Metabolic Disease Research Research Articles

Modelling metabolic diseases and drug response using stem cells and organoids

Metabolic diseases, including obesity, diabetes mellitus and cardiovascular disease, are a major threat to health in the modern world, but efforts to understand the underlying mechanisms and develop rational treatments are limited by the lack of appropriate human model systems. Notably, advances in stem cell and organoid technology allow the generation of cellular models that replicate the histological, molecular and physiological properties of human organs. Combined with marked improvements in gene editing tools, human stem cells and organoids provide unprecedented systems for studying mechanisms of metabolic diseases. Here, we review progress made over the past decade in the generation and use of stem cell-derived metabolic cell types and organoids in metabolic disease research, especially obesity and liver diseases. In particular, we discuss the limitations of animal models and the advantages of stem cells and organoids, including their application to metabolic diseases. We also discuss mechanisms of drug action, understanding the efficacy and toxicity of existing therapies, screening for new treatments and pursuing personalized therapies. We highlight the potential of combining stem cell-derived organoids with gene editing and functional genomics to revolutionize the approach to finding treatments for metabolic diseases.

Nutrient patterns and non-alcoholic fatty liver disease in Iranian Adul: A case-control study.

BackgroundsThe current literature boasts the importance of diet in preventing or managing liver complications. However, there is limited evidence on the association of nutrient patterns (NP) with these complications. In this case-control study, we aimed to examine the possible relationship between nutrient patterns and the risk of non-alcoholic fatty liver disease (NAFLD) amongst the adult Iranian population.MethodsThis case-control study is being conducted at the Metabolic Liver Disease Research Center at Isfahan University of Medical Sciences in 2019. The study included 225 newly diagnosed cases of NAFLD and 450 controls. A validated semi-quantitative food frequency questionnaire (FFQ) assessed dietary intake. Principal component analysis using Varimax rotation obtained nutrient patterns. Logistic regression was performed to estimate NAFLD risk.ResultsWe identified four major nutrient patterns. The first nutrient pattern was high in consumption of lactose, animal protein, vitamin D, riboflavin, pantothenic acid, vitamin B12, calcium, phosphorus, zinc, and potassium. The second nutrient pattern included fiber, plant protein, vitamin A, thiamine, niacin, copper, and selenium, while the third featured plant protein, zinc, copper, magnesium, manganese, chromium, and selenium. The fourth was characterized by fructose, vitamin A, pyridoxine, vitamin C, and potassium. After adjusting for confounders, individuals in the highest tertile of NP4 had lower odds of NAFLD (OR: 0.56, 95% CI: 0.32–0.98, P_trend = 0.042); compared to those who were in the lowest tertile.ConclusionHigh compliance to a nutrient pattern characterized by fructose, vitamin C, vitamin A, pyridoxine, and potassium mainly supplied from fruits, vegetables, and nuts is inversely proportional to the odds of NAFLD. Also our findings indicate a very high fiber intake, a relatively optimal dietary fat profile, and a pretty low sugar intake for cases and controls, unseen in western countries. However, these initial findings need to be approved with further studies to confirm the relationship between nutrient patterns and NAFLD.

Dietary phytochemical index and the risk of non-alcoholic fatty liver disease: A case-control study among Iranian adults

BackgroundsDietary phytochemical index (DPI) is an inexpensive method for estimating the amounts of phytochemicals in foods. No study has investigated the association between DPI and non-alcoholic fatty liver disease (NAFLD). Our study aimed to compare DPI in patients with NAFLD and the control group. MethodsThis is a case-control study of 250 subjects with NAFLD and 450 healthy subjects attending the Metabolic Liver Disease Research Center as a referral center affiliated to Isfahan University of Medical Sciences. DPI was calculated based on data collected from a 168-item validated food frequency questionnaire. Sociodemographic data, physical activity, and anthropometric measures such as body weight, height, and waist circumference were determined. ResultsIn the final adjusted model, the odds ratio (OR) of NAFLD across the DPI tertiles decreased significantly (OR = 0.55, 95 %CI = 0.31–0.95) (P-trend = 0.03). The highest vs. lowest tertiles of vegetable and olives PI were significantly associated with a lower risk of NAFLD (OR and 95 % CI = 0.26 (0.14–0.47); OR and 95 % CI = 0.51 (0.29–0.90), p for trend < 0.001, respectively), however, there was no significant relation between other PI components and NAFLD. ConclusionThis case-control study suggested that a higher PI score is associated with a reduced chance of NAFLD after adjusting for confounding variables. In addition, the highest tertile of vegetable and olives PI was significantly associated with a lower risk of NAFLD.

