Am J Physiol Endocrinol Metab

280: E745E751, 2001.

Adipose tissue tumor necrosis factor and interleukin-6

expression in human obesity and insulin resistance
PHILIP A. KERN, SUBRAMANIAN RANGANATHAN, CHUNLING LI,
LINDA WOOD, AND GOURI RANGANATHAN
Division of Endocrinology, Department of Medicine, University of Arkansas for Medical Sciences
and the Central Arkansas Veterans Healthcare System, Little Rock, Arkansas 72205
Received 1 August 2000; accepted in final form 23 January 2001

Kern, Philip A., Subramanian Ranganathan, Chunling Li, Linda Wood, and Gouri Ranganathan. Adipose
tissue tumor necrosis factor and interleukin-6 expression in
human obesity and insulin resistance. Am J Physiol Endocrinol Metab 280: E745E751, 2001.Adipose tissue expresses tumor necrosis factor (TNF) and interleukin (IL)-6,
which may cause obesity-related insulin resistance. We measured TNF and IL-6 expression in the adipose tissue of 50
lean and obese subjects without diabetes. Insulin sensitivity
(SI) was determined by an intravenous glucose tolerance test
with minimal-model analysis. When lean [body mass index
(BMI) 25 kg/m2] and obese (BMI 3040 kg/m2) subjects
were compared, there was a 7.5-fold increase in TNF secretion (P 0.05) from adipose tissue, and the TNF secretion
was inversely related to SI (r 0.42, P 0.02). IL-6 was
abundantly expressed by adipose tissue. In contrast to TNF,
plasma (rather than adipose) IL-6 demonstrated the strongest relationship with obesity and insulin resistance. Plasma
IL-6 was significantly higher in obese subjects and demonstrated a highly significant inverse relationship with SI (r
0.71, P 0.001). To separate the effects of BMI from SI,
subjects who were discordant for SI were matched for BMI,
age, and gender. By use of this approach, subjects with low SI
demonstrated a 3.0-fold increased level of TNF secretion
from adipose tissue and a 2.3-fold higher plasma IL-6 level
(P 0.05) compared with matched subjects with a high SI.
Plasma IL-6 was significantly associated with plasma nonesterified fatty acid levels (r 0.49, P 0.002). Thus the local
expression of TNF and plasma IL-6 are higher in subjects
with obesity-related insulin resistance.

a national epidemic with enormous

public health implications (25), and recent studies
have demonstrated a further 6% increase in the incidence of obesity [body mass index (BMI) 30 kg/m2]
over a 7-yr period (30). There is a strong correlation
between obesity and insulin resistance in both diabetic
and nondiabetic subjects (27), and the risk of diabetes
increases 11-fold as the BMI increases from 20 to 30
(8). Although insulin resistance accompanies all patients who become obese, the degree of insulin resistance varies considerably, and the relationships be-

tween obesity, insulin resistance, and type 2 diabetes

are not well understood.
Obesity represents an expansion of adipose tissue
mass, and one explanation for obesity-related insulin
resistance is the production of factors by adipose tissue
that render some subjects more insulin resistant than
others. Numerous adipocyte secretory products have
recently been described that play a role in carbohydrate and lipid metabolism (14, 21, 23). One such
adipocyte secretory product is tumor necrosis factor
(TNF)-. A new role for TNF was proposed in 1993 with
the description of TNF expression by adipose tissue
and the elevated expression of TNF in obese, insulinresistant rodents and humans (17, 20, 24). Although it
is unclear how adipose TNF expression may cause
insulin resistance (36), TNF is known to impair insulin
receptor signaling (18). TNF also inhibits lipoprotein
lipase (LPL) and stimulates lipolysis in adipocytes (34),
and the resulting increase in circulating nonesterified
fatty acids (NEFA) would be expected to contribute to
insulin resistance (7).
Another adipocyte secretory product that may be
involved in insulin resistance is interleukin (IL)-6,
which is a cytokine secreted by many cells, including
adipocytes and adipose stromal cells (11, 15). Like
TNF, IL-6 inhibits the expression of LPL, but, unlike
TNF, IL-6 does not stimulate lipolysis (13, 16). IL-6
secretion is increased in the adipocytes of obese
subjects (29) and may be important either as a circulating hormone or as a local regulator of insulin
action.
Although many studies have examined the role of
TNF in insulin resistance, relatively few of these have
been in humans, and none has examined cytokine
expression in detail along with the measurement of
insulin resistance. In this study, we examined the
expression of TNF and IL-6 in human adipose tissue
from nondiabetic subjects with varying degrees of obesity and insulin resistance. We found that TNF secretion from human adipose tissue and circulating plasma
IL-6 were both highly associated with obesity-associated insulin resistance.

