http://informahealthcare.

com/arp
ISSN: 1381-3455 (print), 1744-4160 (electronic)

Arch Physiol Biochem, 2014; 120(1): 1–11

! 2014 Informa UK Ltd. DOI: 10.3109/13813455.2013.838971

REVIEW ARTICLE

A vascular piece in the puzzle of adipose tissue dysfunction:

mechanisms and consequences
Tiago Rodrigues, Paulo Matafome, and Raquel Seiça
Archives of Physiology and Biochemistry Downloaded from informahealthcare.com by Cornell University on 12/28/14

Laboratory of Physiology, Faculty of Medicine, Institute of Biomedical Imaging and Life Sciences (IBILI), University of Coimbra, Portugal

Abstract Keywords
In the last years, several studies unravelled many aspects of adipose tissue pathophysiology in Adipocytokines, adipose tissue, angiogenesis,
metabolic diseases. Some studies suggested hypoxia as one of such aspects, despite the exact glycation, metabolism, microcirculation,
mechanisms and pathophysiological significance is still partially unknown. Adipose tissue was microvasculature, vasoactive factors
shown to be hypoxic in obesity, mainly resulting from adipocyte hypertrophy, leading to
increased activation of inflammatory pathways. In animal and cell models, hypoxia-induced History
inflammation was shown to lead to endocrine alterations and dysmetabolism. However, recent
evidences suggest that instead of a simple low oxygenation theory, adipose tissue Received 5 July 2013
microvasculature may be regulated by a series of factors, including vasoactive factors like Revised 21 August 2013
angiotensin II, angiogenesis and glycation, among others. This review summarizes the current Accepted 23 August 2013
knowledge about the role of these factors in the regulation of adipose tissue irrigation and the Published online 24 September 2013
functional consequences of adipose tissue microvascular dysfunction.
For personal use only.

Introduction decreased lipid esterification. As well, free fatty acids

inhibit insulin signalling through nuclear factor-kappa B
Obesity has reached epidemic proportions worldwide and
(NF-B)-dependent mechanisms (Guilherme et al., 2008;
abdominal obesity is a major risk factor for metabolic
Qatanani & Lazar, 2007). Adipose tissue inflammation leads
syndrome, cardiovascular diseases and ultimately to type 2
to increased circulating free fatty acids, which can accumulate
diabetes (Goossens, 2008; World Health Organization, 2000).
ectopically in muscle and liver. This may cause functional and
Besides the large number of cell types present in adipose
structural lesions in these tissues and possibly conduct to
tissue, it also has a large and dynamic vascular network,
systemic insulin resistance and ultimately to type 2 diabetes
which is in continuous re-modelling and is crucial for tissue
(Boden, 2011; Galic et al., 2010; Guilherme et al., 2008;
support during its expansion or regression (Lijnen, 2008;
Kaneto et al., 2010; Ozcan et al., 2004). Another consequence
Rajala & Scherer, 2003; Rutkowski et al., 2009). As a
of hypertrophy is that adipocyte’s volume may become higher
consequence of nutritional fluxes (higher in visceral adipose
than the oxygen diffusion distance, leading to local hypoxic
tissue), adipocytes continually accumulate lipids (triglycer-
regions (Hosogai et al., 2007; Trayhurn et al., 2008a). It has
ides) in lipid droplets, which may lead to hypertrophy and
metabolic dysregulation. On the other hand, hyperplasia may
been suggested that hypoxia development in adipose tissue 14
20
activates inflammatory pathways, causing insulin-resistance
be observed, resulting from increased pre-adipocyte differen-
and impaired lipid storage (Figures 1 and 2) (Galic et al.,
tiation. Hyperplasia is typically associated with better meta-
2010; Golay & Ybarra, 2005; Guilherme et al., 2008;
bolic regulation as it allows a better vascularization (Golay &
Rutkowski et al., 2009; Tilg & Moschen, 2006). The
Ybarra, 2005; Weyer et al., 2000).
activation of inflammatory mechanisms completely changes
Hypertrophy results in the accumulation of secondary
adipose tissue secretome. This compromises the expression of
products of lipid metabolism, causing progressive low-grade
anti-inflammatory adipokines and favours the secretion of
inflammation, insulin resistance and lipolysis. The regulation
pro-inflammatory, chemo-attractant and growth factors.
of substrate uptake by inflammatory mechanisms is a
Besides changing adipocyte metabolism, these products
physiological response aiming to decrease adipocyte
influence tissue angiogenesis and leukocyte recruitment,
volume. Inflammation strongly inhibits peroxisome prolifer-
causing an inflammatory feedback in the tissue (Guilherme
ating-activated receptor g (PPARg) activity, resulting in
et al., 2008; Trayhurn et al., 2008b; Vázquez-Vela et al.,
2008) (Figures 1 and 2). However, the in vivo regulation of
Correspondence: Paulo Matafome, Faculty of Medicine, Pole III of such mechanisms may be more complex than that previously
University of Coimbra, Subunit 1, 1st floor, Azinhaga de Santa Comba,
Celas, 3000-354 Coimbra, Portugal. Tel: +351239480014. Fax: demonstrated. Recently, Goossens and colleagues developed a
+351239480034. E-mail: paulomatafome@gmail.com method to measure in vivo oxygenation in adipose tissue.
 2 T. Rodrigues et al. Arch Physiol Biochem, 2014; 120(1): 1–11
Archives of Physiology and Biochemistry Downloaded from informahealthcare.com by Cornell University on 12/28/14
For personal use only.

Figure 1. Events occurring in adipose tissue undergoing an inappropriate growth of the vascular network during tissue expansion. Adipocyte
hypertrophy and incorrect angiogenesis leads to hypoxia, activation of inflammatory pathways, adipocyte death and macrophage recruitment. Ang-2,
angiopoietin-2; CCR2, cytokines receptor; FFAs, free fatty acids; FFA-Sat, saturated free fatty acids; HIF-1, hypoxia inducible factor-1; ICAM,
intercellular adhesion molecule; IBa, NF-B inhibitor alpha; MCP-1, monocyte chemo-attractant protein-1; MMPs, matrix metalloproteinases;
NF-B, nuclear factor kappa b; PerA, Perilipin A; Tie-2, membrane receptor activated by angiopoietins; TLR4, toll-like receptor 4; TNF-a, Tumour
necrosis factor alpha; uPA, plasminogen activator urokinase-type; VEGF, vascular endothelial growth factor; VEGFR, VEGF receptor; VLDL,
very-low density lipoprotein.

They showed that decreased adipose tissue blood flow may
impair oxygen pressure in tissue. Nevertheless, the adipose
tissue of obese patients was hyperoxic, possibly resulting from
decreased metabolic activity (Goossens et al., 2011).
Recent evidence supports the idea that instead of a simple
low oxygenation theory, adipose tissue microvasculature may
be regulated by a series of other factors (Scalia, 2013).
Apparently, most of the mechanisms known to regulate
systemic arterial tone also act on adipose tissue arterioles.
These factors regulate blood flow in the tissue, although little
attention has been devoted to this matter (Bagi et al., 2012).
More, microvascular dysfunction has been considered sec-
ondary to adipose tissue dysfunction. Recent data suggest that
microvascular dysfunction may in fact precede many of the
Archives of Physiology and Biochemistry Downloaded from informahealthcare.com by Cornell University on 12/28/14
For personal use only.

Figure 2. Mechanisms of inflammatory activation in adipocytes as a consequence of lipid accumulation and hypoxia. Activation of inflammatory
pathways leads to insulin resistance, lipolysis, PPARg down-regulation and expression of growth and chemo-attractant factors. AP1, adaptor protein-1;
cAMP, cyclic adenosine monophosphate; FATP, fatty acid binding protein; FFAs, free fatty acids; FFA-Sat, saturated free fatty acids; HDL, high
density lipoprotein; HIF-1, hypoxia inducible factor-1; HSL, hormone-sensitive lipase; IBa, NF-B inhibitor alpha; IRS-1, insulin receptor
substract-1; JNK, C-jun n-terminal kinase; LPL, lipoprotein lipase; MCP-1, monocyte chemoattractant protein-1; MMPs, matrix metalloproteinases;
NF-B, nuclear factor kappa b; PerA, perilipin A; PKC, protein kinase C; PO2, oxygen pressure; PPARg, peroxisome proliferating-activated receptor g;
Ser, serine; TLR4, toll-like receptor 4; TNF-a, Tumour necrosis factor alpha; uPA, plasminogen activator urokinase-type; VEGF, vascular endothelial
growth factor; VEGFR, VEGF receptor; VLDL, very-low density lipoprotein.