CXCL5 inhibits excessive oxidative stress by regulating white adipocyte differentiation

Chemokines have been well-documented as a major factor in immune cell migration and the regulation of immune responses. However, recent studies have reported that chemokines have diverse roles, both in immune cells and other cell types, including adipocytes. This study investigated the molecular functions of C-X-C motif chemokine ligand 5 (CXCL5) in white adipose cells using Cxcl5 knock-out (KO) mice fed a high-fat diet (HFD). The expression of Cxcl5 decreased by 90% during adipocyte differentiation and remained at a low level in mature adipocytes. Moreover, adipogenesis was enhanced when adipocytes were differentiated from the stromal vascular fraction (SFV) of Cxcl5 KO mice. Feeding an HFD increased the generation of reactive oxygen species (ROS) and promoted abnormal adipogenesis in Cxcl5 KO mice. Oxidative stress and insulin resistance occurred in Cxcl5 KO mice due to decreased antioxidant enzymes and failure to remove ROS. These results indicate the principal roles of CXCL5 in adipogenesis and ROS regulation in adipose tissue, further suggesting that CXCL5 is a valuable chemokine for metabolic disease research.

The therapeutic effects of chicory seed aqueous extract on cardio-metabolic profile and liver enzymes in nonalcoholic fatty liver disease; a double blind randomized clinical trial

Introduction: As diabetes and obesity increase worldwide, non-alcoholic fatty liver disease (NAFLD) becomes a more worrying health threat. Objectives: This study was designed to assess the impacts of chicory seed aqueous extract on the treatment of NAFLD. Patients and Methods: Around 60 patients with NAFLD who referred to Zanjan Metabolic Disease Research Center between March 2016 and April 2017 were allocated into treatment and placebo groups, randomly. The participants in the treatment group (n=30) were scheduled to consume 8 ml of chicory seed syrup (made by soaking 100 g of dried seeds in one liter of boiling water) twice daily for 12 weeks. The control group’s patients received placebo syrup with an identical figure and flavor and also with the same prescript. The analysis of covariance (ANCOVA) test, chi-square test, independent t-test and paired t test were applied for analysis of data. From the point of statistical view, P &lt; 0.05 was considered significant. Results: The body mass index (BMI), liver enzymes, fasting blood sugar test (FBS), HbA1c, fatty liver grading and all the indices of lipid profile decreased significantly (all P values &lt; 0.001) in the chicory group. The shifting change in fatty liver grading was also striking in treatment group’s patients compared to controls. Conclusion: The findings of this study support the application of chicory seed in the treatment of NAFLD due to the ameliorative effects on the metabolic indices of the disease. Trial Registration: This clinical trial protocol has been registered in Iranian Registry of Clinical Trial (identifier: IRCT2016061228411N1; https://en.irct.ir/trial/23063, ethical code #IR.ZUMS.REC.1395.195).

Institute Focus: Hypertension, Cardiorenal, and Metabolic Diseases Research at the University of Mississippi Medical Center

Institute Focus: Hypertension, Cardiorenal, and Metabolic Diseases Research at the University of Mississippi Medical Center

The Accumulation and Molecular Effects of Trimethylamine N-Oxide on Metabolic Tissues: It's Not All Bad.

Since elevated serum levels of trimethylamine N-oxide (TMAO) were first associated with increased risk of cardiovascular disease (CVD), TMAO research among chronic diseases has grown exponentially. We now know that serum TMAO accumulation begins with dietary choline metabolism across the microbiome-liver-kidney axis, which is typically dysregulated during pathogenesis. While CVD research links TMAO to atherosclerotic mechanisms in vascular tissue, its molecular effects on metabolic tissues are unclear. Here we report the current standing of TMAO research in metabolic disease contexts across relevant tissues including the liver, kidney, brain, adipose, and muscle. Since poor blood glucose management is a hallmark of metabolic diseases, we also explore the variable TMAO effects on insulin resistance and insulin production. Among metabolic tissues, hepatic TMAO research is the most common, whereas its effects on other tissues including the insulin producing pancreatic β-cells are largely unexplored. Studies on diseases including obesity, diabetes, liver diseases, chronic kidney disease, and cognitive diseases reveal that TMAO effects are unique under pathologic conditions compared to healthy controls. We conclude that molecular TMAO effects are highly context-dependent and call for further research to clarify the deleterious and beneficial molecular effects observed in metabolic disease research.

