibitory for linoleic and linolenic acids and the
least for palmitic acid [117].
4. Assessing the endothelial function in vivo
Endothelial function can be assessed by experi-
mentally exposing the blood vessels to pharmacolog-
ical agents or shear stress. These techniques are
widely employed as a reproducible parameter with
which to assess endothelial function (and NO bio-
availability) in different pathological conditions. In
patients with coronary artery disease, the infusion of
acetylcholine (Ach) into the epicardial coronary arter-
ies induces a paradoxical vasoconstriction rather than
vasodilation. The impedance plethysmography is an-
other commonly used approach for the direct mea-
surement of limb blood flow in baseline and
stimulated conditions. Intraarterial infusions of metha-
choline, bradykinine or Ach are usually performed to
assess endothelial function. Because forearm blood
flow (ml/min/100 ml) is measured, venous occlusion
plethysmography reflects resistance vessel function in
the forearm [118]. The measurement of flow-depen-
dent dilation is another non-invasive widely used
approach to determine endothelial function. This tech-
nique uses a stimulus that is particularly relevant
physiologically for endothelium-dependent vasodila-
tion (i.e., laminar shear stress), the tangential force
exerted by blood flow over the endothelium surface,
which then increases NO, which, in turn, increases
artery calibre. The difference in calibre before and
after the increase in blood flow is called the flow-
mediated vasodilation. With this approach it was
shown that the major risk factors for coronary artery
disease impair the endothelium response, i.e., the
flow-mediated vasodilation. Another, more sophisti-
cated, approach that assesses the integrity of the l-
arginine/NO pathway is the infusion of stably labelled
A. Avogaro, S.V. de Kreutzenberg / Clinica Chimica Acta 360 (2005) 926 18
l-
15
Narginine and the subsequent determination in
urine of
15
nitrates, stable metabolites of NO
[119,120].
Endothelial damage can also be assessed by mea-
suring some endothelial-derived markers. von Will-
ebrand factor (vWF), which cross links platelets and
thus stimulates clotting, is released from endothelial
storage granules and may rapidly increase in response
to vascular injury and endothelial damage. However,
high levels of vWF are a poor prognostic indicator for
myocardial infarction, re-infarction and mortality and
also of other cardiovascular events such as stroke
[121]. Thrombomodulin (TM) is a transmembrane
anticoagulant proteoglycan located on the vascular
endothelium surface: levels of TM are elevated in
diabetes mellitus and atherosclerotic disease. In gen-
eral, elevated levels of TM indicate endothelial injury
and some suggest that TM may be a marker of endo-
thelial cell membrane injury rather than endothelial
cell activation. E-selectin is a cell-surface-bound leu-
kocyte adhesion molecule specific to endothelial cells.
It mediates the interaction between leukocytes, plate-
lets and the endothelium. Increased surface expression
of E-selectin is probably a reflection of endothelial
activation rather than damage. The soluble form of E-
selectin can be detected in healthy controls, and is
raised in patients with ischaemic heart disease, ath-
erosclerosis, hypertension and diabetes. It has been
recently shown that levels of E-selectin may predict
the onset of type 2 diabetes in people at risk to develop
this disease and its concentration is significantly rela-
ted to future death from cardiovascular causes among
patients with coronary artery disease [122]. Other
important endothelium-derived badhesion moleculesQ,
which attract and banchorQ the cells involved in the
inflammatory reaction are VCAM and ICAM [123].
They have been shown to be increased in patients with
metabolic syndrome but without evidence of athero-
sclerotic disease: therefore, their increased circulating
levels may represent a fairly acceptable marker of
endothelium activation even without evidence of
established damage. If we assume that the measure-
ment of endothelial function represents a surrogate
of endothelial NO availability, several groups have
shown that endothelium dependent vasodilation pro-
vides prognostic information in terms of future
cardiovascular events [124]. A potentially relevant
information in terms of future cardiovascular mor-
bidity and mortality may also be obtained by the
amount of circulating endothelial progenitor cells in
peripheral blood: they closely correlate with the
amount of risk factors in patients with CHD
[125,126].