Address for reprint requests and other correspondence: P. A. Kern,

Central Arkansas Veterans Healthcare System, 598/151 LR 4300
West 7th St., Little Rock, AR 72205 (E-mail: KernPhilipA
@uams.edu).

The costs of publication of this article were defrayed in part by the

payment of page charges. The article must therefore be hereby
marked advertisement in accordance with 18 U.S.C. Section 1734
solely to indicate this fact.

type 2 diabetes

OBESITY HAS BECOME

http://www.ajpendo.org

E745

E746

ADIPOSE EXPRESSION OF TNF AND IL-6

Table 1. Characteristics of the study subjects

Women
Men

Age,
yr

BMI,
kg/m2

Fat,
%

TG,
mg/dl

LDL,
mg/dl

HDL,
mg/dl

FBG,
mg/dl

39
11

40 1.6
42 3.3

36 1.4
33 3.8

43 1.2
27 4.9

118 12
143 24

125 5
124 11

53 2
45 1.8

93 2
100 3

Data are expressed as means SEM. BMI, body mass index; TG, triglyceride; LDL and HDL, low- and high-density lipoprotein,
respectively; FBG, fasting blood glucose.
METHODS

Subjects. Fifty subjects were recruited for these studies.

This research was approved by the Institutional Review
Board, and all subjects gave informed consent. All subjects
were weight stable at the time of the study. Subjects initially
underwent an oral glucose tolerance test using 75 g of glucose, and blood glucose was measured fasting and at 2 h.
Subjects with diabetes (fasting blood sugar 126 mg/dl, 2-h
glucose 200 mg/dl) were excluded. Of the 50 subjects, 15
had impaired glucose tolerance based on a 2-h glucose of
140200 mg/dl, and three of these subjects had impaired
fasting glucose based on a fasting glucose of 110126 mg/dl.
Subjects then underwent a frequently sampled intravenous
glucose tolerance test (FSIVGTT) and an adipose tissue biopsy. The FSIVGTT and the biopsy were performed at least 3
days apart.
Characteristics of the subjects that comprised this study
are shown in Table 1. Blood lipids were measured using
standard clinical assays, and plasma NEFA were measured
using a colorimetric assay (Waco Chemical, Richmond, VA).
Of the 50 subjects studied, 39 were women and 8 were
African-American. The subjects ranged from lean to very
obese, and insulin sensitivity (SI; using the SI index from the
FSIVGTT] varied considerably. Some subjects demonstrated
moderate dyslipidemia, but no subject demonstrated fasting
triglycerides 400 mg/dl. Body composition was determined
using bioelectric impedance (38).
SI measurements. The measurement of in vivo SI was
performed in the fasting state with the minimal-model analysis of the FSIVGTT (4, 5). We used the classic tolbutamidemodified test, which has been validated against the euglycemic clamp in humans (6, 41). In brief, catheters were placed
for glucose injection and blood sampling. Four basal blood
samples were obtained, and the patient was given an intravenous glucose bolus (11.4 g/m2) at time 0. At 20 min after the
glucose injection, patients were given an injection of tolbutamide (125 mg/m2), again followed by frequent blood sampling, according to the standard protocol. Together, 4 basal
and 27 postglucose blood samples were taken, the last one at
240 min. Glucose was measured in a glucose analyzer by use
of the glucose oxidase method, and insulin was measured
using radioimmunoassay. These measurements were performed in the Endocrinology Laboratory of the Indiana University School of Medicine (Indianapolis, IN). The SI was
calculated using the MINMOD program (4) and was expressed in microunits per milliliter per minute.
Adipose tissue biopsy. Abdominal subcutaneous adipose
tissue (10 g) was removed from each patient by incision,
which avoids trauma to fat cells and minimizes the amount of
blood in contact with the fat cells. Some of the tissue was
immediately frozen in liquid N2 for later RNA extraction,
whereas the rest of the tissue was placed into cold DMEM for
other assays.
Adipose tissue cytokine secretion. TNF and IL-6 may function in an autocrine or paracrine manner; hence, we wished
to measure the local secretion of these cytokines into the