 4 T. Rodrigues et al.
alterations observed in adipose tissue in obesity. The impair-
ment of the mechanisms regulating blood flow in adipose
tissue may influence its ability to expand correctly and thus
may be associated with its dysfunction. The following
sections summarize the current knowledge about adipose
tissue microvascular lesions observed in obesity and how this
can be implicated in altered tissue and systemic metabolism.
Regulation of adipose tissue microvasculature
During the embryonic development of adipose tissue, the
vascular network and perivascular extracellular matrix are
formed before the adipocytes. Angiogenesis and adipogenesis
are mutually regulated, being each adipocyte surrounded by at
least one blood vessel (Christiaens & Lijnen, 2010; Hausman
Archives of Physiology and Biochemistry Downloaded from informahealthcare.com by Cornell University on 12/28/14
& Richardson, 2004; Mannerås-Holm & Krook, 2012;
Rutkowski et al., 2009; Zhang & Zhang, 2009). Expansion
or retraction of the microvasculature is permanently required.
This plasticity is particularly important after adiposity
changes, in order to prevent the development of hypoxic
regions. In this context, adipocyte behaviour during tissue
growth depends on the type of vascular network alteration.
In case of adipocyte hyperplasia, neo-vascularization is
favoured, allowing adipocyte differentiation and regular
irrigation. However, if adipocytes are more hypertrophic,
existent capillaries suffer remodeling and dilation (Figures 1
and 2) (Christiaens & Lijnen, 2010; Mannerås-Holm &
Krook, 2012; Rutkowski et al., 2009). In such conditions,
For personal use only.
adipocyte diameter can reach 150–200 mm, although the
diffusion rate of oxygen is not higher than 100 mm (Gustafson,
2010; Trayhurn et al., 2008a; Wood et al., 2009).
Lean individuals show a post-prandial increase of adipose
tissue irrigation and adipose arterioles are responsive to
angiotensin II (AngII, vasoconstrictor) and isoprenaline
(vasodilator). However, such events are not observed in
obese and type 2 diabetic patients (Chen et al., 2006;
Goossens et al., 2011; Tobin et al., 2010; Trayhurn et al.,
2008a; Wang et al., 2007; Wood et al., 2009). In fact, obese
patients with regional hypoxia in adipose tissue do not show
altered systemic oxygen pressure or haemoglobin concentra-
tion and saturation, suggesting that hypoxia derives from
impaired adipose tissue irrigation (Goossens, 2008; Spencer
et al., 2011; Trayhurn et al., 2008a). Previous studies
demonstrated a 30–40% reduction of adipose tissue irrigation
in obese patients and animal models, in part due to the
regression of the vascular network (Goossens, 2008; Ye,
2009). One of the factors probably involved in decreased
tissue perfusion is the impairment of endothelium-dependent
relaxation in adipose tissue arterioles (Farb et al., 2012;
Georgescu et al., 2011). We recently showed that decreased
irrigation in adipose tissue may trigger important systemic
metabolic alterations. Using normal rats, we observed that a
partial reduction of blood supply in one single fat depot
causes hyperinsulinemia 48 hours after the surgery
(Rodrigues et al., in press).
Vasoactive factors – renin-angiotensin system
Despite the vascular system of the adipose tissue being
highly regulated by several angiogenic factors and extracel-
lular matrix regulators, blood pressure inside the tissue is
Arch Physiol Biochem, 2014; 120(1): 1–11
also a critic factor for its homeostasis. This is highly
regulated by the renin-angiotensin system, among other less-
studied vasoactive factors (Villela & Kramer-Aguiar, 2009).
Angiotensinogen is cleaved to Angiotensin I (AngI) by the
enzyme renin, which is released from the kidney in
consequence of low perfusion pressure. AngI is subsequently
cleaved to Angiotensin II (AngII) mainly by angiotensin
converting enzyme (ACE), but also by chymase and
cathepsin G (Negro, 2008; Weir, 2007). AngII receptors-1
(AT1) are the most expressed and are responsible for many
of the pathological effects commonly associated to AngII
action, such as vasoconstriction, aldosterone production in
the adrenal glands and salt and water retention in renal
tubules. On the other hand, angiotensin receptors-2 (AT2)
seem to antagonize AT1 function (Steckelings et al., 2009,
2010; Weir, 2007).
Angiotensinogen is mainly produced in the liver. However,
its expression was also noticed in other tissues, namely
adipose tissue. Although adipocytes produce low levels of
angiotensinogen, adipose tissue may become the second
higher source of angiotensinogen in obese individuals, due to
the expansion of the fat mass. Angiotensinogen circulating
levels are correlated with the body mass index (BMI) and
further increase in obese individuals after a sympathetic
stimulation (Kalupahana & Moustaid-Moussa, 2012a). In
addition, angiotensinogen production in liver was observed to
remain unchanged in models of obesity, suggesting a role of
adipose tissue in higher angiotensinogen production in
obesity (see a comprehensive review at Kalupahana &
Moustaid-Moussa, 2012a). An animal model with angioten-
sinogen expression only in adipocytes showed detectable
circulating levels, demonstrating that angiotensinogen pro-
duced in adipose tissue have the ability to circulate and
change the arterial function (Kalupahana & Moustaid-
Moussa, 2012b). The fact that angiotensinogen is highly
produced in adipose tissue suggests that renin-angiotensin
system (RAS) may strongly influence adipose tissue circula-
tion and physiology. This may have direct effects on
endothelial cells and influence blood pressure in tissue
capillaries, what may inhibit the mechanical stimulus to
angiogenesis.
AT1 and AT2 receptors, ACE and renin receptor were all
shown to be present in the adipose tissue and AngII is known
to have direct effects on adipocytes regulating adipogenesis
and lipolysis/lipogenesis (Kalupahana & Moustaid-Moussa,
2012b; Steckelings et al., 2009; Weir, 2007). Activation
of adipose RAS system leads to increased adiposity.
AngII was shown to increase lipogenesis but to decrease
adipogenesis through the down-regulation of PPARg, what
may cause adipocyte hypertrophy. RAS blockade with ACE
inhibitors leads to decreased adipocyte size and increased
adipocyte number in models of obesity (Kalupahana &
Moustaid-Moussa, 2012a). The involvement of each of the
AngII receptors in these actions is still not completely
understood. Apparently, both AngII receptors are involved.
AT1 was shown to inhibit lipolysis and its specific inhibition
increased adipocyte differentiation and decreased cell size
(Iwai et al., 2007; Tomono et al., 2008). As well, AT2
receptors increase lipogenesis and inhibit adipogenesis and
thus mediate AngII-induced adipocyte hypertrophy
 DOI: 10.3109/13813455.2013.838971
(Iwai et al., 2009; Kalupahana & Moustaid-Moussa, 2012a;
Tsuchiya et al., 2006).
The mechanisms of AngII action in adipose tissue may
also include the regulation of the inflammatory cascade.
RAS system is known to strongly influence the inflammatory
mechanisms observed in the atherosclerotic plaques.
Despite that its influence in adipose tissue vasculature is
unknown, AngII was shown to increase monocyte chemo-
attractant protein 1 (MCP-1) expression in adipocytes and
pre-adipocytes a NF-B- dependent manner (Kalupahana &
Moustaid-Moussa, 2012a; Tsuchiya et al., 2006). MCP-1
stimulates angiogenesis through direct induction of endothe-
lial cell proliferation and increased macrophage recruitment
(Niu et al., 2008; Suganami & Ogawa, 2010). Together
Archives of Physiology and Biochemistry Downloaded from informahealthcare.com by Cornell University on 12/28/14
with the fact that AngII is known to stimulate matrix
metalloproteinases (MMPs) in other tissues, these mechan-
isms may contribute to the regulation of adipose tissue
microvasculature.