4.1. Obesity and endothelial dysfunction: evidence
from adult human studies
Obesity, and particularly abdominal fat distribu-
tion, have a major influence on metabolic and cardio-
vascular risk factors. Many prospective studies have
shown that increased abdominal fat accumulation is
an independent risk factor for CAD, hypertension,
stroke and type 2 diabetes. The strong link between
increased abdominal fat and hyperinsulinemia, insulin
resistance, elevated plasma FFA levels, hypertension,
predisposition to thrombosis, hypertriglyceridemia,
small, dense LDL particles and reduced HDL has
been recognized for decades and characterizes this
condition by widespread vascular dysfunction. Thus,
it is complicated to dissect the influence of obesity
and the effect of associated risk factors on endothelial
function. Nonetheless, several studies show that obe-
sity is independently associated with endothelial dys-
function in humans [127,128].
The increase in forearm blood flow in response to
Ach is inversely related to body mass index and waist
to hip ratio [129]: this study also showed that the
presence of endothelial dysfunction in obese humans
is due to a reduced NO bioavailability determined by
an increased production of reactive oxygen species.
The link between central obesity and endothelial func-
tion is further supported by the observation that insu-
lin sensitivity is partly determined by the ability of
endothelium to produce NO. Thus, the haemodynamic
resistance of endothelium to insulin in terms of NO
production would further aggravate metabolic insulin
resistance and in general metabolic/haemodynamic
coupling [130]. The association between obesity/insu-
lin resistance and endothelial dysfunction is strongly
supported by the fact that endothelium-dependent va-
sodilation is impaired in proportion to insulin resis-
tance and various indices of adiposity under baseline
conditions. de Jongh et al. have found that obese
women, compared with lean women, had impaired
capillary recruitment in the basal state and during
hyperinsulinemia, and impaired acetylcholine-mediat-
A. Avogaro, S.V. de Kreutzenberg / Clinica Chimica Acta 360 (2005) 926 19
ed vasodilation in the basal state and during hyper-
insulinemia [131]. They also found that the capillary
recruitment and acetylcholine-mediated vasodilation
were positively correlated with insulin sensitivity
and negatively with blood pressure in both lean and
obese women.
We recently tested the hypothesis that visceral
obesity is characterized not only by endothelium-de-
pendent dysfunction but also by a NO-independent
function [132]. We found that forearm blood flow
changes in response to bradykinin administration
were blunted irrespective of both nitric oxide synthase
and cyclooxygenase inhibition. We also found that a
substantial bradykinin-mediated vasodilation of the
forearm microcirculation persists, despite inhibition
of cyclooxygenase and of NO: this reveals alternative
vasodilator mechanism(s) such as EDHF release.
The distribution of fat, rather than obesity per se,
appears to negatively influence endothelial function:
Hashimoto et al. found that the subjects with visceral
type obesity, rather than those with the subcutaneous
type, are associated with impaired flow-mediated en-
dothelium-dependent vasodilatation of the brachial
artery [133]. However, Higashi et al. found that, in
patients with essential hypertension, obesity and hy-
pertension are independently involved in abnormal
endothelium-dependent vasodilation by attenuated
nitric oxide production [134].
As found experimentally, endothelin may account
substantially for the impaired vascular tone observed
in human obesity; Mather et al. have found that in
obese patients, the administration of a specific blocker
of endothelin receptor A reverses the baseline defect
in endothelium-dependent vasodilation, thus suggest-
ing an important role of endothelin in determining
endothelial dysfunction in obesity [135,136]. The
presence of a widespread vascular regulation in vis-
ceral obesity is confirmed by Nielsen et al., who
found that the vasoconstrictor response to angiotensin
II was greater in obese men than in nonobese men
[137]. In obese patients, the presence of a peripheral
endothelial dysfunction is paralleled by the occur-
rence of endothelial dysfunction also in coronary
vessels: Al Suwaidi et al. found that obesity is inde-
pendently associated with coronary endothelial dys-
function in patients with normal or mildly diseased
coronary arteries [138,139]. These data may explain
why a body mass index N27 kg/m
2
is an independent
variable for sudden death in patients with stable an-
gina [140].
