Background: The primary goal of bariatric surgery is to not only lose weight but also resolve comorbidities and improve quality of life. It is crucial to identify predictors of surgical outcomes. The current study investigates pre-surgical depression, pre-surgical anxiety, and demographic factors (age, gender, education, race, and baseline body mass index) as predictors of post-surgical outcomes as well as examines difference in the effect of laparoscopic Roux-en-Y gastric bypass versus laparoscopic adjustable gastric banding on post-surgical surgical outcomes. Methods: The study is a retrospective one-group pre-test-post-test design study that examined 88 (Females = 81, Males = 7) bariatric surgery participants at St. Luke's-Roosevelt Hospital. Data collected at baseline (three weeks prior to surgery) and 1 year post-surgery from participants administered the Zung Self-rating Depression Scale, the Liebowitz Social Anxiety Scale - Self-Report Version, and Quality of Life - Lite Scale were analyzed. Participants underwent either laparoscopic Roux-en-Y gastric bypass surgery or laparoscopic adjustable gastric banding surgery. Results: Age (F = 4.0, p = 0.05) and baseline body mass index (F = 5.8, p = 0.02) were significant predictors of % excess weight loss. Age (F = 4.2, p = 0.04) and baseline body mass index (F = 33.6, p < 0.001) were significant predictors of absolute weight loss (kg). Baseline body mass index (F = 4.2, p = 0.046) was also a significant predictor of total quality of life. The effect of laparoscopic Roux-en-Y gastric bypass versus laparoscopic adjustable gastric banding differed in changes in pre- to post-surgical total quality of life (F = 12.5, p = 0.001), % weight loss (F = 126.3, p < 0.001), % excess weight loss (F = 124.8, p < 0.001), and absolute weight loss (F = 87.7, p < 0.001). Baseline depression and baseline anxiety were not predictive of weight loss (% excess weight loss, % weight loss, or absolute weight loss), but baseline anxiety was predictive of post-surgical depression (F = 13.0, p = 0.001), post-surgical anxiety (F = 43.8, p < 0.001), and post-surgical total quality of life (F = 8.6, p = 0.005). Conclusion: The data show that younger age and lower baseline body mass index are positive predictors of weight loss, lower baseline body mass index and lower baseline anxiety are positive predictors of quality of life, and lower baseline anxiety is a positive predictor of post-surgical depression and anxiety. The data also show that baseline depression and baseline anxiety are not predictors of post-surgical weight loss. Hence, the data suggest that younger adults have a bigger chance to succeed at greater weight loss after surgery. In addition, treating baseline anxiety disorder might result in better quality of life after surgery. Interventions that are effective in lowering baseline body mass index might help with greater post-surgical weight loss and better post-surgical quality of life. Those with better scores on the baseline depression and anxiety assessment do not necessarily have greater weight loss after surgery, so denial of surgery to those with psychopathology should be further examined. Long-term follow-up is necessary.

Retinoic acid (RA)-signaling is involved in a broad spectrum of cellular processes, including formation of most embryonic tissues, epithelial differentiation, and is a critical regulator of stem cell differentiation in vitro. Studies from our lab have focused on the role of RA-signaling in the urinary tract, where we find that it plays multiple roles. By inducing expression of a floxed dominant-negative mutant Rar receptor, termed RaraDN, in the bladder, we find that RA-receptor signaling from the bladder epithelium plays distinct roles during urinary tract development; it is required for establishing mature ureter-bladder connections and for differentiation of the bladder epithelia. Congenital abnormalities of the kidney and urinary tract (CAKUT) characterize a range of lower urinary tract defects such as kidney and ureter agenesis, hydronephrosis, and vesicoureteral reflux. Development of the lower urinary tract, which consists of the kidneys, ureters, bladder, and urethra, is crucial for removal of toxic substances from the blood and depends on patent connections between the ureter and the bladder. Impaired vitamin A signaling, either by maternal vitamin A deficiency in mice, or deleting RA-synthesizing enzymes and RA-receptors, leads to syndromic urinary tract abnormalities similar to those seen in humans. Our previous studies have suggested that proper ureter-bladder connections depend on signals derived from the bladder. By selectively inhibiting RA-signaling in the bladder epithelium, we show that RA-receptor signaling from the bladder is required for nephric duct (ND) insertion into the cloacal epithelium, CND maturation, and late-stage ureteral apoptosis in part through Ret. In addition, we find that RA acts independently of Ret where it regulates bladder growth and epithelial differentiation. The bladder epithelium, or urothelium, is a stratified epithelium that lines the major portion of the lower urinary tract and provides a crucial barrier between urine and blood. It contains basal, intermediate, and umbrella cells that synthesize and traffic uroplakin proteins to its apical surface. Vitamin A has been shown to be necessary for preventing keratinization of the bladder epithelia, and in vitro, it can induce the differentiation of endodermal ES cells into populations of cells that express markers of the urothelium. Recent studies suggest that Shh-expressing population in the adult bladder contains progenitors that can repopulate the urothelium after damage. Here we report that RA-receptor-dependent signaling temporally regulates Shh-expressing urothelial progenitors and is required for formation of intermediate and umbrella cells during early development. Furthermore, we find that in the absence of RA-signaling, Shh-progenitors undergo a fate change, down-regulating uroplakins and up-regulating squamous markers, suggesting that RA is normally required for either positively regulating urothelial differentiation or negatively suppressing squamous differentiation.