Sex- and age-dependent outcomes of 9-hour time-restricted feeding of a Western high-fat high-sucrose diet in C57BL/6J mice.

SUMMARYTime-restricted feeding (TRF) is a nutritional intervention wherein food intake is limited to a consistent 8- to 10-h daily window without changes in nutritional quality or quantity. TRF can prevent and treat diet-induced obesity (DIO) and associated metabolic disease in young male mice fed an obesogenic diet, the gold standard preclinical model for metabolic disease research. Because age and sex are key biological variables affecting metabolic disease pathophysiology and response to therapies, we assessed their impact on TRF benefits by subjecting young 3-month-old or middle-aged 12-month-old male and female mice to ad libitum or TRF of a Western diet. We show that most of the benefits of TRF are age-independent but are sex-dependent. TRF protects both sexes against fatty liver and glucose intolerance while body weight benefits are observed only in males. We also find that TRF imparts performance benefits and increases survival to sepsis in both sexes.

The Effects of Erchen Decoction on Gut Microbiota and Lipid Metabolism Disorders in Zucker Diabetic Fatty Rats.

Obesity is a chronic metabolic disease caused by genetic and environmental factors that has become a serious global health problem. There is evidence that gut microbiota is closely related to the occurrence and development of obesity. Erchen Decoction (ECD), a traditional Chinese medicine, has been widely used for clinical treatment and basic research of obesity and related metabolic diseases in recent years. It can significantly improve insulin resistance (IR) and lipid metabolism disorders. However, there is no microbiological study on its metabolic regulation. In this study, we investigated the effects of ECD on obesity, especially lipid metabolism and the composition and function of gut microbiota in Zucker diabetic fatty (ZDF) rats, and explored the correlation between the biomarkers of gut microbiota and metabolite and host phenotype. The results showed that ECD could reduce body weight, improve IR and lipid metabolism, and reduce the concentration of free fatty acids (FFA) released from white adipose tissue (WAT) due to excessive lipolysis by interfering with the insulin receptor substrate 1 (IRS1)/protein kinase B (AKT)/protein kinase A (PKA)/hormone-sensitive triglyceride lipase (HSL) signaling pathway in ZDF rats. Additionally, ECD gradually adjusted the overall structure of changed gut microbiota, reversed the relative abundance of six genera, and changed the function of gut microbiota by reducing the content of propionic acid, a metabolite of gut microbiota, in ZDF rats. A potentially close relationship between biomarkers, especially Prevotella, Blautia, and Holdemania, propionic acid and host phenotypes were demonstrated through correlation analysis. The results suggested that the beneficial effects of ECD on obesity, especially lipid metabolism disorders, are related to the regulation of gut microbiota in ZDF rats. This provides a basis for further research on the mechanism and clinical application of ECD to improve obesity via gut microbiota.

Resistance Training for Rehabilitation in Patients with Idiopathic Pulmonary Fibrosis

Resistance Training for Rehabilitation in Patients with Idiopathic Pulmonary Fibrosis Baruch Vainshelboim()1 and Jonathan Myers2 1Cardiovascular and Metabolic Disease Research Institute, Mountain View, CA, USA 2Cardiology Division, Veterans Affairs Palo Alto Health Care System / Stanford University, Palo Alto, CA, USA © The Authors Abstract Idiopathic pulmonary fibrosis (IPF) is a debilitating condition that causes severe symptoms, impaired functional capacity and poor quality of life. Exercise training has been shown to be a safe and effective therapy for improving physical function, dyspnea and quality of life in patients with IPF. However, due to pathophysiological limitations and symptom burden, conducting safe and effective exercise interventions is challenging; optimal program components and training modalities are yet to be established. Resistance training (RT) is a well-established exercise modality for combating effects of aging, disuse and chronic diseases, although there are scarce data available among patients with IPF. The current review briefly summarizes the pathophysiology and clinical manifestations of IPF and describes the numerous health and clinical benefits of RT among older adults and patients with respiratory disease. It then explores the potential RT mechanisms for overcoming exercise limitations in IPF, which may provide a therapeutic opportunity for rehabilitation. Finally, the review suggests practical RT recommendations for pulmonary rehabilitation programs in patients with IPF.