Angiogenesis
Although angiogenesis was initially faced as a mechanism
that should be inhibited in order to achieve decreased adipose
tissue expansion, recent studies suggested that it is essential
for tissue homeostasis and to prevent insulin resistance in
already expanded adipose tissue (Gealekman et al., 2012;
Lemoine et al., 2012; Lijnen, 2008; Mannerås-Holm &
For personal use only.
Krook, 2012). In fact, most of the known pro- and anti-
angiogenic factors are produced by many of the cells present
in adipose tissue. Inflammation is highly responsible for
angiogenesis as well, leading to remodelling of the extracel-
lular matrix and endothelial cell proliferation. The study of
adipose tissue’s leukocytes demonstrated their pro-angiogenic
actions due to the broad range of cytokines and growth factors
produced by these cells. Even in lean models, vascularization
of adipose tissue was reduced after macrophage removal
(Ye, 2009). Angiogenic factors may increase vascular stability
and integrity or induce loss of stability and increase
cellular migration and proliferation when vascular growth is
required (Christiaens & Lijnen, 2010; Lijnen, 2008; Zhang &
Zhang, 2009).
The main stimulus to vascular growth is hypoxia, mainly due
to the stabilization of the hypoxia inducible factor-1 (HIF-1)
(Hosogai et al., 2007; Regazzetti et al., 2009; Rutkowski et al.,
2009). In the presence of oxygen, HIF-1a factor is hydroxylated
in proline residues and consequently ubiquitinated and
degraded in the proteasome. On the other hand, during hypoxia
proline-hydroxylases are inhibited, leading to stabilization of
HIF-1a and activation of gene expression (Semenza, 2004;
Wood et al., 2009). Among these genes are the vascular
endothelial growth factor (VEGF), angiopoietins (Ang-1 and
Ang-2), MMPs, leptin and plasminogen activators (Cao, 2007;
Christiaens & Lijnen, 2010; Goossens et al., 2011; Hosogai
et al., 2007; Yamakawa et al., 2003; Ye, 2009).
VEGF is crucial for endothelial cell proliferation, migra-
tion and survival, ultimately leading to angiogenesis
(Christiaens & Lijnen, 2010; Hausman & Richardson, 2004;
Lijnen, 2008; Tam et al., 2009). Most of VEGF actions in
adipose tissue are mediated by VEGF-A, although other
VEGF forms are also involved in the angiogenic process
A vascular piece in the puzzle of adipose tissue dysfunction 5
(Christiaens & Lijnen, 2010). VEGF is produced mainly by
stromal cells and mature adipocytes since the first embryonic
stages of adipose tissue, acting in the adjacent capillaries
(Christiaens & Lijnen, 2010; Neels et al., 2004). During
adipose tissue expansion, VEGF was also shown to be
produced by the inflammatory cells recruited to the tissue.
The blockade of its receptor (VEGFR2) was shown to inhibit
angiogenesis and pre-adipocyte differentiation, showing that
angiogenesis and adipogenesis are mutually regulated (Cao,
2007; Hausman & Richardson, 2004; Tam et al., 2009).
However, VEGF involvement in adipose tissue dysfunction is
still controversial. Transgenic mice with VEGF over-
expression brown and white adipose tissue were recently
shown to be protected from high-fat diet-induced hypoxia and
inflammation in adipose tissue (Elias et al., 2012). However,
animal models of obesity and obese patients were shown to
have higher VEGF circulating levels, which are decreased
after weight loss (Gómez-Ambrosi et al., 2010).
Contradictory reports may also be influenced by the different
characteristics of genetic models compared with diet-induced
and the stage of adipose tissue dysfunction. According to
recent data, VEGF over-expression may be useful during
adipose tissue expansion, allowing sustained angiogenesis. On
the other hand, VEGF inhibition may be useful in the context
of pre-existing adipose tissue dysfunction, inhibiting inflam-
mation and improving metabolism and insulin signalling (Sun
et al., 2012). Although insulin and AMP-activated protein
kinase (AMPK) may induce VEGF expression, its main
regulator is HIF-1a (Treins et al., 2002; Vona-Davis & Rose,
2009; Ye, 2009). Recent reports from our colleagues show
that HIF-1a stabilization in hypoxic conditions can be
compromised by hyperglycaemia, which may contribute to
different observations regarding VEGF expression in models
of obesity and type 2 diabetes (Bento et al., 2010a, 2010b).
Ang-1 and Ang-2 have opposite effects on vessel stabil-
ization. Ang-1 increases vessel stability and interaction
between endothelial cells and pericytes and extracellular
matrix. Ang-1 also leads to the expression of transforming
growth factor b (TGFb) and structural proteins, such as
integrins, fibrin and vitronectin (Hausman & Richardson,
2004; Hemmeryckx et al., 2010; Lijnen, 2008). On the other
hand, Ang-2 expression is stimulated in hypoxic conditions
and its receptors commonly co-localize with VEGF receptors
(Figure 1) (Bento et al., 2010a; Hausman & Richardson,
2004). Ang-2 is essential for vessel growth as it turns cell
interactions weaker, allowing VEGF-induced proliferation
and migration. However, VEGF inhibition after Ang-2-
induced cell destabilization leads to vessel dysfunction
(Bento et al., 2010a; Hausman & Richardson, 2004). Our
group showed that VEGF/Ang-2 ratio is highly regulated.
Decreased hypoxia-induced HIF-1a stabilization in hypergly-
caemia may imbalance this ratio, leading to the formation of
aberrant capillaries (Figure 1). More, these effects are thought
to be mediated by glucose-derived methylglyoxal (MG)
(Bento et al., 2010a).
Transforming growth factor (TGF) b was shown to be
essential for adipose tissue development, as its inhibition
results in uncompleted vessel formation. TGFb is produced by
adipocytes and stromal cells in hypoxic conditions, regulating
the deposition of extracellular matrix and leading to vessel
 6 T. Rodrigues et al.
stabilization. However, in conditions of prolonged hypoxia,
TGFb is conducive to fibrosis, as observed in the adipose
tissue of obese individuals (Figure 1) (Christiaens & Lijnen,
2010; Hausman & Richardson, 2004; Ye, 2009).
Angiogenesis may also be regulated by adipocytokines.
Leptin was long shown to have receptors in endothelial cells
and a strong angiogenic role (Cao, 2007; Christiaens &
Lijnen, 2010; Hausman & Richardson, 2004; Lijnen, 2008).
Leptin was shown to promote in vitro proliferation, migration
and survival and to inhibit the apoptosis of endothelial cells.
In addition, leptin was shown to increase VEGF and MMP
production, further increasing vessel growth (Cao, 2007;
Christiaens & Lijnen, 2010; Hausman & Richardson, 2004;
Lijnen, 2008; Ye, 2009). On the other hand, adiponectin was
Archives of Physiology and Biochemistry Downloaded from informahealthcare.com by Cornell University on 12/28/14
suggested to balance the pro-angiogenic effects of leptin.
Adiponectin was shown to have anti-angiogenic and pro-
apoptotic actions on endothelial cells (Vona-Davis & Rose,
2009). Unlike adiponectin, leptin is produced proportionally
to fat mass and its angiogenic effects may be a physiological
mechanism to compensate for adipose tissue expansion.
Glycation
Non-enzymatic glycosylation, also named glycation, was
described for the first time by Louis-Camille Maillard. This
reaction occurs in the presence of reducing sugars (glucose,
fructose and others) which are able to react with amine groups
For personal use only.
of several biologic molecules, such as proteins, lipids and
nucleic acids (Brownlee, 2005; Goldin et al., 2006; Negre-
Salvayre et al., 2009). Glycation changes physical and
chemical properties of the molecules, as well as their
biological functions, in a process which occurs through
several complex reactions and molecular rearrangements that
originate Schiff bases, Amadori products and finally
advanced glycation end-products (AGE) (Goldin et al.,
2006; Negre-Salvayre et al., 2009). Alternatively, AGE may
form from intermediary products of glucose metabolism such
as gliceraldehyde-3-phosphate, dihydroxyacetone-phosphate
and MG (see reviews at Negre-Salvayre et al., 2009; Desai
et al., 2010; Matafome et al., 2013).
