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Background: Obesity is an important risk factor for diabetes, cardiovascular disease, and periodontal dis-
ease. Adipocytes appear to secrete proinflammatory cytokines which may be the molecules linking the path-
ogenesis of these diseases. We evaluated the relationship between obesity, periodontal disease, and diabetes
mellitus insulin resistance as well as the plasma levels of tumor necrosis factor alpha (TNFa) and its soluble
receptors (sTNFa) to assess the relationship of inflammation to obesity, diabetes, and periodontal infections.
Methods: The relationship between periodontal disease, obesity, and insulin resistance was examined in the
Third National Health and Nutrition Examination Survey (NHANES III). In a population of 12,367 non-diabetic
subjects, the variable body mass index (BMI) was used as an assessment of obesity and periodontal disease
was assessed by mean clinical attachment loss. The plasma levels of TNFa and sTNFa were assessed in sub-
sets of 1,221 adults from Erie County, New York, who represented the highest and lowest quartile of BMI. These
subjects had extensive periodontal and medical evaluations.
Results: In the NHANES III portion of the study, BMI was positively related to severity of periodontal attach-
ment loss (P <0.001). Weighted multiple logistic regressions showed that this relationship is likely mediated by
insulin resistance, since overweight individuals (with BMI ‡27 kg/m2) with high levels of insulin resistance (IR)
exhibited an odds ratio of 1.48 (95% confidence interval 1.13 - 1.93) for severe periodontal disease as com-
pared to overweight subjects with low IR. In the Erie County adult population, the highest levels of TNFa and
sTNFa receptors were found in those individuals in the highest quartile of BMI. A positive correlation of
TNFa levels with periodontal disease was found only in those in the lowest quartile of BMI.
Conclusions: Obesity is a significant predictor of periodontal disease and insulin resistance appears to me-
diate this relationship. Furthermore, obesity is associated with high plasma levels of TNFa and its soluble
receptors, which in turn may lead to a hyperinflammatory state increasing the risk for periodontal disease
and also accounting in part for insulin resistance. Further studies of the molecular basis of insulin resistance
and its relationship to diabetes, periodontal disease, and obesity are necessary to fully test the hypothesis
that adipocyte production of proinflammatory cytokines is a pathogenic factor linking obesity to diabetes
and periodontal infections. J Periodontol 2005;76:2075-2084.
KEY WORDS
Diabetes; insulin resistance; obesity; periodontal disease; soluble tumor necrosis factor receptor;
TNF-alpha.
* Department of Oral Biology, School of Dental Medicine, and Department of Microbiology, School of Medicine and Biomedical Sciences, Office of Science,
Technology Transfer, and Economic Outreach (STOR), University at Buffalo, Buffalo, NY.
† Periodontal Disease Research Center, Department of Oral Biology, School of Dental Medicine, University at Buffalo.
‡ Formerly, Department of Pathophysiology/Periodontal Science, Okayama University, Graduate School of Medicine and Dentistry, Okayama, Japan;
Currently, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama University.
§ Retired; formerly, Department of Periodontology and Endodontology, Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama
University.
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Inflammation Links Obesity to Diabetes and Periodontal Disease: A Model Volume 76 • Number 11 (Suppl.)
O
besity, one of the most significant health
risks of modern society, is now recognized as were associated in adults, and high waist circumfer-
a chronic disease with a multifactorial etiol- ence was associated with periodontal disease in 18-
ogy. The incidence of obesity and elevated body to 34-year-olds.14 None of the above studies address
mass index (BMI) has dramatically increased in the the nature of the association of obesity and periodon-
Western world.1 Although the fundamental mecha- titis, or the relationship of obesity to insulin resistance,
nisms underlying this increase in obesity are not well a key feature of type 2 diabetes mellitus.