Nonmonotonic response of type 2 diabetes by low concentration organochlorine pesticide mixture: Findings from multi-omics in zebrafish

Exposure to a single organochlorine pesticide (OCP) at high concentration and over a short period of exposure constrain our understanding of the contribution of chemical exposure to type 2 diabetes (T2D). A total of 450 male and female zebrafish was exposed to mixtures of five OCPs at 0, 0.05, 0.25, 2.5, and 25 μg/L for 12 weeks. T2D-related hematological parameters (i.e., glucose, insulin, free fatty acid, and triglycerides) and mitochondrial complex I to IV activities were assessed. Metabolomics, proteomics, and transcriptomics were analyzed in female livers, and their data-driven integration was performed. High fasting glucose and low insulin levels were observed only at 0.05 μg/L of the OCP mixture in females, indicating a nonlinear and sexually dependent response. We found that exposure to the OCP mixture inhibited the activities of mitochondrial complexes, especially III and IV. Combining individual and integrated omics analysis, T2D-linked metabolic pathways that regulate mitochondrial function, insulin signaling, and energy homeostasis were altered by the OCP mixture, which explains the observed phenotypic hematological effects. We demonstrated the cause-and-effect relationship between exposures to OCP mixture and T2D using zebrafish model. This study gives an insight into mechanistic research of metabolic diseases caused by chemical exposure using zebrafish.

Laboratory animal research of metabolic bone diseases in Greece: Laws and ethics

Laboratory animal research of metabolic bone diseases in Greece: Laws and ethics

Evaluation of the quality of clinical data collection for a pan-Canadian cohort of children affected by inherited metabolic diseases: lessons learned from the Canadian Inherited Metabolic Diseases Research Network

BackgroundThe Canadian Inherited Metabolic Diseases Research Network (CIMDRN) is a pan-Canadian practice-based research network of 14 Hereditary Metabolic Disease Treatment Centres and over 50 investigators. CIMDRN aims to develop evidence to improve health outcomes for children with inherited metabolic diseases (IMD). We describe the development of our clinical data collection platform, discuss our data quality management plan, and present the findings to date from our data quality assessment, highlighting key lessons that can serve as a resource for future clinical research initiatives relating to rare diseases.MethodsAt participating centres, children born from 2006 to 2015 who were diagnosed with one of 31 targeted IMD were eligible to participate in CIMDRN’s clinical research stream. For all participants, we collected a minimum data set that includes information about demographics and diagnosis. For children with five prioritized IMD, we collected longitudinal data including interventions, clinical outcomes, and indicators of disease management. The data quality management plan included: design of user-friendly and intuitive clinical data collection forms; validation measures at point of data entry, designed to minimize data entry errors; regular communications with each CIMDRN site; and routine review of aggregate data.ResultsAs of June 2019, CIMDRN has enrolled 798 participants of whom 764 (96%) have complete minimum data set information. Results from our data quality assessment revealed that potential data quality issues were related to interpretation of definitions of some variables, participants who transferred care across institutions, and the organization of information within the patient charts (e.g., neuropsychological test results). Little information was missing regarding disease ascertainment and diagnosis (e.g., ascertainment method – 0% missing).DiscussionUsing several data quality management strategies, we have established a comprehensive clinical database that provides information about care and outcomes for Canadian children affected by IMD. We describe quality issues and lessons for consideration in future clinical research initiatives for rare diseases, including accurately accommodating different clinic workflows and balancing comprehensiveness of data collection with available resources. Integrating data collection within clinical care, leveraging electronic medical records, and implementing core outcome sets will be essential for achieving sustainability.

Meet the First Authors.

Meet the First Authors.