medium. Immediately after the biopsy, adipose tissue pieces

of 500 mg were minced and placed into serum-free DMEM
(pH 7.4, 10 mM HEPES) at 37C for varying times. Figure 1
illustrates the secretion of TNF and IL-6 into the medium of
three subjects. There was little secretion of either cytokine
into the medium for the first 60 min, followed by an increase
in secretion over the next 60 min. Medium cytokine levels
continued to increase for up to 24 h. To compare TNF and
IL-6 secretion among different subjects, we measured cytokine levels in the medium after 2 h at 37C. All data were
normalized to adipose DNA content to control for differences
in fat cell size. In general, IL-6 secretion from adipose tissue
was much higher than TNF. In all subjects studied, the TNF
level in the medium at 2 h was 0.78 0.14 pg/g DNA, and
the IL-6 level in the medium was 9.8 1.8 pg/g DNA.
Measurement of TNF and IL-6. Adipose tissue TNF protein
was measured using an ELISA (R&D Systems, Minneapolis,
MN). This assay demonstrates an 8% intra-assay and a 15%
interassay variation. This ELISA method was used to measure TNF in fasting plasma as well as TNF secretion by
adipose tissue (see Relationship between TNF and obesity).
TNF mRNA levels were measured by competitive RT-PCR,
as described by us previously (24). IL-6 was measured in
fasting plasma and secreted from adipose tissue using an
ELISA assay (R&D Systems). This assay demonstrates intraand interassay variations of 5%.
Statistics. All data are expressed as means SE. To
analyze data between groups, a one-way ANOVA was performed, and secondary analysis was performed with the
Students t-test with Bonferroni correction. Analysis of
trends was performed using linear regression after log transformation. The Wilcoxon matched-pair sign-rank test was
used for the paired data in Table 2.

Fig. 1. Tumor necrosis factor (TNF)- and interleukin (IL)-6 secretion from adipose tissue. TNF and IL-6 are secreted into the medium
over time from adipose tissue. Data represent means and SE of 3
representative subjects. Both cytokines are expressed as pg/g DNA.

ADIPOSE EXPRESSION OF TNF AND IL-6

Fig. 2. Effect of body mass index (BMI) on plasma TNF, adipose

secretion of TNF into the medium, and TNF mRNA levels. Subjects
were divided into BMI groups as described in the text, representing
lean subjects (BMI 25) and subjects with increasing degrees of
obesity. A: plasma TNF was measured and expressed as pg/ml, along
with TNF secreted into the medium of the adipose tissue expressed
as pg/g DNA, as described in METHODS. B: TNF mRNA levels were
measured using RT-PCR, as described in METHODS. *P 0.05 vs. BMI
3040 and BMI 40.
RESULTS

Relationship between TNF and obesity. To better

define the effects of obesity on TNF expression, we
measured TNF mRNA in the adipose tissue from each
subject, along with plasma TNF and TNF secretion
from the adipose tissue. Subjects were divided into four
BMI groups representing lean (BMI 25, n 9), overweight (BMI 2530, n 9), moderately obese (BMI
3040, n 17), and very obese subjects (BMI 40, n
15). Figure 2B shows TNF mRNA levels from subjects
with increasing BMI. There was considerable variability among the obese subject groups with respect to TNF
mRNA levels, such that the differences between normal lean subjects (BMI 25 kg/m2) and obese subjects
were not statistically significant (NS; Fig. 2B). TNF
protein was also measured in these subjects; however,
as shown in Fig. 2A, there was no relationship between
plasma TNF and BMI. However, TNF secretion from
the adipose tissue was higher in obese subjects. Mean
TNF secretion was 0.16 0.06 pg/g DNA in lean
subjects (BMI 25 kg/m2), and 1.21 0.36 pg/g DNA

E747

in subjects with a BMI between 30 and 40 kg/m2 (P

0.05). Subjects with a BMI 45 kg/m2 demonstrated
slightly lower TNF secretion (0.90 0.21 pg/g DNA),
but this was not significantly decreased compared with
subjects with a BMI of 3040 kg/m2. This effect of BMI
on TNF secretion was still present when women and
Caucasians were each considered separately and when
subjects with impaired glucose tolerance were eliminated. TNF secretion from adipose tissue was also low
in subjects with low body fat. TNF secretion in subjects
with 30%, 3045%, and 45% body fat was 0.16
0.07 (n 10), 0.76 0.16 (n 14), and 1.1 0.28
pg/g DNA (n 18, P 0.05 vs. 30% group).
TNF expression and insulin sensitivity. As expected,
there was a significant relationship between obesity
and insulin sensitivity. As described previously by others (22), the relationship between BMI and SI is curvilinear and best represented by a log/log transformation, and in our subjects, BMI and SI were significantly
related (r 0.65, P 0.001). Because SI varies
considerably among nonobese subjects with normal
glucose tolerance, we did not divide SI into subgroups
but instead examined TNF expression over the spectrum of SI. There was no significant relationship between either plasma TNF or TNF mRNA levels and SI
(data not shown). However, there was a significant
decrease in TNF secretion with increasing SI (Fig. 3),
such that most of the insulin-sensitive subjects (SI 5)
had lower levels of TNF secretion, and most of the
insulin-resistant subjects (SI 2) had the highest levels of TNF secretion.
IL-6 expression with obesity and insulin resistance.
The adipose tissue fragments secreted relatively high
levels of IL-6. When IL-6 expression was examined in
the same BMI groups, as described in the preceding
section for TNF, there was a tendency for an increase
in IL-6 secretion from adipose tissue with increasing
BMI and increasing body fat (Fig. 4B); however, these
changes were not statistically significant. Plasma IL-6,
however, was strongly associated with increasing obesity (Fig. 4A). In lean subjects (BMI 25), plasma IL-6
was 0.73 0.23 pg/ml and increased about fourfold to
2.86 0.61 pg/ml in the most obese subjects (BMI 40,

Fig. 3. Relationship between TNF expression and insulin sensitivity

(SI). TNF secretion into the medium was measured in subjects along
with measurements of SI. TNF secretion is expressed as pg/g DNA
of adipose tissue, and the data are log transformed.