AGE contribute to macro and microvascular diabetic
complications, mainly by two pathways. First, by formation
of permanent cross-links with proteins of the extracellular
matrix and plasma, which changes their structure and function
and, second, by interaction with AGE receptor (RAGE) in the
cell surface, leading to intracellular propagation of inflam-
matory signals. Such signals include the activation of
the TGF-b, leading to the synthesis of structural proteins
and fibrosis (Brownlee, 2005; Goldin et al., 2006; Matafome
et al., 2012; Matafome et al., 2013; Negre-Salvayre et al.,
2009).
The involvement of AGE in adipose tissue dysfunction is
an almost unstudied subject. Until now, most of the studies
focused on insulin resistance, showing that fructose supple-
mentation or direct MG administration lead to insulin
resistance in adipose tissue. Additionally, MG administration
to 3T3-L1 adipocytes resulted in decreased activation of the
insulin pathway (Dhar et al., 2011; Jia and Wu, 2007;
Riboulet-Chavey, 2006). However, the physiological signifi-
cance of these studies is questionable, as authors used MG
Arch Physiol Biochem, 2014; 120(1): 1–11
concentrations above the physiological range. Regarding this
matter, we developed a rat model with oral MG administra-
tion that had tissue and plasma MG concentrations similar to
type 2 diabetic Goto-Kakizaki rats. This model showed
several structural and functional alterations in adipose tissue,
but not insulin resistance (Matafome et al., 2012).
MG-induced AGE accumulation is long known to cause
vascular dysfunction in several models (Berner et al., 2012;
Cantero et al., 2007; Kim et al., 2012; Sena et al., 2012).
However, until the last years, adipose tissue microvascular
dysfunction was seen as a consequence of hyperglycaemia, as
observed for common diabetic complications, such as retin-
opathy or nephropathy. However, two major ideas should be
retained. First, adipose tissue dysfunction is not a simple
consequence of hyperglycaemia. Given its important meta-
bolic and endocrine actions, adipose tissue dysfunction due to
microvascular lesions may decisively influence metabolic
control and thus the progression of type 2 diabetes. Second,
glycation may occur from the early stages of type 2 diabetes
development, even before open hyperglycaemia is observed.
This suggests that AGE accumulation may lead to a time-
dependent dysfunction of adipose tissue microvasculature,
leading to an accelerated adipose tissue dysfunction and
systemic dysmetabolism. In our model of MG-induced AGE
accumulation, we observed increased fibrosis and impaired
apoptotic markers and VEGF/Ang2 ratio after a chronic
administration. This was associated with decreased irrigation
and more hypoxic regions. In addition, macrophage recruit-
ment to the tissue was increased (Matafome et al., 2012).
More recently, we showed that these effects were time-
dependent and were reverted by the dicarbonyl scavenger
drug pyridoxamine (Rodrigues et al., 2013). Altogether,
these results suggest that progressive AGE accumulation in
adipose tissue leads to microvascular dysfunction, what may
hamper a correct expansion of the tissue (Rutkowski et al.,
2009). During the process of expansion, the formation of
hypoxic regions is the trigger to induce angiogenesis. If
angiogenesis does not occur in order to compensate for
hypoxia, the tissue may become dysfunctional. Using a short
period of MG administration in order to avoid its long-
term effects, we recently showed that MG decreases the
ability of adipose tissue to adapt to a surgery-induced
reduction of blood supply (Rodrigues et al., in press). In
rats with MG-induced glycation, a partial decrease of blood
supply caused a higher activation of inflammatory pathways
and Perilipin A degradation, as well as decreased PPARg
tissue levels and adiponectinemia, suggesting adipocyte
dysfunction (Rodrigues et al., in press). Our results suggest
that glycation not only impairs adipose tissue microvascu-
lature, but also compromises its ability to adapt to such
conditions, leading to metabolic alterations commonly
observed in type 2 diabetes. However, the physiological
relevance of such mechanisms in the context of type 2
diabetes development has still to be proved.
Consequences of hypoxia
Genetic and diet-induced obese animal models commonly
have decreased endothelial cell markers, lower partial oxygen
pressure, higher accumulation of a hypoxia probe
 DOI: 10.3109/13813455.2013.838971
(pimonidazole) and lactate production (endogenous marker of
hypoxia). When hypoxia in adipose tissue becomes perman-
ent, stress-response pathways are activated, leading to
inflammation, decreased glucose and lipid uptake and
changes of the secretome (Hosogai et al., 2007; Pang et al.,
2008; Spencer et al., 2011; Trayhurn et al., 2008a; Wood
et al., 2009; Ye et al., 2007).
Activation of cellular inflammation and stress
pathways
Following hypertrophy, excessive intracellular accumulation
of free fatty acids and their metabolites such as diacylclycerol
and ceramides, as well as the activation of toll-like receptors
Archives of Physiology and Biochemistry Downloaded from informahealthcare.com by Cornell University on 12/28/14
(TLR) by circulating free fatty acids, are known to activate
stress and inflammatory pathways. Such pathways include
several protein kinase C (PKC) isoforms, c-jun N-terminal
kinase/stress-activated protein kinase (JNK/SAPK) and kinase
of the inhibitor of NF-B (IKK)b, all ending in the
degradation of the NF-B inhibitor (IBa) in the proteasome
and consequent NF-B activation (Figure 2) (Boden, 2011;
Brownlee, 2005; Guilherme et al., 2008; Moeschel et al.,
2004; Qatanani & Lazar, 2007; Ueki & Kondo, 2004; Wellen
& Hotamisligil, 2005). Hypoxia was also shown to directly
activate similar mechanisms (Figure 2). NF-B activation in
response to hypoxia is well documented, namely in tumors.
HIF-1a was suggested to mediate the inflammatory activity,
For personal use only.
as nitric oxide sintetase (iNOS)-mediated nitric oxide (NO)
production was observed to be decreased in cells lacking
HIF-1a (Zarember & Malech, 2005). In addition, NF-kB was
also shown to regulate HIF-1 activity. IKKa and IKKb
presence was shown to be necessary for HIF-1a stabilization
even in hypoxia. Interestingly, NF-B activation in response
to cytokines also increases HIF-1a expression (Uden et al.,
2008; Ye, 2009). These data show that HIF-1 and NF-B
strongly co-operate to activate cellular mechanisms of
response to hypoxia.
The formation of hypoxic regions in adipose tissue causes
HIF-1-mediated expression of angiogenic factors and the
glucose transporter-1 (GLUT-1) (He et al., 2011; Rausch
et al., 2008; Wang et al., 2007; Ye et al., 2007). The
expression of such genes in hypoxic adipocytes was shown to
depend on decreased PPARg activity. PPARg inhibition
resulted in increased HIF-1-dependent expression of inflam-
matory genes (Pino et al., 2012). Such genes include pro-
inflammatory cytokines and chemokines such as MCP-1,
interleukins and tumour necrosis factor-a (TNF-a), as well as
adhesion molecules as intercellular adhesion molecule-1
(ICAM-1), possibly resulting from higher HIF-1a interaction
with NF-B (Figure 1) (Donath & Shoelson, 2011; Pino et al.,
2012; Uden et al., 2008). HIF-1 inhibition in vivo results in
decreased blood vessel density, insulin resistance and adipos-
ity in high-fat fed mice (Jiang et al., 2011; Park et al., 2012).
Apparently, the regulation of HIF-1 interaction with NF-B
alternatively to PPARg influences the genes that are
expressed in hypoxia. This may be of particular relevance
in chronic hypoxia where the permanent activation of such
mechanisms may lead to severe implications on adipose
tissue metabolic and endocrine function, which may
have systemic repercussions (Donath & Shoelson, 2011;
A vascular piece in the puzzle of adipose tissue dysfunction 7
Krishnan et al., 2012; Rutkowski et al., 2009; Tilg &
Moschen, 2006; Trayhurn et al., 2008b).
There is still no consensus about the role of adipose cell
types in tissue’s response to hypoxia, as it is not possible yet
to completely isolate the different cell fractions in vivo and
the use of cell lines does not entirely mimic in vivo
conditions. However, higher NF-B and HIF-1 activity in
hypoxic 3T3 adipocytes was observed to lead to increased
expression of interleukine-6 (IL-6), MCP-1, MMPs, TGFb
and leptin (Halberg et al., 2009; Trayhurn et al., 2008b; Wood
et al., 2009; Ye, 2009). As well, pre-adipocytes cultured in
hypoxia show increased MCP-1, TNFa, GLUT1 and VEGF
expression and acquire the ability to secrete leptin.