2473-PUB: Differential Effects of High-Fat Diet and Niacin on Nonalcoholic Fatty Liver Disease in C57BL/6J and B6129SF2/J Mice: A Metabolomic Analysis

Recent studies have demonstrated significant metabolic changes in different strains of mice fed a high-fat diet (HFD). Pharmacological doses of niacin can improve nonalcoholic fatty liver disease (NAFLD) in HFD-fed rodents. However, previous study from our lab demonstrated that niacin increases the hepatic triglyceride content and histological score in HFD-fed B6129SF2/J (B6129) mice but has no effect in C57BL/6J (B6) mice. Therefore, the aim of this study was to identify the mechanism responsible for niacin-induced fatty liver in B6129 mice using targeted liver metabolomic analysis. Livers were collected from B6 and B6129 mice, which were fed either a chow (10% fat) or HFD (60% fat) for 20 weeks with niacin (360 mg/kg/day) or vehicle supplementation from week 5 to week 20. Two hundred polar metabolites were identified in these livers. A total of 21 and 26 metabolites identified as different between chow and HFD group in B6 and B6129 mice, respectively. In B6 mice, only 6 metabolites were identified as different with niacin treatment and no specific pathways appeared to be impacted. In contrast to B6 mice, 16 metabolites and 5 pathways were impacted by niacin in HFD-fed B6129 mice. Of the metabolites that were changed in these pathways, only hydroxyphenylpyruvate (also known as 4-Hydroxyphenylpyruvate, 4-HPP) did not change with HFD feeding but significantly decreased with niacin treatment. 4-HPP is an intermediate in the metabolism of phenylalanine/tyrosine and improves mitochondrial oxidation in rats subjected to hemorrhagic shock. Therefore, decreased 4-HPP by niacin may lead to decreased beta-oxidation in the liver and subsequent lipid accumulation and liver damage in B6129 mice. Further lipidomic analysis suggested different hepatic lipid profiles with HFD and niacin treatment in B6129 mice, which may explain the increased NAFLD development in these mice with niacin treatment. Disclosure H. Fang: None. Z. Li: None. E. Graff: Research Support; Self; Elanco Animal Health. K.J. McCafferty: None. R.L. Judd: None. Funding Boshell Diabetes and Metabolic Diseases Research Program

The Therapeutic Role of Xenobiotic Nuclear Receptors Against Metabolic Syndrome.

Diabetes, with an increased prevalence and various progressive complications, has become a significant global health challenge. The concrete mechanisms responsible for the development of diabetes still remain incompletely unknown, although substantial researches have been conducted to search for the effective therapeutic targets. This review aims to reveal the novel roles of Xenobiotic Nuclear Receptors (XNRs), including the Peroxisome Proliferator-Activated Receptor (PPAR), the Farnesoid X Receptor (FXR), the Liver X Receptor (LXR), the Pregnane X Receptor (PXR) and the Constitutive Androstane Receptor (CAR), in the development of diabetes and provide potential strategies for research and treatment of metabolic diseases. We retrieved a large number of original data about these five XNRs and organized to focus on their recently discovered functions in diabetes and its complications. Increasing evidences have suggested that PPAR, FXR, LXR ,PXR and CAR are involved in the development of diabetes and its complications through different mechanisms, including the regulation of glucose and lipid metabolism, insulin and inflammation response and related others. PPAR, FXR, LXR, PXR, and CAR, as the receptors for numerous natural or synthetic compounds, may be the most effective therapeutic targets in the treatment of metabolic diseases.

Nutritional management of phenylalanine hydroxylase (PAH) deficiency in pediatric patients in Canada: a survey of dietitians\u2019 current practices