understood, it has become clear that genetic and The relationship between obesity and proinflam-
environmental factors and socioeconomic and be- matory cytokines has been extensively studied. For
havioral influences leading to excess caloric intake, example, Vendrell et al.15 found elevations of soluble
decreased physical activity, and metabolic and tumor necrosis factor receptor 1 and 2 (sTNF-aRI and
endocrine abnormalities are likely important factors. sTNF-aRII) in obese patients. It has been proposed
Obesity is associated with increased morbidity and that adipocytes produce several proinflammatory
mortality2,3 and is either an independent or ag- cytokines including TNF, leptin, and interleukin-1,
gravating factor for a number of diseases such as leading to a proinflammatory state associated with
hypertension, coronary heart disease (CHD), osteo- obesity.16 Evaluation of proinflammatory cytokines also
arthritis, and type 2 diabetes mellitus.4 In addition, occurs in chronic infections. For example, Nishimura
there is a strong association between obesity and and coworkers showed that serum TNF-a concen-
mortality. In the United States (U.S.), deaths attrib- trations were elevated in periodontitis patients as
compared to periodontally healthy subjects. Those
utable to obesity constitute a significant cause of
periodontal patients with elevated TNF-a concentra-
mortality, second only to smoking.5 The prevalence
tions had reduced levels after periodontal therapy.17,18
of obesity is increasing at alarming rates, both in the
The purpose of the present study was to examine
U.S. and worldwide, reaching epidemic proportions,
the relationship between obesity and periodontal dis-
particularly among children and adolescents.6 This
ease, and to evaluate to what extent insulin resistance
global epidemic places more of the population at risk
and associated systemic TNF-a levels and sTNF-a
for concomitant diseases.
receptors may account for this relationship.
Obesity is a major contributor to the development of
type 2 diabetes mellitus,4 and the prevalence of diabe-
tes mellitus in the U.S. is also increasing at an alarming MATERIALS AND METHODS
rate. The number of diagnosed cases of diabetes has Data and Study Sample
increased 30% in less than 10 years, earning the unfor- Data from the Third National Health and Nutrition Ex-
tunate distinction of likely becoming the next lifestyle- amination Survey (NHANES III) were used for a por-
disease epidemic affecting this population. tion of this study.19 NHANES III was conducted from
Periodontal disease is a complication of diabetes 1988 to 1994 using a multistage stratified sampling
mellitus.7 The presence of periodontal disease in a di- design. Detailed information on sample design, oper-
abetic individual is a serious health hazard, for once ation of NHANES III, blood specimen collection, and
the disease is established, the chronic nature of this laboratory procedures utilized to analyze blood sam-
infection contributes to worsening diabetic status lead- ples has been described.20 Blood specimens were col-
ing to more severe diabetes-related complications.8,9 lected and immediately stored under appropriate
Conversely, treatment of periodontal infection results conditions until they were shipped to analytical labo-
in improvement of diabetes metabolic control and a de- ratories for testing. Fasting insulin was measured
crease in diabetes treatment requirements.10 by radioimmunoassay, and fasting glucose was as-
An association has been reported between obesity sessed using a chemistry system.i Serum cholesterol
and periodontal disease in a cohort of 241 otherwise was also measured.¶ Serum triglycerides were mea-
sured enzymatically after hydrolization to glycerol us-
healthy Japanese subjects.11 A national survey of
ing the same analyzer. Glycated hemoglobin was
older people in Great Britain showed that those with
measured by ion-exchange high-performance liquid
more than 20 teeth are more likely to have a normal
chromatography.# C-reactive protein (CRP) was mea-
BMI, and those with less than 20 natural teeth were,
sured using latex-enhanced nephelometry.
on average, three times more likely to be obese.12
Height was measured with a stadiometer to the
An analysis of the Third National Health and Nutrition
nearest 0.1 cm. Weight was measured with a Toledo
Examination Survey (NHANES III) showed that waist
to hip ratio, BMI, fat-free mass, and log sum of subcu- i Cobas Mira Chemistry System, Roche Diagnostic Systems, Montclair, NJ.
taneous fat had significant correlations with periodon- ¶ Hitachi 704 Analyzer, Boehringer Mannheim Diagnostics, Indianapolis,
IN.
tal disease, suggesting that abnormal fat metabolism # DIAMAT Glycated Hemoglobin Analyzer System, BioRad Laboratories,
may be an important factor in the pathogenesis of Hercules, CA.