E748

ADIPOSE EXPRESSION OF TNF AND IL-6

Fig. 5. Relationship between plasma IL-6 and SI. Plasma IL-6 was
measured as described in METHODS and expressed as pg/ml. Data are
log transformed.

Fig. 4. Effect of BMI on IL-6 expression. A: plasma IL-6 (pg/ml) was

measured in subjects from the same BMI groups as described in Fig.
2. *P 0.05 vs. BMI 3040 and BMI 40 groups. **P 0.05 vs. BMI
40 group. B: adipose tissue IL-6 secretion (pg/g DNA) was measured in subjects as described in METHODS.

P 0.05). In a similar manner, plasma IL-6 was lower

in subjects with low percent body fat. Plasma IL-6 was
0.84 0.19 pg/ml (n 10) in subjects with 30% body
fat and was 2.05 0.38 (n 14) and 2.58 0.44 (n
18) pg/ml in subjects with 3045 and 45% fat, respectively (P 0.05). The relationship between SI and
plasma IL-6 was examined in the same manner as
described for TNF. In contrast to TNF, adipose-secreted IL-6 demonstrated no significant relationship
with SI (r 0.04, P NS). However, there was a
highly significant relationship (r 0.71, n 38, P
0.001) between plasma IL-6 and SI, as shown in Fig. 5.
Plasma IL-6 was 3.0 0.53 pg/ml in the most insulinresistant subjects (SI 2) and was 0.82 0.19 pg/ml in
the most insulin-sensitive subjects (SI 5, P 0.05).
One mechanism by which TNF may cause insulin
resistance is through an increase in adipocyte lipolysis,
leading to a rise in plasma NEFA. Hence, the relationship between cytokine expression and plasma NEFA
was examined. The only significant relationship with
plasma NEFA levels was with plasma IL-6 and adipose

TNF secretion. As shown in Fig. 6, there were significant increases in plasma NEFA levels in subjects with
higher levels of plasma IL-6 (r 0.54, P 0.001).
There was also a significant association between
plasma NEFA and TNF secretion (r 0.35, n 37, P
0.05), although this association was less robust than
the association with IL-6.
Cytokines and insulin resistance independent of obesity. Insulin resistance is exacerbated by obesity, leading to a significant relationship between SI and BMI.
Therefore, we examined the relationship between adipose cytokine expression and SI without the confounding effects of BMI. To factor out obesity, we identified
subjects who were of the same BMI but who were
discordant for SI. We compared the cytokine expression
of subjects with insulin resistance (SI 2.0) with that
of subjects with less insulin resistance (SI 3.0) who
were matched for BMI (5 kg/m2), age (10 yr), and
gender. Using these criteria, we were able to match
nine subjects with SI 2.0 with nine subjects with SI
3.0. As shown in Table 2, these subjects were well
matched for age and BMI, and there were significant
differences in SI by virtue of subject selection. No
differences were noted between plasma TNF or adipose

Fig. 6. Relationship between plasma IL-6 and plasma nonesterified

fatty acids (NEFA). Plasma IL-6 levels were plotted against the
plasma NEFA level for each subject.

E749

ADIPOSE EXPRESSION OF TNF AND IL-6

Table 2. Insulin-sensitive and insulin-resistant subjects matched for BMI and age

Insulin sensitive
Insulin resistant

SI

BMI

Age,
yr

Plasma TNF,
pg/ml

Plasma IL-6,
pg/ml

Adipose TNF Secretion,

pg/g DNA

4.6 0.34
1.5 0.12*

34.9 1.8
34.8 2.4

40.3 3.0
39.1 2.8

1.72 0.26
1.87 0.31

1.43 0.30
3.21 0.79*

0.47 0.15
1.42 0.47*

Values are means SE. SI, insulin sensitivity; TNF, tumor necrosis factor; IL-6, interleukin-6. * P 0.05 vs. insulin sensitive.