Interestingly, the differentiation of hypoxic pre-adipocytes
to adipocytes was observed to decrease, favouring their
transformation to macrophages (Goossens, 2008; Goossens
et al., 2011; Olefsky & Glass, 2010; Tilg & Moschen, 2006).
Using conditioned medium from hypoxic adipocytes and pre-
adipocytes, Mack and colleagues showed that pre-adipocytes
exert a stronger influence on the expression of adhesion
molecules and activation of proliferation pathways in endo-
thelial cells (Mack et al., 2009).
Regarding the molecular mechanisms activated in hypoxia,
it is important to mention that many of the previous studies
exploring inflammatory mechanisms used cultured hypoxic
adipocytes (1% oxygen) and control adipocytes under ambient
air (21% oxygen), which is not observed in vivo. Recently,
Famulla and colleagues suggested that adipocytes cultured
under 21% oxygen may become hyperoxic, as the physio-
logical oxygen concentration was shown to be 3–11%
(Famulla et al., 2012; Goossens et al., 2011). Authors
reported that 21% oxygen may impair adipocyte metabolism,
differentiation and secretory function, in relation to adipo-
cytes cultured below 10% oxygen (Famulla et al., 2012). This
raises new important questions for future studies.
Inhibition of substrate uptake
The impact of the vascular dysfunction in adipocyte glucose
uptake is observable from the fact that the ability of insulin to
suppress lipolysis is correlated with the vessel density in the
adipose tissue of obese patients (Pasarica et al., 2010). More,
Jun and colleagues recently showed that mice submitted to
acute hypoxia showed decreased adipocyte ability to uptake
triglycerides, in part due to decreased lipoprotein lipase
activity, causing hypertriglyceridemia (Jun & Shin, 2012).
In cultured adipocytes, hypoxia was shown to directly inhibit
insulin signalling, decreasing glucose uptake. More, this was
dependent on HIF-1 activation, despite the precise mechan-
isms not being described (Bugianesi et al., 2005; Chen et al.,
2006; Gentil et al., 2006; Regazzetti et al., 2009; Wood et al.,
2009; Ye, 2009). However, HIF-1 over-expression in the
adipose tissue of mice fed a high-fat diet prevented the
development of insulin resistance (Zhang et al., 2011). These
results suggest that acute HIF-1 activation inhibits insulin
signalling but it is crucial for angiogenesis during adipose
tissue expansion, allowing the correct development of the
microvascular network.
The down-regulation of insulin signalling is a direct
consequence of the activation of PKC, JNK and IKKb, as
 8 T. Rodrigues et al.
these proteins are serine kinases that phosphorylate insulin
receptor and its substrate (IRS-1), inhibiting downstream
signalling (Figure 2) (reviewed by Wellen & Hotamisligil,
2005; Guilherme et al., 2008). In particular, JNK is activated
by lipid-induced PKC activation, free fatty acids-induced
TLR activation and inflammatory cytokines such as TNF-a,
leading to IKKb and suppressor of cytokine signalling
(SOCS) activation (Figure 2). SOCS was shown to signalize
IRS-1 to proteasomal degradation, reinforcing the inhibition
of insulin signalling (Ueki and Kondo, 2004). However,
recent data is insufficient to understand if these pathways are
directly activated in hypoxia or if they are secondarily
activated by cytokines and free fatty acids released in
consequence of hypoxia. The mechanisms of HIF-1-mediated
Archives of Physiology and Biochemistry Downloaded from informahealthcare.com by Cornell University on 12/28/14
down-regulation of insulin signalling in adipocytes should
retain future attention.
A major function of insulin in adipocytes is to inhibit
lipolysis and consequent fatty acid release to the circulation.
Lipolysis is highly activated by the increase of intracellular
levels of cyclic adenosine monophosphate (cAMP), as in
fasting, leading to the activation of hormone-sensitive lipase
(HSL). On the other hand, insulin is a direct repressor of
AMPc production by adenylate cyclase (Guilherme et al.,
2008; Juge-Aubry et al., 2005; Ye, 2008). Cytokines like
TNF-a activate adenylate cyclase and thus increase lipolysis.
More, these mechanisms include Perilipin A degradation,
allowing the binding of HSL to triglycerides stored in lipid
For personal use only.
droplets (Figure 2) (Guilherme et al., 2008; Juge-Aubry et al.,
2005). Thus, hypoxia-induced insulin resistance and TNF-a
production lead to increased lipolysis and increased circulat-
ing free fatty acids (FFA).
Along with lipolysis, decreased fatty acid storage is also
caused by decreased PPARg activity. In cultured adipocytes,
hypoxia was observed to reduce PPARg activity and
adiponectin secretion (Regazzetti et al., 2009; Wood et al.,
2009; Ye, 2009). Decreased PPARg activity in hypoxic
adipocytes leads to decreased expression of enzymes involved
in fatty acids uptake and esterification, decreasing adipocyte
ability to store lipids (Figure 2) (Guilherme et al., 2008; Juge-
Aubry et al., 2005; Wellen & Hotamisligil, 2003). Besides its
relevant metabolic activities, PPARg apparently has pro-
angiogenic properties when activated in endothelial cells.
PPARg agonists troglitazone and rosiglitazone were shown to
induce in vitro endothelial cell proliferation (Kakiuchi-Kiyota
et al., 2009; Kakiuchi-Kiyota & Arnold, 2011). Similar
results were observed with rosiglitazone in cultured adipose
tissue explants from obese patients (Gealekman et al., 2012).
Alterations of the secretome
Hypoxia-induced inflammation causes important alterations of
the secretory profile of adipose tissue. Besides stimulating
angiogenesis, these changes strongly contribute to the propa-
gation of the inflammatory feedback and to continually inhibit
substrate uptake. Importantly, these mechanisms may be
essential for tissue homeostasis during its expansion.
However, their chronic activation in obesity causes permanent
low-grade inflammation, insulin resistance, lipolysis and
macrophage recruitment (Kimura et al., 2011; Olefsky &
Glass, 2010; Qatanani & Lazar, 2007; Tilg & Moschen, 2006).
Arch Physiol Biochem, 2014; 120(1): 1–11
Most of the products secreted by the adipose tissue
regulate simultaneously metabolic and inflammatory adapta-
tions of adipose tissue to hypoxia. Adiponectin has anti-
inflammatory insulin sensitizer effects and its expression was
observed to be decreased in the hypoxic adipose tissue of
obese mice and in hypoxic cultured human adipocytes, in part
through PPARg down-regulation (Hosogai et al., 2007; Wang
et al., 2007). On the other hand, the expression of other
factors like leptin, resistin, visfatin, MCP-1, migration
inhibitory factor (MIF), TNF-a and VEGF is increased,
contributing to inflammation, angiogenesis and insulin
resistance (Figure 2) (Golay & Ybarra, 2005; Gustafson,
2010; Hosogai et al., 2007; Juge-Aubry et al., 2005; Maury &
Brichard, 2010; Rajala & Scherer, 2003; Segawa et al., 2006;
Tilg & Moschen, 2006; Wang et al., 2007). As well, some
adipocytokines have the ability to influence blood flow.
While adiponectin is known to stimulate vasodilation through
the activation of AMP-activated protein kinase (AMPK) and
the opening of voltage-gated potassium channels, leptin and
resistin lead to vasoconstriction (Zhang & Zhang, 2009).
However, these results were obtained in non-adipose arteri-
oles and may not be directly transposed to adipose tissue
perfusion.
MCP-1 is a potent chemo-attractant factor, which induces
monocyte recruitment to adipose tissue, as observed in several
animal models of obesity and vascular dysfunction in adipose
tissue (Maury & Brichard, 2010; Matafome et al., 2012;
Olefsky & Glass, 2010; Rausch et al., 2008; Wang et al.,
2007; Ye et al., 2007). The MCP-1 secreted by adipocytes and
infiltrating macrophages leads to a progressive monocyte
chemo-attraction, perpetuating the inflammatory loop
(Guilherme et al., 2008; Olefsky & Glass, 2010; Ye, 2009).