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J Periodontol • November 2005 (Suppl.) Genco, Grossi, Ho, Nishimura, Murayama
self-zeroing weight scale and recorded to the nearest and as such were adjusted for in the final model. To
0.01 kg. From these two measurements, the body obtain estimates representative of the entire U.S. sam-
mass index (weight in kilograms divided by height in pling frame, weighting of the sample data was done.23
meters squared) was calculated. Analyses were performed using a statistical software
Periodontal assessments included measurements program incorporating the sampling weights.**
of gingival bleeding, calculus, probing depth, and at-
Plasma Levels of TNF-a, sTNF-aRI, and sTNF-aRII
tachment level carried out at two sites (buccal and
A subset of the University at Buffalo myocardial in-
mesio-buccal) of two randomly selected quadrants,
farction in periodontal disease case control study24
one upper and one lower. Individual subject mean at-
was used. In this study, 1,221 adult controls with no
tachment levels (AL) were calculated in millimeters.
history of myocardial infarction were assessed by ex-
We utilized mean AL ‡1.5 mm to define a case of peri-
tensive periodontal and medical examinations as well
odontal disease. This case definition has been utilized
as laboratory studies. A subset of individuals (305
previously to analyze data from NHANES III to deter-
subjects) in the highest quartile of BMI, (‡30.8 kg/
mine the risk for periodontal disease associated with
m2) was selected. Of these, 41 had periodontal dis-
serum levels of specific nutrients and inflammatory
ease as evidenced by having two or more teeth with
mediators.21,22
attachment loss ‡6 mm and one or more teeth with
Demographic variables included gender, race, and
probing depth ‡5 mm. Two hundred sixty-four
ethnicity (non-Hispanic white, non-Hispanic black,
(264) were identified in the highest BMI quartile as
Mexican, and other), number of years of education
having little or no periodontal disease. In the lowest
completed, and age at examination. Smoking status
quartile for BMI (<24.6 kg/m2), 305 subjects were as-
was categorized as never, former, or current cigarette
sessed. Of these, 35 (11.5%) had periodontal disease
smoker. For former and current smokers, overall ex-
based on the same criteria, while 270 subjects had lit-
posure to tobacco was calculated as packyears; i.e.,
tle or no periodontal disease.
number of cigarettes smoked per day · number of
Test subjects selected from the highest quartile of
years smoked.
BMI included the 41 with periodontal disease, and 50
The analyses were carried out on participants of
randomly selected from the 264 with little or no peri-
both genders aged 20 to 90 years, with no clinical di-
odontal disease. From the lowest quartile of BMI, the
agnosis of diabetes mellitus. Specifically, participants
35 with periodontal disease and 50 randomly selected
responding that they had previously been told by
from the 270 with little or no periodontal disease were
a physician that they had diabetes, or who had fasting
selected. This resulted in four groups for analysis of
blood glucose levels of >126 mg/dl were considered to
systemic cytokines: A: high BMI with periodontal dis-
have previously diagnosed diabetes and were ex-
ease (41); B: high BMI with little or no periodontal dis-
cluded from this analysis. In order to improve the
ease (50); C: low BMI with periodontal disease (35);
reliability of periodontal assessment, individuals
and low BMI with little or no periodontal disease (50).
included in this analysis were required to have at least
six natural teeth. Samples Analyzed
Ethylenediamine tetracetic acid (EDTA) plasma was
Statistical Analysis of the NHANES III Data frozen at -86F. Samples were coded and kept frozen
Descriptive statistics including means, standard devi- until assay. About 5% of the samples were analyzed in
ations, and percentages were used to summarize the duplicate as a quality control. Assessment of TNF-a
demographic variables and health-related behaviors and soluble TNF receptor levels was carried out as
of the study sample. An index of insulin resistance described by Nishimura and coworkers.17
(IR) was constructed from the product of fasting insu- Statistical analyses of TNF-a and sTNF-a receptors
lin · fasting glucose. The sample was stratified by BMI were carried out using analysis of variance (ANOVA),
into overweight and non-overweight (BMI ‡27 and with P values expressed as the result of a t test. The
<27 kg/m2) and in quartiles of insulin resistance. Mean correlation coefficients were calculated to measure
values of total cholesterol, triglycerides, C-reactive the linear relationship of clinical attachment loss to
protein, glucose, insulin, and glycated hemoglobin plasma levels of TNF-a and sTNF-a receptors.