IL-6 expression. However, the insulin-resistant subjects had significantly higher levels of plasma IL-6 as
well as significantly higher levels of adipose TNF secretion (P 0.05). In these matched subjects, TNF
secretion and plasma IL-6 were two- to threefold
higher in the insulin-resistant subjects.
Previous studies have demonstrated that IL-6 and
TNF interact with each other in both 3T3-L1 adipocytes and mice (3, 16). We examined TNF and IL-6
expression from each subjects adipose tissue to determine whether there was any relationship between IL-6
and TNF expression. As shown in Fig. 7, there was a
strong linear relationship between the secretions of
IL-6 and TNF from the adipose tissue (r 0.81, P
0.0001). On the other hand, there was no significant
relationship between plasma IL-6 and plasma TNF
(data not shown).
DISCUSSION

Since the initial description of TNF expression by

adipose tissue, several lines of evidence have suggested
that TNF overproduction by adipose tissue may be
involved in the pathogenesis of the insulin resistance of
obesity. TNF mRNA levels were high in obese, insulinresistant rodents, and the infusion of a soluble TNF
binding protein into insulin-resistant fa/fa rats improved insulin sensitivity and improved the defect in
insulin receptor and insulin receptor substrate-1 autophosphorylation in fat and muscle (18, 20). Recent
studies using genetic manipulations resulting in
knockout or depletion of TNF or TNF receptor have
confirmed the importance of TNF in rodent insulin

Fig. 7. Relationship between IL-6 and TNF secretion from adipose

tissue. IL-6 and TNF (pg/g DNA) were measured in the medium
from adipose tissue pieces cultured for 2 h, and the level of medium
IL-6 was plotted against the level of TNF.

resistance (9, 19, 40), although one such study (37)

found no role for TNF or the TNF receptor in insulin
resistance.
Relatively few studies have examined the relationship between TNF and insulin resistance in humans.
Studies by us (24) and others (1, 17) demonstrated
elevated levels of adipose TNF mRNA and protein in
obese subjects and a decrease in TNF with weight loss.
No study has examined the relationship between SI
and TNF, although one study noted a significant correlation between TNF mRNA levels and fasting insulin
(17), and several studies observed a decrease in TNF
after weight loss (12, 17, 24). High TNF secretion from
human adipose tissue was associated with decreased
[3H]glucose incorporation into lipids (26).
It is not clear whether TNF functions locally or
circulates in a sufficiently high concentration to influence distant targets. Plasma TNF has been measured,
and several studies have observed increased plasma
TNF levels in obese subjects and in subjects with
hyperinsulinemia or insulin resistance (10, 42, 43).
Plasma TNF was elevated in male diabetic subjects
compared with male controls, but no such relationship
was observed in women (35). In an attempt to bind
plasma TNF and reverse insulin resistance in humans,
diabetic or insulin-resistant subjects have been given
an injection of anti-TNF binding protein. In both studies, there was no improvement in insulin resistance
(31, 33).
The role of IL-6 in insulin resistance has been much
less studied. IL-6 is secreted by many cells, including
adipocytes and adipose stromal cells (11, 15) and is
increased after a meal (32). Like TNF, IL-6 inhibits the
expression of LPL, but unlike TNF, IL-6 does not
stimulate lipolysis (13, 16). Linking IL-6 to insulin
resistance are studies demonstrating increased IL-6
secretion in the adipocytes of subjects with obesity (29)
and diabetes (2).
In the studies described herein, we measured TNF
and IL-6 gene expression at several levels from the
adipose tissue of lean and obese subjects and related
this expression to SI, a reliable measure of insulin
sensitivity. Both IL-6 and TNF were expressed and
secreted by human adipose tissue, although IL-6 levels
were much higher in both adipose tissue and plasma.
The most consistent relationship between cytokine expression and obesity-related insulin resistance involved increased TNF secretion from adipose tissue
and increased plasma IL-6 levels. Elevated TNF and
IL-6 expression was found in subjects who were only
moderately obese (BMI 30) and increased progressively with decreasing SI. The relationship between