BackgroundPhenylalanine hydroxylase (PAH) deficiency is one of 31 targeted inherited metabolic diseases (IMD) for the Canadian Inherited Metabolic Diseases Research Network (CIMDRN). Early diagnosis and initiation of treatment through newborn screening has gradually shifted treatment goals from the prevention of disabling complications to the optimization of long term outcomes. However, clinical evidence demonstrates that subtle suboptimal neurocognitive outcomes are present in the early and continuously diet-treated population with PAH deficiency. This may be attributed to variation in blood phenylalanine levels to outside treatment range and this, in turn, is possibly due to a combination of factors; disease severity, dietary noncompliance and differences in practice related to the management of PAH deficiency. One of CIMDRN’s goals is to understand current practices in the diagnosis and management of PAH deficiency in the pediatric population, from the perspective of both health care providers and patients/families.ObjectivesWe investigated Canadian metabolic dietitians’ perspectives on the nutritional management of children with PAH deficiency, awareness of recently published North American treatment and nutritional guidelines in relation to PAH deficiency, and nutritional care practices within and outside these guidelines.MethodsWe invited 33 dietitians to participate in a survey, to ascertain their use of recently published guidelines and their practices in relation to the nutritional care of pediatric patients with PAH deficiency.ResultsWe received 19 responses (59% response rate). All participants reported awareness of published guidelines for managing PAH deficiency. To classify disease severity, 89% of dietitians reported using pre-treatment blood phenylalanine (Phe) levels, alone or in combination with other factors. 74% of dietitians reported using blood Phe levels ≥360 μmol/L (6 mg/dL) as the criterion for initiating a Phe-restricted diet. All respondents considered 120-360 μmol/L (2–6 mg/dL) as the optimal treatment range for blood Phe in children 0–9 years old, but there was less agreement on blood Phe targets for older children. Most dietitians reported similar approaches to diet assessment and counseling: monitoring growth trends, use of 3 day diet records for intake analysis, individualization of diet goals, counseling patients to count grams of dietary natural protein or milligrams of dietary Phe, and monitoring blood Phe, tyrosine and ferritin.ConclusionWhile Canadian dietitians’ practices in managing pediatric PAH deficiency are generally aligned with those of the American College of Medical Genetics and Genomics (ACMG), and with the associated treatment and nutritional guidelines from Genetic Metabolic Dietitians International (GMDI), variation in many aspects of care reflects ongoing uncertainty and a need for robust evidence.

Effects of Rodent Diet Choice and Fiber Type on Data Interpretation of Gut Microbiome and Metabolic Disease Research

Poor diet reporting and improperly controlling laboratory animal diet continues to reduce our ability to interpret data effectively in animal studies. In order to make the best use of our resources and improve research transparency, proper reporting methods that include a diet design are essential to improving our understanding of the links between gut health and metabolic disease onset. This unit will focus on the importance of diet choice in laboratory animal studies, specifically as it relates to gut health, microbiome, and metabolic disease development. The two most commonly used diet types, grain-based (GB) diets, and purified ingredient diets, will each be described, with particular emphasis on their differences in dietary fiber. A further description of how these diet types and fiber can affect gut morphology and microbiota will be provided as well as how purified ingredient diets may be improved upon. © 2018 by John Wiley & Sons, Inc.

The common use of improper control diets in diet-induced metabolic disease research confounds data interpretation: the fiber factor

Diets used to induce metabolic disease are generally high in fat and refined carbohydrates and importantly, are usually made with refined, purified ingredients. However, researchers will often use a low fat grain-based (GB) diet containing unrefined ingredients as the control diet. Such a comparison between two completely different diet types makes it impossible to draw conclusions regarding the phenotypic differences driven by diet. While many compositional differences can account for this, one major difference that could have the greatest impact between GB and purified diets is the fiber content, both in terms of the level and composition. We will review recent data showing how fiber differences between GB diets and purified diets can significantly influence gut health and microbiota, which itself can affect metabolic disease development. Researchers need to consider the control diet carefully in order to make the best use of precious experimental resources.

Use and Importance of Nonhuman Primates in Metabolic Disease Research: Current State of the Field.

Obesity and its multiple metabolic sequelae, including type 2 diabetes, cardiovascular disease, and fatty liver disease, are becoming increasingly widespread in both the developed and developing world. There is an urgent need to identify new approaches for the prevention and treatment of these costly and prevalent metabolic conditions. Accomplishing this will require the use of appropriate animal models for preclinical and translational investigations in metabolic disease research. Although studies in rodent models are often useful for target/pathway identification and testing hypotheses, there are important differences in metabolic physiology between rodents and primates, and experimental findings in rodent models have often failed to be successfully translated into new, clinically useful therapeutic modalities in humans. Nonhuman primates represent a valuable and physiologically relevant model that serve as a critical translational bridge between basic studies performed in rodent models and clinical studies in humans. The purpose of this review is to evaluate the evidence, including a number of specific examples, in support of the use of nonhuman primate models in metabolic disease research, as well as some of the disadvantages and limitations involved in the use of nonhuman primates. The evidence taken as a whole indicates that nonhuman primates are and will remain an indispensable resource for evaluating the efficacy and safety of novel therapeutic strategies targeting clinically important metabolic diseases, including dyslipidemia and atherosclerosis, type 2 diabetes, hepatic steatosis, steatohepatitis, and hepatic fibrosis, and potentially the cognitive decline and dementia associated with metabolic dysfunction, prior to taking these therapies into clinical trials in humans.