Furthermore, these signals also promote pre-adipocyte differ-
entiation into macrophages (Goossens, 2008; Olefsky &
Glass, 2010; Tilg & Moschen, 2006). In addition, macrophage
exit from adipose tissue is strongly inhibited by MIF
(Ye, 2009). Macrophage accumulation in adipose tissue and
alteration of their sub-populations (M1 and M2) completely
change tissue’s secretome. Interestingly, M1 polarity was
shown to be increased in hypoxia, at least in part through HIF-
1-dependent mechanisms (Fujisaka et al., 2013). Besides
having the ability to remove death adipocytes and to secrete
inflammatory factors (also mediate the angiogenic stimulus in
endothelial cells), macrophages are usually located in hypoxic
regions and secrete a broad range of angiogenic and matrix
remodelling factors (VEGF, MMPs, resistin, among others),
favouring angiogenesis (Olefsky & Glass, 2010; Ye, 2009).
Conclusions
Despite the exact mechanisms being partially unknown,
hypoxia has been shown to activate inflammatory pathways
in adipose tissue, leading to insulin resistance, lipolysis,
PPARg inhibition and macrophage recruitment. This com-
pletely changes adipose tissue secretome, which may con-
tribute to accelerated systemic dysmetabolism and thus to
type 2 diabetes.
In the recent years, many studies have been conducted in
order to determine the causes of adipose tissue hypoxia. From
excessive adipocyte volume to impaired angiogenesis and
 DOI: 10.3109/13813455.2013.838971
blood flow, many hypotheses have been proposed. Even if the
involvement of such mechanisms in adipose tissue vascular
dysfunction has been observed in several animal and human
models, the physiological relevance of each one of them is
still poorly understood. The real importance of the RAS
system in the dysfunction of adipose tissue microvasculature
is still unknown. The role of glycation in angiogenesis
disturbance and its pathophysiological significance should
continue to be focused on in the future. Furthermore, other
unstudied mechanisms may interplay in the regulation of
adipose tissue irrigation. Such mechanisms may include, for
example, gastrointestinal hormones, catecholamines, gluco-
corticoids or growth hormone, among others.
Archives of Physiology and Biochemistry Downloaded from informahealthcare.com by Cornell University on 12/28/14
Declaration of interest
The authors report no conflicts of interest. The authors alone
are responsible for the content and writing of this article.
References
Bagi Z, Feher A, Cassuto J. (2012). Microvascular responsiveness in
obesity: Implications for therapeutic intervention. Brit J Pharm, 165:
544–60.
Bento C, Fernandes R, Matafome P, et al. (2010a). Methylglyoxal-
induced imbalance in the ratio of vascular endothelial growth factor to
angiopoietin 2 secreted by retinal pigment epithelial cells leads to
endothelial dysfunction. Exp Phys, 95:955–70.
For personal use only.
Bento C, Fernandes R, Ramalho J, et al. (2010b). The chaperone-
dependent ubiquitin ligase CHIP targets HIF-1a for degradation in the
presence of methylglyoxal. PloS One, 5:e15062.
Berner A, Brouwers O, Pringle R, et al. (2012). Protection against
methylglyoxal-derived AGEs by regulation of glyoxalase 1 prevents
retinal neuroglial and vasodegenerative pathology. Diabetologia, 55:
845–54.
Boden G. (2011). Obesity, insulin resistance and free fatty acids. Curr
Opin Endocrinol Diabetes Obes, 18:1–11.
Brownlee, M. (2005). The pathobiology of diabetic complications:
A unifying mechanism. Diabetes, 54:1615–25.
Bugianesi E, McCullough A, Marchesini G. (2005). Insulin resistance: A
metabolic pathway to chronic liver disease. Hepatology, 42:987–1000.
Cantero A, Portero-Otı́n M, Ayala V, et al. (2007). Methylglyoxal
induces advanced glycation end product (AGEs) formation and
dysfunction of PDGF receptor-beta: Implications for diabetic athero-
sclerosis. FASEB J (Official publication of the Federation of American
Societies for Experimental Biology), 21:3096–106.
Cao Y. (2007). Angiogenesis modulates adipogenesis and obesity. J Clin
Invest, 117:2362–8.
Chen B, Lam L, Wang Y, et al. (2006). Hypoxia dysregulates the
production of adiponectin and plasminogen activator inhibitor-1
independent of reactive oxygen species in adipocytes. Biochem
Biophys Research Comm, 341:549–56.
Christiaens V, Lijnen R. (2010). Angiogenesis and development of
adipose tissue. Molec Cell Endocrin, 318:2–9.
Desai M, Chang T, Wang H, et al. (2010). Oxidative stress and aging: Is
methylglyoxal the hidden enemy? Canadian J Phys Pharm, 88:
273–84.
Dhar A, Dhar I, Jiang B, et al. (2011). Chronic methylglyoxal infusion by
minipump causes pancreatic beta-cell dysfunction and induces type 2
diabetes in Sprague-Dawley rats. Diabetes, 60:899–908.
Donath Y, Shoelson E. (2011). Type 2 diabetes as an inflammatory
disease. Nature Rev Immunol, 11:98–107.
Elias I, Franckhauser S, Ferré T, et al. (2012). Adipose tissue
overexpression of vascular endothelial growth factor protects against
diet-induced obesity and insulin resistance. Diabetes, 61:1801–13.
Famulla S, Schlich R, Sell H, Eckel J. (2012). Differentiation of human
adipocytes at physiological oxygen levels results in increased
adiponectin secretion and isoproterenol-stimulated lipolysis.
Adipocyte, 1:132–41.
A vascular piece in the puzzle of adipose tissue dysfunction 9
Farb M, Ganley-Leal L, Mott M, et al. (2012). Arteriolar function in
visceral adipose tissue is impaired in human obesity. Arteriosclerosis,
Thromb, Vasc Biol, 32:467–73.
Fujisaka S, Usui I, Ikutani M, et al. (2013). Adipose tissue hypoxia
induces inflammatory M1 polarity of macrophages in an HIF-1a-
dependent and HIF-1a-independent manner in obese mice.
Diabetologia, 56:1403–12.
Galic S, Oakhill S, Steinberg R. (2010). Adipose tissue as an endocrine
organ. Molec Cell Endocrin, 316:129–39.
Gealekman O, Guseva N, Gurav K, et al. (2012). Effect of rosiglitazone
on capillary density and angiogenesis in adipose tissue of normogly-
caemic humans in a randomised controlled trial. Diabetologia, 55:
2794–9.
Gentil C, Le Jan S, Philippe J, et al. (2006). Is oxygen a key factor in the
lipodystrophy phenotype? Lipids Health Disease, 5:1–11.
Georgescu A, Popov D, Constantin A, et al. (2011). Dysfunction of
human subcutaneous fat arterioles in obesity alone or obesity
associated with Type 2 diabetes. Clin Sci, 120:463–72.
Golay A, Ybarra J. (2005). Link between obesity and type 2 diabetes.
Best practice and research. Clin Endocrin Metab, 19:649–63.
Goldin A, Beckman J, Schmidt M, Creager M. (2006). Advanced
glycation end products: Sparking the development of diabetic vascular
injury. Circulation, 114:597–605.
Gómez-Ambrosi J, Catalán V, Rodrı́guez A, et al. (2010). Involvement of
serum vascular endothelial growth factor family members in the
development of obesity in mice and humans. J Nutri Biochem, 21:
774–80.
Goossens H. (2008). The role of adipose tissue dysfunction in the
pathogenesis of obesity-related insulin resistance. Physiol Behav, 94:
206–18.
Goossens H, Bizzarri A, Venteclef N, et al. (2011). Increased adipose
tissue oxygen tension in obese compared with lean men is
accompanied by insulin resistance, impaired adipose tissue capillar-
ization, and inflammation. Circulation, 124:67–76.
Guilherme A, Virbasius V, Puri V, Czech P. (2008). Adipocyte
dysfunctions linking obesity to insulin resistance and type 2 diabetes.
Nature reviews. Molec Cell Biol, 9:367–77.
Gustafson B. (2010). Adipose tissue, inflammation and atherosclerosis.
J Athero Thromb, 17:332–41.
Halberg N, Khan T, Trujillo E, et al. (2009). Hypoxia-inducible factor
1alpha induces fibrosis and insulin resistance in white adipose tissue.
Molec Cell Biol, 29:4467–83.
Hausman J, Richardson L. (2004). Adipose tissue angiogenesis. J Animal
Sci, 82:925–34.