E750

ADIPOSE EXPRESSION OF TNF AND IL-6

plasma IL-6 and SI was very strong, with a highly

significant inverse correlation and a fivefold difference
between the most insulin-resistant and most insulinsensitive subjects. Thus both TNF and IL-6 were associated with both obesity and insulin resistance; however, it was the adipose-secreted form of TNF and the
plasma level of IL-6 that displayed the strongest relationships.
The subjects in this study were heterogeneous with
regard to degree of obesity, gender, and race, and it is
possible that a study using a more focused group of
subjects would yield different results. However, we
observed no consistent effect of gender or race on cytokine expression in these subjects. This study also relied
on plasma cytokine levels and cytokine secretion from
adipose tissue, and these measurements may not be
reflective of cytokine biological effects at the tissue
level.
Because obesity and insulin resistance are related to
each other, we wished to determine whether TNF and
IL-6 expression were related to insulin resistance independently of obesity. As described in Table 2, we
paired insulin-resistant subjects with more-insulinsensitive subjects and matched them for BMI and age.
By use of this analysis, high levels of TNF secretion
and plasma IL-6 were both significantly associated
with insulin resistance. Thus the expression of these
cytokines was associated with insulin resistance independently of obesity.
There are differences in the expression of TNF and
IL-6 that may be important in understanding their
functions. IL-6 was secreted at high levels from adipose
tissue, and there was a significant arteriovenous difference in IL-6 across the adipose tissue bed, whereas
there was no arteriovenous difference with TNF (29).
We found no relationship between plasma TNF and
obesity or insulin resistance, although other studies
have noted increased plasma TNF with obesity (2, 10,
42, 43). IL-6 and TNF may interact with each other, as
suggested by the strong correlation between TNF secretion and IL-6 secretion in this study and by previous
studies that demonstrated increased IL-6 expression in
response to TNF (3, 16). Together, these data suggest
that TNF functions locally at the level of the adipocyte
in a paracrine fashion, perhaps stimulating the secretion of NEFA, IL-6, or other circulating substances. On
the other hand, plasma IL-6 circulates at high levels
and may be more important systemically and perhaps
represents a hormonal factor that induces muscle insulin resistance.
It is noteworthy that two studies have tried, and
failed, to reverse insulin resistance with an injection of
anti-TNF binding proteins (31, 33). On the basis of the
studies described herein, we can speculate on several
possible reasons for the failure of anti-TNF therapy in
humans. If TNF functions in a paracrine or autocrine
fashion in adipose tissue, then the anti-TNF binding
proteins may not reach the microcirculation in sufficient concentration to prevent TNF-mediated effects.
In addition, our data raise the possibility that IL-6 is

the major circulating component of obesity-related insulin resistance.

The development of insulin resistance with increasing adiposity suggests that an adipocyte product may
be important in insulin resistance. Both TNF and IL-6
are adipocyte products that are overexpressed in obese
insulin-resistant subjects, and we have shown that the
secretion of these cytokines is interrelated. Some of
these cytokines may function systemically, others may
function locally, and still others may function to increase the secretion or synthesis of other adipocyte
factors or to act as an adjuvant to the actions of other
insulin resistance factors. One such insulin resistance
factor is NEFA, which are closely associated with insulin resistance (28, 39). TNF stimulates lipolysis in
adipocytes (34); hence, it is possible that TNF functions
at the level of the adipocyte to stimulate lipolysis.
Although IL-6 is not known to stimulate lipolysis (13,
16), we found a significant relationship between
plasma IL-6 and plasma NEFA levels, whereas the
relationship between TNF expression and plasma
NEFA was much less robust.
These studies provide the first comprehensive analysis of IL-6 expression in obese, insulin-resistant humans and add to the data on TNF expression. Together, these studies suggest that obesity-related
insulin resistance represents a complex syndrome, mediated by a number of adipocyte secretory products,
which ultimately lead to defects in insulin action in
other target organs.
We thank Dr. Richard Evans for statistical assistance, Denise
Hargrove for assistance with subject recruitment, and the nurses of
the General Clinical Research Center at the University of Arkansas
for Medical Sciences and Central Arkansas Veterans Healthcare
System. We also thank Dr. Richard Bergman for supplying the
MINMOD program, and Sarah Dunn for excellent secretarial assistance.
This study was supported by a Veterans Affairs Department Merit
Review Grant M01-RR-14288 of the General Clinical Research Center, a Career Development Award from the American Diabetes Association, and DK-39176 from the National Institutes of Health.
REFERENCES
1. Arner P. Obesity and insulin resistance in Swedish subjects.
Diabet Med 13, Suppl 6: S85S86, 1996.
2. Bastard JP, Jardel C, Bruckert E, Blondy P, Capeau J,
Laville M, Vidal H, and Hainque B. Elevated levels of interleukin 6 are reduced in serum and subcutaneous adipose tissue
of obese women after weight loss. J Clin Endocrinol Metab 85:
33383342, 2000.
3. Berg M, Fraker DL, and Alexander HR. Characterization of
differentiation factor/leukaemia inhibitory factor effect on lipoprotein lipase activity and mRNA in 3T3-L1 adipocytes. Cytokine 6: 425432, 1994.
4. Bergman RN, Finegood DT, and Ader M. Assessment of
insulin sensitivity in vivo. Endocr Rev 6: 4586, 1985.
5. Bergman RN, Phillips LS, and Cobelli C. Physiologic evaluation of factors controlling glucose tolerance in man. Measurement of insulin sensitivity and beta-cell sensitivity from the
response to intravenous glucose. J Clin Invest 68: 14561467,
1981.
6. Bergman RN, Prager R, Volund A, and Olefsky JM. Equivalence of the insulin sensitivity index in man derived by the
minimal model method and the euglycemic glucose clamp. J Clin
Invest 79: 790800, 1987.