4.2. Obesity and endothelial dysfunction: evidence
from children and adolescent studies
Overweight prevalence among children is becom-
ing a worrisome clinical problem [141]. As children
become more overweight and obese, the likelihood
increases that girls will remain overweight upon en-
tering adulthood. When they become pregnant, their
risk of developing glucose intolerance and gestational
diabetes increases markedly. Consequently, they then
produce heavier babies who are themselves prone to
become obese in early childhood [142].
In 92 Japanese obese children aged 615 years,
systolic blood pressure was associated with hyperin-
sulinemia, hyperleptinemia and visceral accumulation,
regardless of a family history of hypertension, not
only in childhood but also later in adult obesity
[143]. In obese children, a significantly lower arterial
compliance than the healthy controls has been
reported, a lower distensibility of the common carotid
artery and endothelium dependent and independent
function, which were negatively correlated to an an-
droid distribution of body fat [144]. In another recent
study, overweight children presented an impaired ar-
terial endothelial function and increased carotid intima
media thickness [145]. The degree of endothelial
dysfunction was correlated with BMI on multivariate
analysis.
5. Weight loss, caloric restriction and endothelium
Several reports indicate that weight loss and lifestyle
modifications can improve endothelial function.
Hamdy et al. showed that 6 months of weight reduction
and exercise improve macrovascular endothelial func-
tion and reduce selective markers of endothelial acti-
vation and coagulation in obese subjects with
metabolic syndrome regardless of the degree of glucose
tolerance [146]; these findings have been confirmed
also by the group of Sciacqua et al. [147]. A recent
study showed that weight reduction with very-low-
calorie diet improves flow-mediated vasodilation in
obese individuals and that the improvement is related
to the reduction in plasma glucose concentration [148].
A. Avogaro, S.V. de Kreutzenberg / Clinica Chimica Acta 360 (2005) 926 20
In children, an improvement of endothelial function
has been observed when both diet and exercise were
associated [149]. After a 2-week low calories (800
kcal/die), a significant improvement in flow-mediated
dilatation was observed in obese hypertensive patients
[150]. In 56 healthy premenopausal obese women with
a mean body mass index of 37.2 kg/m
2
after 1 year of a
multidisciplinary program of weight reduction able to
lead to a decrement of body weight of 10%, a reduc-
tion of cytokine and adhesin concentrations, with im-
provement of vascular responses to l-arginine was
observed [151,152].
6. Conclusions
The risk of developing coronary heart disease is
directly related to the concomitant burden of obesity-
related risk factors. Modest weight loss can improve
endothelial function and affect the entire cluster of
coronary heart disease risk factors simultaneously.
The statement from the American Heart Association
Council on Nutrition, Physical Activity and Metabo-
lism emphasizes the fact that weight loss and physical
activity can prevent and treat obesity-related coronary
heart disease risk factors and should be considered a
primary therapy for obese patients with cardiovascular
disease. Further, in obesity, multiple, interrelated
mechanisms contribute to endothelial cell dysfunc-
tion: since patients with obesity are at particular risk
for developing CHD, endothelial dysfunction must be
either prevented or corrected by modifying lifestyle
and, if this is not adequate, by correcting each single
risk factor without establishing hierarchic priority. A
pharmacological approach could also be indicated,
since specific classes of drugs, such as thiazolidine-
diones, ACE-inhibitors and statins [153155] can
ameliorate endothelial function by reducing oxidative
stress, enhancing nitric oxide bioavailability and re-
ducing inflammation.
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