He Q, Gao Z, Yin J, et al. (2011). Regulation of HIF-1{alpha} activity in
adipose tissue by obesity-associated factors: adipogenesis, insulin, and
hypoxia. Am J Physiol Endocrin Metab, 300:877–85.
Hemmeryckx B, Loeckx D, Dresselaers T, et al. (2010). Age-associated
adaptations in murine adipose tissues. Endocrine J, 57:925–30.
Hosogai N, Fukuhara A, Oshima K, et al. (2007). Adipose tissue hypoxia
in obesity and its impact on adipocytokine dysregulation. Diabetes,
56:901–11.
Iwai M, Chen R, Imura Y, Horiuchi M. (2007). Tak-536, a new AT1
receptor blocker, improves glucose intolerance and adipocyte differ-
entiation. Am J Hyper, 20:579–86.
Iwai M, Tomono Y, Inaba S, et al. (2009). AT2 receptor deficiency
attenuates adipocyte differentiation and decreases adipocyte number
in atherosclerotic mice. Am J Hyper, 22:784–91.
Jia X, Wu L. (2007). Accumulation of endogenous methylglyoxal
impaired insulin signaling in adipose tissue of fructose-fed rats. Molec
Cell Biochem, 306:133–9.
Jiang C, Qu A, Matsubara T, et al. (2011). Disruption of hypoxia-
inducible factor 1 in adipocytes improves insulin sensitivity
and decreases adiposity in high-fat diet-fed mice. Diabetes, 60:
2484–95.
Juge-Aubry E, Henrichot E, Meier C. (2005). Adipose tissue:
A regulator of inflammation. Best Practice Res Clin Endocrin
Metab, 19:547–66.
Jun J, Shin M. (2012). Acute hypoxia induces hypertriglyceridemia by
decreasing plasma triglyceride clearance in mice. Am J Physiol
Endocrin Metab, 303:377–88.
Kakiuchi-Kiyota S, Vetro J, Suzuki S, et al. (2009). Effects of the
PPARgamma agonist troglitazone on endothelial cells in vivo and
in vitro: Differences between human and mouse. Toxicol Appl
Pharmacol, 237:83–90.
 10 T. Rodrigues et al.
Kakiuchi-Kiyota S, Arnold L. (2011). Evaluation of direct and indirect
effects of the PPARÎ3 agonist troglitazone on mouse endothelial cell
proliferation. Toxicol Pathol, 39:1032–45.
Kalupahana S, Moustaid-Moussa N. (2012a). The renin-angiotensin
system: a link between obesity, inflammation and insulin resistance.
Obesity Rev (Official Journal of the International Association for the
Study of Obesity), 13:136–49.
Kalupahana S, Massiera F, Quignard-Boulange A, et al. (2012b).
Overproduction of angiotensinogen from adipose tissue induces
adipose inflammation, glucose intolerance, and insulin resistance.
Obesity, 20:48–56.
Kaneto H, Katakami N, Matsuhisa M, Matsuoka T. (2010). Role of
reactive oxygen species in the progression of type 2 diabetes and
atherosclerosis. Mediators Inflam, 2010:1–11.
Kim J, Kim S, Kim S, et al. (2012). Accumulation of argpyrimidine, a
methylglyoxal-derived advanced glycation end product, increases
apoptosis of lens epithelial cells both in vitro and in vivo. Exp Molec
Med, 44:167–75.
Archives of Physiology and Biochemistry Downloaded from informahealthcare.com by Cornell University on 12/28/14
Kimura R, Takahashi N, Murota K, et al. (2011). Activation of
peroxisome proliferator-activated receptor-a (PPARa) suppresses
postprandial lipidemia through fatty acid oxidation in enterocytes.
Biochem Biophys Res Comm, 410:1–6.
Krishnan J, Danzer C, Simka T, et al. (2012). Dietary obesity-associated
Hif1a activation in adipocytes restricts fatty acid oxidation and energy
expenditure via suppression of the Sirt2-NADþ system. Genes
Develop, 26:259–70.
Lemoine Y, Ledoux S, Quéguiner I, et al. (2012). Link between adipose
tissue angiogenesis and fat accumulation in severely obese subjects.
J Clin Endocrin Metab, 97:775–80.
Lijnen R. (2008). Angiogenesis and obesity. Cardio Res, 78:286–93.
Mack I, Belaiba S, Djordjevic T, et al. (2009). Functional analyses reveal
the greater potency of preadipocytes compared with adipocytes as
endothelial cell activator under normoxia, hypoxia, and TNFalpha
exposure. Am J Physiol Endocrin Metab, 297:735–48.
For personal use only.
Mannerås-Holm L, Krook A. (2012). Targeting adipose tissue angio-
genesis to enhance insulin sensitivity. Diabetologia, 55:2562–4.
Matafome P, Santos-Silva D, Crisóstomo J, et al. (2012). Methylglyoxal
causes structural and functional alterations in adipose tissue inde-
pendently of obesity. Arch Physiol Biochem, 118:58–68.
Matafome P, Sena C, Seiça R. (2013). Methylglyoxal, obesity, and
diabetes. Endocrine, 43:1–37.
Maury E, Brichard M. (2010). Adipokine dysregulation, adipose tissue
inflammation and metabolic syndrome. Molec Cell Endocrin, 314:
1–16.
Moeschel K, Beck A, Weigert C, et al. (2004). Protein kinase C-zeta-
induced phosphorylation of Ser318 in insulin receptor substrate-1
(IRS-1) attenuates the interaction with the insulin receptor and the
tyrosine phosphorylation of IRS-1. J Biol Chem, 279:25157–63.
Neels G, Thinnes T, Loskutoff J. (2004). Angiogenesis in an in vivo
model of adipose tissue development. FASEB J, 19:1–19.
Negre-Salvayre A, Salvayre R, Augé N, et al. (2009). Hyperglycemia and
glycation in diabetic complications. Antiox Redox Sig, 11:3071–109.
Negro R. (2008). Endothelial effects of antihypertensive treatment:
Focus on irbesartan. Vasc Health Risk Manage, 4:89–101.
Niu J, Azfer A, Zhelyabovska O, et al. (2008). Monocyte chemotactic
protein (MCP)-1 promotes angiogenesis via a novel transcription
factor, MCP-1-induced protein (MCPIP). J Biol Chem, 283:14542–51.
Olefsky M, Glass K. (2010). Macrophages, inflammation, and insulin
resistance. Ann Rev Physiol, 72:219–46.
Ozcan U, Cao Q, Yilmaz E, et al. (2004). Endoplasmic reticulum stress
links obesity, insulin action, and type 2 diabetes. Science, 306:457–61.
Pang C, Gao Z, Yin J, et al. (2008). Macrophage infiltration into adipose
tissue may promote angiogenesis for adipose tissue remodeling in
obesity. Am J Physiol Endocrin Metab, 295:313–22.
Park S, David E, Huang Park B, et al. (2012). In vivo delivery of cell-
permeable antisense hypoxia-inducible factor 1a oligonucleotide to
adipose tissue reduces adiposity in obese mice. J Cont Release
(Official Journal of the Controlled Release Society), 161:1–9.
Pasarica M, Rood J, Ravussin E, et al. (2010). Reduced oxygenation in
human obese adipose tissue is associated with impaired insulin
suppression of lipolysis. J Clin Endocrin Metab, 95:4052–5.
Pino E, Wang H, McDonald M. (2012). Roles for peroxisome
proliferator-activated receptor g (PPARg) and PPARg coactivators
1a and b in regulating response of white and brown adipocytes to
hypoxia. J Bio Chem, 287:18351–8.
Arch Physiol Biochem, 2014; 120(1): 1–11
Qatanani M, Lazar M. (2007). Mechanisms of obesity-associated
insulin resistance: Many choices on the menu. Genes Develop, 21:
1443–55.
Rajala W, Scherer E. (2003). Minireview: The adipocyte – At the
crossroads of energy homeostasis, inflammation, and atherosclerosis.
Endocrinology, 144:3765–73.
Rausch E, Weisberg S, Vardhana P, Tortoriello V. (2008). Obesity in
C57BL/6J mice is characterized by adipose tissue hypoxia and
cytotoxic T-cell infiltration. Inter J Obesity, 32:451–63.