ADIPOSE EXPRESSION OF TNF AND IL-6

7. Boden G. Role of fatty acids in the pathogenesis of insulin
resistance and NIDDM. Diabetes 46: 310, 1997.
8. Carey VJ, Walters EE, Colditz GA, Solomon CG, Willett
WC, Rosner BA, Speizer FE, and Manson JE. Body fat
distribution and risk of noninsulin-dependent diabetes mellitus
in women. The Nurses Health Study. Am J Epidemiol 145:
614619, 1997.
9. Cheung AT, Ree D, Kolls JK, Fuselier J, Coy DH, and
Bryer-Ash M. An in vivo model for elucidation of the mechanism of tumor necrosis factor-alpha (TNF-alpha)-induced insulin
resistance: evidence for differential regulation of insulin signaling by TNF-alpha. Endocrinology 139: 49284935, 1998.
10. Corica F, Allegra A, Corsonello A, Buemi M, Calapai G,
Ruello A, Nicita Mauro V, and Ceruso D. Relationship between plasma leptin levels and the tumor necrosis factor-alpha
system in obese subjects. Int J Obes 23: 355360, 1999.
11. Crichton MB, Nichols JE, Zhao Y, Bulun SE, and Simpson
ER. Expression of transcripts of interleukin-6 and related cytokines by human breast tumors, breast cancer cells, and adipose
stromal cells. Mol Cell Endocrinol 118: 215220, 1996.
12. Dandona P, Weinstock R, Thusu K, Abdel-Rahman E, Aljada A, and Wadden T. Tumor necrosis factor-alpha in sera of
obese patients: fall with weight loss. J Clin Endocrinol Metab 83:
29072910, 1998.
13. Feingold KR, Doerrler W, Dinarello CA, Fiers W, and
Grunfeld C. Stimulation of lipolysis in cultured fat cells by
tumor necrosis factor, interleukin-1, and the interferons is
blocked by inhibition of prostaglandin synthesis. Endocrinology
130: 1016, 1992.
14. Flier JS. The adipocyte: storage depot or node on the energy
information superhighway? Cell 80: 1518, 1995.
15. Fried SK, Bunkin DA, and Greenberg AS. Omental and
subcutaneous adipose tissues of obese subjects release interleukin-6: depot difference and regulation by glucocorticoid. J Clin
Endocrinol Metab 83: 847850, 1998.
16. Greenberg AS, Nordan RP, McIntosh J, Calvo JC, Scow
RO, and Jablons D. Interleukin 6 reduces lipoprotein lipase
activity in adipose tissue of mice in vivo and in 3T3-L1 adipocytes: a possible role for interleukin 6 in cancer cachexia. Cancer
Res 52: 41134116, 1992.
17. Hotamisligil GS, Arner P, Caro JF, Atkinson RL, and
Spiegelman BM. Increased adipose tissue expression of tumor
necrosis factor-alpha in human obesity and insulin resistance.
J Clin Invest 95: 24092415, 1995.
18. Hotamisligil GS, Budavari A, Murray D, and Spiegelman
BM. Reduced tyrosine kinase activity of the insulin receptor in
obesity-diabetes. Central role of tumor necrosis factor-. J Clin
Invest 94: 15431549, 1994.
19. Hotamisligil GS, Johnson RS, Distel RJ, Ellis R, Papaioannou VE, and Spiegelman BM. Uncoupling of obesity from
insulin resistance through a targeted mutation in aP2, the adipocyte fatty acid binding protein. Science 274: 13771379, 1996.
20. Hotamisligil GS, Shargill NS, and Spiegelman BM. Adipose
expression of tumor necrosis factor-: direct role in obesitylinked insulin resistance. Science 259: 8791, 1993.
21. Hotamisligil GS and Spiegelman BM. Tumor necrosis factor
: a key component of the obesity-diabetes link. Diabetes 43:
12711278, 1994.
22. Kahn SE, Prigeon RL, McCulloch DK, Boyko EJ, Bergman
RN, Schwartz MW, Neifing JL, Ward WK, Beard JC, and
Palmer JP. Quantification of the relationship between insulin
sensitivity and -cell function in human subjects. Evidence for a
hyperbolic function. Diabetes 42: 16631672, 1993.
23. Kern PA. Potential role of TNF and lipoprotein lipase as
candidate genes for obesity. J Nutr 127: 1917S1922S, 1997.
24. Kern PA, Saghizadeh M, Ong JM, Bosch RJ, Deem R, and
Simsolo RB. The expression of tumor necrosis factor in human
adipose tissue. Regulation by obesity, weight loss, and relationship to lipoprotein lipase. J Clin Invest 95: 21112119, 1995.
25. Kuczmarski RJ, Flegal KM, Campbell SM, and Johnson
CL. Increasing prevalence of overweight among US adults: the

26.