Children with acute lymphoblastic leukemia (ALL) are at elevated risk for nutrition-related morbidities both during and after therapy. The degree to which dietary intake fluctuates during cancer therapy and possibly contributes to the development of nutrition-related morbidities is unknown. This study presents the results of the first prospective study describing changes in dietary intake in 667 children undergoing treatment for ALL. Dietary intake was evaluated with a food frequency questionnaire at three timepoints reflecting different intensities of cancer therapy: diagnosis (Time 1-no therapy), induction (Time 2- high-dose therapy), and continuation (Time 3- low-dose therapy). Dietary intake was compared to the Dietary Reference Intakes (DRIs) and normative data. Contrary to expectations, total caloric intake in the majority of patients exceeded the DRIs with a smaller percentage of patients below the DRI for calories. The majority of patients were within the DRI for all other macronutrients with an increase in intake of fat at Time 2. Despite adequate caloric intake, the majority of patients had low dietary intakes of calcium, vitamin D, and vitamin E while excess dietary intakes were observed for zinc and niacin. For folate, most patients were either below or above the DRI. In general, dietary intakes were reflective of normative data suggesting intakes are not significantly altered during treatment for ALL. This study was successful in identifying priority nutrients for dietary intervention and scientific inquiry. The effect of these strategies on the development of nutrition-related morbidities in children with ALL may be considered for future research initiatives.

Childhood obesity is a serious public health concern, yet evidence linking childhood obesity and related modifiable behaviors is lacking. This study examines cross-sectional associations among two measures of weight status, energy balance related behaviors (EBRB), and psychosocial mediators. Participants included children (N=1382) who participated in baseline assessments for the Food, Health and Choices childhood obesity study during Spring and Fall 2012. Participants were mostly low-income Hispanic and Black children, ages 9-13, from New York City public elementary schools in upper Manhattan and the Bronx. Body mass index percentile for age (BMI) and percent body fat (%BF) were calculated using a Tanita body composition analyzer and stadiometer. The Food, Health and Choices Questionnaire (FHC-Q), administered in participating classrooms, measured self-reported EBRB, such as sweetened beverage intake and physical activity frequency, as well as psychosocial mediators, such as outcome expectations and autonomy. Statistical analyses included Pearson correlations, regression analyses, one-way ANOVA, ANCOVA, and descriptive statistics. Despite a high correlation between BMI and %BF, a wide range of %BF was observed for each category of weight status determined by BMI: underweight, normal weight, overweight, and obese. Unexpectedly, slight but significant inverse correlations were observed between BMI/%BF and processed packaged snack and sweetened beverage intake. Overweight and obese children reported healthier EBRB than normal weight children. Mediator analyses identified habit strength as a predictive variable for most EBRB. Means for mediator scales indicated healthier levels of autonomous motivation, competence, goal setting skills, behavioral intentions, and outcome expectations among overweight and obese children compared to normal weight children. Results suggest more healthful behaviors and mediators may already be in place in overweight/obese children compared to normal weight children. However, EBRB for all children was far removed from current dietary and activity recommendations indicating room for improvement in this population. Further investigation of associations among childhood obesity, EBRB, and psychosocial mediators is warranted, as is the development of %BF standards for children.