Regazzetti C, Peraldi P, Grémeaux T, et al. (2009). Hypoxia
decreases insulin signaling pathways in adipocytes. Diabetes, 58:
95–103.
Riboulet-Chavey A, Pierron A, Durand I, et al. (2006). Methylglyoxal
impairs the insulin signaling pathways independently of the formation
of intracellular reactive oxygen species. Diabetes, 55:1289–99.
Rodrigues T, Paulo M, Santos-Silva D, et al. (2013). Reduction of
methylglyoxal-induced glycation by pyridoxamine improves adipose
tissue microvascular lesions. J Diab Res, 2013:1–9.
Rodrigues T, Matafome P, Seiça R. (in press). Methylglyoxal further
impairs adipose tissue metabolism after partial decrease of blood
supply. Arch Physiol Biochem.
Rutkowski M, Davis E, Scherer E. (2009). Mechanisms of obesity and
related pathologies: The macro- and microcirculation of adipose
tissue. FEBS J, 276:5738–46.
Scalia R. (2013). The microcirculation in adipose tissue inflammation.
Rev Endo Metab Disorders, 14:69–76.
Segawa K, Fukuhara A, Hosogai N, et al. (2006). Visfatin in adipocytes
is upregulated by hypoxia through HIF1alpha-dependent mechanism.
Biochem Biophys Research Comm, 349:875–82.
Semenza L. (2004). Hydroxylation of HIF-1: Oxygen sensing at the
molecular level. Physiology, 19:176–82.
Sena C, Matafome P, Crisóstomo J, et al. (2012). Methylglyoxal
promotes oxidative stress and endothelial dysfunction. Pharm Res
(Official Journal of the Italian Pharmacological Society), 65:
497–506.
Spencer M, Unal R, Zhu B, et al. (2011). Adipose tissue extracellular
matrix and vascular abnormalities in obesity and insulin resistance.
J Clin Endocrin Metab, 96:1990–8.
Steckelings M, Rompe F, Kaschina E, et al. (2010). The past, present and
future of angiotensin II type 2 receptor stimulation. J Renin-Angio-
Aldo Syst (JRAAS), 11:67–73.
Steckelings M, Rompe F, Kaschina E, Unger T. (2009). The evolving
story of the RAAS in hypertension, diabetes and CV disease: Moving
from macrovascular to microvascular targets. Fund Clinical Pharm,
23:693–703.
Suganami T, Ogawa Y. (2010). Adipose tissue macrophages: their role in
adipose tissue remodeling. J Leukocyte Biol, 88:33–9.
Sun K, Wernstedt I, Kusminski M, et al. (2012). Dichotomous effects of
VEGF-A on adipose tissue dysfunction. Proc National Acad Sci USA,
109:5874–9.
Tam J, Duda G, Perentes Y, et al. (2009). Blockade of VEGFR2 and not
VEGFR1 can limit diet-induced fat tissue expansion: Role of local
versus bone marrow-derived endothelial cells. PloS One, 4:e4974.
Tilg H, Moschen R. (2006). Adipocytokines: mediators linking adipose
tissue, inflammation and immunity. Nature Rev Immunology, 6:
772–83.
Tobin L, Simonsen L, Bülow J. (2010). Real-time contrast-enhanced
ultrasound determination of microvascular blood volume in abdom-
inal subcutaneous adipose tissue in man. Evidence for adipose tissue
capillary recruitment. Clin Physiol Func Imag, 30:447–52.
Tomono Y, Iwai M, Inaba S, et al. (2008). Blockade of AT1 receptor
improves adipocyte differentiation in atherosclerotic and diabetic
models. Am J Hyper, 21:206–12.
Trayhurn P, Wang B, Wood S. (2008a). Hypoxia in adipose tissue: a
basis for the dysregulation of tissue function in obesity? Brit J
Nutrition, 100:227–35.
Trayhurn P, Wang B, Wood S. (2008b). Hypoxia and the endocrine and
signalling role of white adipose tissue. Arch Physiol Biochem, 114:
267–76.
Treins C, Giorgetti-Peraldi S, Murdaca J, et al. (2002). Insulin stimulates
hypoxia-inducible factor 1 through a phosphatidylinositol 3-kinase/
target of rapamycin-dependent signaling pathway. J Bio Chem, 277:
27975–81.
Tsuchiya K, Yoshimoto T, Hirono Y, et al. (2006). Angiotensin II
induces monocyte chemoattractant protein-1 expression via a nuclear
 DOI: 10.3109/13813455.2013.838971
factor-kappaB-dependent pathway in rat preadipocytes. Am J Physiol
Endocrin Metab, 291:E771–8.
Uden V, Kenneth S, Rocha S. (2008). Regulation of hypoxia inducible
factor-1a by NF-kB. Biochem J, 412:477–84.
Ueki K, Kondo T. (2004). Suppressor of cytokine signaling 1 (SOCS-1)
and SOCS-3 cause insulin resistance through inhibition of tyrosine
phosphorylation of insulin receptor substrate proteins. Mol Cell Biol,
24:5434–46.
Vázquez-Vela M, Torres N, Tovar R. (2008). White adipose tis-
sue as endocrine organ and its role in obesity. Arch Med Res, 39:
715–28.
Villela N, Kramer-Aguiar L. (2009). Metabolic disturbances linked to
obesity: The role of impaired tissue perfusion. Arquivos brasileiros de
endocrinologia e metabolismo, 53:238–45.
Vona-Davis L, Rose P. (2009). Angiogenesis, adipokines and breast
cancer. Cyto Growth Factor Rev, 20:193–201.
Wang B, Wood S, Trayhurn P. (2007). Dysregulation of the expres-
sion and secretion of inflammation-related adipokines by hypoxia in
Archives of Physiology and Biochemistry Downloaded from informahealthcare.com by Cornell University on 12/28/14
human adipocytes. Pflügers Archiv: Euro J Physiol, 455:479–92.
Weir R. (2007). Targeting mechanisms of hypertensive vascular disease
with dual calcium channel and renin-angiotensin system blockade.
J Human Hyper, 21:770–79.
Wellen K, Hotamisligil G. (2003). Obesity-induced inflammatory
changes in adipose tissue. J Clin Invest, 112:1785–8.
Wellen K, Hotamisligil G. (2005). Inflammation, stress, and diabetes.
J Clin Invest, 115:1111–19.
Weyer C, Foley E, Bogardus C, et al. (2000). Enlarged subcutaneous
abdominal adipocyte size, but not obesity itself, predicts type II
For personal use only.
A vascular piece in the puzzle of adipose tissue dysfunction 11
diabetes independent of insulin resistance. Diabetologia, 43:
1498–506.
Wood S, De Heredia F, Wang B, Trayhurn P. (2009). Cellular hypoxia
and adipose tissue dysfunction in obesity. Proc Nutrition Soc, 68:
370–7.
World Health Organization. (2000). Obesity: preventing and managing
the global epidemic. Report of a WHO consultation. WHO Tech Rep
Series, 894:1–253.
Yamakawa M, Liu X, Date T, et al. (2003). Hypoxia-inducible factor-1
mediates activation of cultured vascular endothelial cells by inducing
multiple angiogenic factors. Circ Res, 93:664–73.
Ye J. (2008). Emerging role of adipose tissue hypoxia in obesity and
insulin resistance. Int J Obesity, 33:22–25.
Ye J. (2009). Emerging role of adipose tissue hypoxia in obesity and
insulin resistance. Int J Obesity, 33:54–66.
Ye J, Gao Z, Yin J, He Q. (2007). Hypoxia is a potential risk factor for
chronic inflammation and adiponectin reduction in adipose tissue of
ob/ob and dietary obese mice. Am J Physiol Endocrin Metab, 293:
1118–28.
Zarember K, Malech L. (2005). HIF-1a: A master regulator of innate
host defenses? J Clin Invest, 115:2003–5.
Zhang H, Zhang C. (2009). Regulation of microvascular function by
adipose tissue in obesity and type 2 diabetes: Evidence of an adipose-
vascular loop. Am J Biomed Sci, 1:1–13.
Zhang X, Lam K, Ye H, et al. (2011). Adipose tissue-specific inhibition
of hypoxia-inducible factor 1a induces obesity and glucose intoler-
ance by impeding energy expenditure in mice. Am Soc Biochem Molec
Biol, 285:32869–77.