27.
28.
29.

30.
31.

32.

33.

34.

35.

36.
37.
38.

39.
40.
41.

42.

43.

E751

National Health and Nutrition Examination Surveys, 1960 to

1991. JAMA 272: 205211, 1994.
Lofgren P, Van H, Reynisdottir VS, Naslund E, Ryden M,
Rossner S, and Arner P. Secretion of tumor necrosis factor-
shows a strong relationship to insulin-stimulated glucose transport in human adipose tissue. Diabetes 49: 688692, 2000.
Ludvik B, Nolan JJ, Baloga J, Sacks D, and Olefsky J.
Effect of obesity on insulin resistance in normal subjects and
patients with NIDDM. Diabetes 44: 11211125, 1995.
McGarry JD. What if Minkowski had been ageusic? An alternative angle on diabetes. Science 258: 766770, 1992.
Mohamed-Ali V, Goodrick S, Rawesh A, Katz DR, Miles
JM, Yudkin JS, Klein S, and Coppack SW. Subcutaneous
adipose tissue releases interleukin-6, but not tumor necrosis
factor-alpha, in vivo. J Clin Endocrinol Metab 82: 41964200,
1997.
Mokdad A, Serdula MK, Dietz WH, Bowman B, Marks J,
and Koplan J. The spread of the obesity epidemic in the United
States, 19911998. JAMA 282: 15191522, 1999.
Ofei F, Hurel S, Newkirk J, Sopwith M, and Taylor R.
Effects of an engineered human anti-TNF- antibody (CDP571)
on insulin sensitivity and glycemic control in patients with
NIDDM. Diabetes 45: 881885, 1996.
Orban Z, Remaley AT, Sampson M, Trajanoski Z, and
Chrousos GP. The differential effect of food intake and betaadrenergic stimulation on adipose-derived hormones and cytokines in man. J Clin Endocrinol Metab 84: 21262133, 1999.
Paquot N, Castillo MJ, Lefebvre PJ, and Scheen AJ. No
increased insulin sensitivity after a single intravenous administration of a recombinant human tumor necrosis factor receptor:
Fc fusion protein in obese insulin-resistant patients. J Clin
Endocrinol Metab 85: 13161319, 2000.
Patton JS, Shepard HM, Wilking H, Lewis G, Aggarwal
BB, Eessalu TE, Gavin LA, and Grunfeld C. Interferons and
tumor necrosis factors have similar catabolic effects on 3T3-L1
cells. Proc Natl Acad Sci USA 83: 83138317, 1986.
Pfeiffer A, Janott J, Mohlig M, Ristow M, Rochlitz H,
Busch K, Schatz H, and Schifferdecker E. Circulating tumor
necrosis factor alpha is elevated in male but not female patients
with type II diabetes mellitus. Horm Metab Res 29: 111114,
1997.
Qi C and Pekala PH. Tumor necrosis factor-alpha-induced
insulin resistance in adipocytes. Proc Soc Exp Biol Med 223:
128135, 2000.
Schreyer, SC Chua SA Jr, and LeBoeuf RC. Obesity and
diabetes in TNF- receptor-deficient mice. J Clin Invest 102:
402411, 1998.
Segal KR, Gutin B, Presta E, Wang J, and Van Itallie TB.
Estimation of human body composition by electrical impedance
methods: a comparative study. J Appl Physiol 58: 15651571,
1985.
Unger RH. Lipotoxicity in the pathogenesis of obesity-dependent NIDDM. Genetic and clinical implications. Diabetes 44:
863870, 1995.
Uysal KT, Wiesbrock SM, Marino MW, and Hotamisligil
GS. Protection from obesity-induced insulin resistance in mice
lacking TNF-alpha function. Nature 389: 610614, 1997.
Welch S, Gebhart SSP, Bergman RN, and Phillips LS.
Minimal model analysis of intravenous glucose tolerance testderived insulin sensitivity in diabetic subjects. J Clin Endocrinol
Metab 71: 15081518, 1990.
Winkler G, Lakatos P, Salamon F, Nagy Z, Speer G, Kovacs
M, Harmos G, Dworak O, and Cseh K. Elevated serum
TNF-alpha level as a link between endothelial dysfunction and
insulin resistance in normotensive obese patients. Diabetic Med
16: 207211, 1999.
Zinman B, Hanley AJ, Harris SB, Kwan J, and Fantus IG.
Circulating tumor necrosis factor-alpha concentrations in a native Canadian population with high rates of type 2 diabetes
mellitus. J Clin Endocrinol Metab 84: 272278, 1999.