Stress is an anticipatory or actual disruption of homeostasis which triggers physiological responses to prepare for the threat or to reestablish the system's internal equilibrium. Other than physical stress (e.g. blood loss, infection, pain, and cold) and psychogenic stress (e.g. novel environment (rodent) and immobilization (rodent)), nutrient (metabolic) stress such as high fat diet and fasting can also trigger stress responses. Central to the activation and regulation of the stress response in mammals is the hypothalamus, where signals from the periphery and other regions of the brain are integrated and processed. Insulin and leptin are two important hormones that provide information about the energy status of the body to the hypothalamus. The hypothalamic insulin- and leptin- sensing circuits integrate these signals to coordinate metabolic outcomes such as food intake, energy expenditure, fuel partitioning, etc. Given the tight correlation between stress axis activity and nutrient status, it raises the possibility that hypothalamic insulin- and leptin- sensing circuits may also be involved in coordinating responses of the stress axis, particularly during stress pertaining changes in energy homeostasis. My thesis research focused on understanding the roles and the interactions of hypothalamic insulin and leptin signals in regulating and coordinating metabolic and hypothalamic-pituitary-adrenal (HPA) axis functions. My first project involved understanding the role of hypothalamic insulin signals in hypothalamic leptin receptor deficient animals (L^2.1 KO) in regulating energy metabolism (Chapter 2). We observed an increase in body weight and adiposity in D^2.1 KO mice that lack both hypothalamic insulin receptor (InsR) and leptin receptor (LepRb) signals. These changes were accompanied by reduced energy expenditure, rather than an increase in food intake. Unexpectedly, there was a drastic loss in body temperature in D^2.1 KO during fasting that was significantly exacerbated by single-housing. These results suggest that interactions between hypothalamic insulin and leptin signals are important for regulating energy expenditure and body temperature. Furthermore, this study also highlights the influence of housing conditions on the evaluation of thermogenic defects in mice. My second project involved the study of hypothalamic insulin signals in regulating stress-related functions by using the non-obese hypothalamic InsR-deficient mice (I^2.1 KO)(Chapter 3). We showed that I^2.1 KOs have elevated baseline hypothalamic Avp synthesis, increased activity of the HPA axis after restraint, as well as increased anxiety-like behaviors. This study demonstrated that hypothalamic InsR signals suppress the stress response to restraint, possibly by influencing AVP release to the median eminence and decreasing hypothalamic glucocorticoid receptor (GR) signals, and may also modulate anxiety-like behaviors. My current research focuses are: to remove InsR signals by using more restrictedly expressed Cre lines in order to identify brain nuclei mediating insulin's effect on stress response and/or anxiety-like behaviors; to identify the hypothalamic AVP neuronal population affected by the loss of InsR and potential extra-hypothalamic downstream targets of these neurons; to pinpoint the hypothalamic nuclei where GR signaling is altered in I^2.1 KO. By identifying the critical anatomical and functional components mediating insulin's effects, we hope to provide more understanding of the contribution of central insulin resistance to the development of HPA axis dsyregulation and anxiety disorders in humans.

Fatty acid deposition in non-adipose tissue leads to a cellular dysfunction known as lipotoxicity. Neutral lipid synthesis is known to protect against lipotoxicity but many additional pathways are likely to be integral in this process. In order to identify pathways protective against lipid induced cell death, we performed a genome-wide unsaturated fatty acid (UFA) sensitivity screen in yeast. Of the ~5,500 gene mutants tested, we identified 156 which resulted in sensitivity to growth on media containing palmitoleate. These genes identified many cellular processes, including vesicular trafficking, lipid metabolism and vacuolar protein sorting. Deletion of three members of the GET complex, a complex essential for tail anchored protein insertion into the ER, caused vulnerability to fatty acids. We went on to assess the role of GET3 in cellular lipid metabolism and found that ablation of GET3 results in a defect in vacuolar hydrolysis and a reduction in lipid droplet number; pathways which we hypothesize to be integrally related. Furthermore, a major goal of this study was to find mammalian genes playing an integral role in pathways of lipoprotection. Of the 156 gene deletions found to confer fatty acid sensitivity in yeast, 68 have been conserved in mammals. We demonstrate that two of these mammalian orthologs, ARV1and ASNA1, are vulnerable to fatty acid treatment upon knockdown in the MIN6 pancreatic beta-cell line. These mammalian genes, which were identified through the fatty acid sensitivity screen in yeast, are involved in lipid induced cellular dysfunction in pancreatic beta-cells and, in the case of ARV1, hepatocytes. Therefore, these genes likely play a role in the progression of the lipotoxic diseases; type 2 diabetes and nonalcoholic fatty liver disease.