(HbA1c) were calculated for all quartiles of insulin re-
sistance. Comparisons were made for all dependent RESULTS
variables and quartiles of IR, with the lowest quartile
of IR as the reference group. A total of 12,367 non-diabetic individuals 20 to 90
years old participated in the dental section of the
Multiple logistic regression analyses were used to
NHANES III study. Of these 53.1% were men and
examine the association between obesity and peri-
46.9% women; 38.7% were whites, 27.7% were
odontal disease. Age, gender, education, race and
ethnicity, and smoking were utilized as covariates ** Westvar PC, Version 2.1, WESTAT, Inc., Rockville, MD.
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Inflammation Links Obesity to Diabetes and Periodontal Disease: A Model Volume 76 • Number 11 (Suppl.)
blacks, 29.4% were Mexican Americans, and 4.2% sociated with IR (P <0.05). Significantly greater
were of other racial and ethnic groups; and 43.1% (P <0.05) proportions of non-Hispanic blacks, Mexi-
were overweight (BMI ‡27 kg/m2) (Table 1). Over- can Americans, and other racial groups were in the
weight individuals were slightly older, less educated, upper quartiles of IR compared to white Americans
and had a lower income compared to non-overweight (Table 2). Likewise, significantly more individuals
individuals. A greater proportion of females, non- with less than 12 years of education, lower income
Hispanic blacks, and Mexican Americans were over- levels, and smokers were in the highest quartile of
weight compared to those non-overweight. A greater IR compared to those in the lowest IR quartile (Table
level of attachment loss (P <0.01) and more periodon- 2). There was no significant difference in gender dis-
tal disease (P <0.05) were seen in the overweight tribution among those in different quartiles based on
group (Table 1). insulin resistance.
The distribution of the sample by quartiles of IR is Table 2 also shows that the severity of periodontal
shown in Table 2. Increasing age was significantly as- attachment loss increased proportionally with in-
creasing IR (P <0.05). Individuals in
Table 1.
the highest IR quartile exhibited greater
Demographics, Periodontal Status, Serum Glucose, mean attachment loss compared to
and Lipid Parameters of Obese (BMI ‡ 27 kg/m ) 2 those in the lowest quartile. Following
and Non-Obese (BMI < 27 kg/m ) Individuals 2 a similar trend, the number of teeth lost
increased significantly (P <0.05) with
increasing levels of IR. On average,
Body Mass Index
individuals in the highest IR quartile
Demographic Overall <27 kg/m2 ‡27 kg/m2 had lost 1.1 more teeth compared to
individuals in the lowest IR quartile
N 12,367 7,041 5,326
(Table 2).
Prevalence (%) NA 56.9 43.1
A significant (P <0.05) proportional
Age in years (mean – SE) 43.5 – 0.2 42.2 – 0.2 45.2 – 0.2
increase in BMI was seen with increas-
Periodontal disease (%)* 25.4 24.3 26.9
ing levels of IR (data not shown). Most
Attachment loss in mm (mean – SE)† 1.1 – 0.1 1.1 – 0.1 1.2 – 0.1
individuals in the IR highest quartile
Gender (%) can be considered obese, as they ex-
Female 46.9 51.7 55.0 hibited a mean BMI of 31.8 kg/m2 (data
Male 53.1 48.3 45.0 not shown). Individuals in the highest
quartile of IR had significantly elevated
Race and ethnicity (%)* (P <0.05) levels of total cholesterol and
Non-Hispanic white 38.7 42.6 33.6 triglycerides, mean 208.2 mg/dl and
Non-Hispanic black 27.7 25.8 30.3 187.2 mg/dl, respectively, compared
Mexican American 29.4 26.9 32.7 to 193.2 mg/dl and 96.6 mg/dl in
Other 4.2 4.7 3.4 quartile 1 (Table 3). Fasting glucose
Education (%)* levels in the highest IR group were sig-
<7 years 14.8 12.9 17.3 nificantly elevated (P <0.05) compared
8 to 11 years 20.6 20.1 21.1 to the lowest quartile of IR (Table 3).
12 years 32.4 31.5 33.6 Fasting levels of insulin were more than
>12 years 32.2 35.5 28.0 4 times greater in the highest quartile
compared to the lowest quartile (Table
Annual household income (%)* 3). Levels of glycated hemoglobin
<US$30,000 61.7 60.8 63.0 (HbA1c) were also significantly ele-
‡US$30,000 38.3 39.2 37.0 vated in the highest IR quartile group
Serum parameters (mean – SE)
compared to the lowest, 5.5% versus
Fasting glucose (mg/dl)* 93.3 – 0.1 91.6 – 0.1 95.4 – 0.1
5.1% (Table 3). Table 3 also shows that
Serum insulin (pmol/l)* 67.3 – 0.5 50.0 – 0.4 90.2 – 1.0
C-reactive protein levels were higher in
Hemoglobin A1c (%)* 5.3 – 0.1 5.2 – 0.1 5.4 – 0.1 the two highest quartiles of IR as com-
White blood cell count* 7.2 – 0.1 7.0 – 0.1 7.4 – 0.1 pared to the lowest quartiles.
Cholesterol (mg/dl)* 202.1 – 0.4 196.8 – 0.5 209.0 – 0.6 Multivariate analyses revealed that
Triglyceride (mg/dl)* 135.1 – 0.9 115.7 – 1.0 160.6 – 1.6 BMI is positively and significantly re-
C-reactive protein (mg/dl)* 0.4 – 0.1 0.4 – 0.1 0.5 – 0.1 lated to severity of attachment loss
* Statistically significant when comparing those overweight to those of normal weight (P <0.05).
(P <0.001; Fig. 1). A weighted multiple
† Statistically significant when comparing those overweight with those of normal weight (P <0.01). logistic regression showed that this
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J Periodontol • November 2005 (Suppl.) Genco, Grossi, Ho, Nishimura, Murayama
Table 4.
TNF-a, sTNF-aRI, and sTNF-aRII Plasma Levels
Age
<50 years 49 3.47 – 0.16* 1346.9 – 79.3 2760.7 – 126.3
>50 years 119 4.29 – 0.16 1527.7 – 57.7 3067.7 – 121.2
Gender
Male 70 4.22 – 0.19 1568.4 – 85.5 3141.9 – 179.9
Female 98 3.93 – 0.16 1404.9 – 52.7 2859.8 – 95.6
Smoking status
Never/former 148 4.02 – 0.13 1461.2 – 49.9 2965.2 – 104.2
Current 20 4.24 – 0.28 1549.1 – 147.1 3063.6 – 164.0
BMI
Low BMI (<24.6 kg/m2) 84 3.76 – 0.17* 1276.8 – 43.0† 2771.9 – 97.5*
High BMI (‡30.8 kg/m2) 84 4.34 – 0.17 1661.4 – 77.6 3182.3 – 157.3
Periodontal status
Low periodontal disease (<2 teeth with 100 3.98 – 0.17 1466.4 – 56.8 2900.2 – 101.5
‡6 mm AL, and <1 tooth with ‡5 mm PD)
High periodontal disease (‡2 teeth with 68 4.15 – 0.18 1481.4 – 81.5 3087.9 – 175.8
‡6 mm AL, and ‡1 tooth with ‡5 mm PD)
* P value £0.05.
† P value £0.001.
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J Periodontol • November 2005 (Suppl.) Genco, Grossi, Ho, Nishimura, Murayama
may ultimately lead to amelioration of the significant 17. Nishimura F, Kono T, Fujimoto C, Iwamoto Y,
health burden associated with these diseases. Murayama Y. Negative effects of chronic inflammatory
disease on diabetes mellitus. J Int Acad Periodontol
2000;2:49-55.
ACKNOWLEDGMENT
18. Nishimura F, Iwamoto Y, Mineshiba J, Shimizu A,
This study was supported in part by USPHS grants Soga Y, Murayama Y. Periodontal disease and diabetes
DE04898 and 28298004 from the National Institute mellitus: The role of tumor necrosis factor-alpha in a
of Dental and Craniofacial Research, National Insti- 2-way relationship. J Periodontol 2003;74:97-102.
19. U.S. Department of Health and Human Services.
tutes of Health, and Department of Health and Human
National Center for Health Statistics. National Health
Services, Bethesda, Maryland. and Nutrition Examination Survey III 1988-94,
NHANES III Examination Data File (CD-ROM).
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