This exploratory study examined maternal attitudes, subjective norms and food selection behaviors of 31 mothers (mean age 29.6 years, 50% Hispanic, 34% Black, 47% ≤ high school, 31% marginal health literacy, 71% Women, Infants and Children program participants) for their 2 and 3-year-old children (n=32, 50% female, 34.4% overweight/obese, 72% breastfed during infancy) to identify factors associated with childhood overweight. The Theory of Reasoned Action was used to examine relationships between variables of interest. Subjects were recruited from two primary care sites. Measurements included 5 surveys, child anthropometric measures and a simulation exercise to identify types and quantities of food mothers offered to their child. Selected food items were weighed and organized by food group and compared to USDA recommendations by child's age, gender and activity level. Data were analyzed using descriptive statistics, Spearman's rho correlation coefficients, and multivariate linear regression modeling. On average, mothers offered their children more fruit (237%) and meat (153%) but less vegetables (75%), dairy (79%) and grain (65%) than what is recommended. Mothers of 2 year olds selected greater quantity of food compared to mothers of 3 year old children for all food groups except dairy (p <0.05). Demographic, normative beliefs, maternal attitudes and health literacy meeting criteria were entered into multivariate regression models to predict behavioral intent. Final models explained 13% (dairy- restrictive attitude); 28% (grain- child's age, maternal BMI, physical activity); 40% (fruit-child's age, maternal education, normative belief, and health literacy); 44% (calories- child's age, normative beliefs for all food groups, restrictive attitude); 38% (meat- child's age, Hispanic ethnicity, normative belief) and 51% (vegetable- child's age, television viewing, normative belief and health literacy) of the variance of behavioral intent for the respective food groups. Normative beliefs and health literacy are potentially modifiable. Therefore, appraisal of maternal normative beliefs about dietary recommendations for children and health literacy may identify children at risk for overweight and obesity.

The liver maintains lipid homeostasis by regulating hepatic uptake of circulating fatty acids (FA) and triglycerides (TG), de novo lipogenesis (DNL), FA, and secretion of TG in very low density lipoproteins (VLDL). To investigate the effects of reduced VLDL secretion on hepatic lipid homeostasis, we examined the effects of knockdown of either apolipoproteinB (apoB) or microsomal triglyceride transfer protein (MTP) using antisense oligonucleotides (ASO) for 6 weeks in apobec-1 knockout mice. Despite a similar decrease in VLDL secretion in mice treated with either apoB ASO or MTP ASO, there was an increase in liver TG content only in the MTP ASO-treated mice. There were no differences in either FA uptake or secretion, or lipid synthesis from DNL. However, there was an increase in autophagosomes that co-localized with the endoplasmic reticulum (ER) in the apoB ASO-treated livers. We hypothesized that there is an accumulation of lipid in the ER due to the absence of apoB, the necessary protein for the formation and secretion of VLDL, and so the lipid becomes trapped inside the lumen of the ER. We provide evidence that the ER was engulfed by autophagosome and shuttled to the lysosome where the ER and its lipid content were degraded, leading to an increase in FA oxidation. This increase in autophagy of the ER prevented steatosis. We were surprised, however, that there was no evidence for ER stress after 6 weeks of knockdown of apoB and so we next examined the effect of only 3 weeks of ASO treatment and found that at this earlier time point, apoB ASO-treated mice had increased steatosis as compared to control ASO-treated mice and that the level of steatosis was similar to that caused by MTP ASO-treated mice. Furthermore, at 3 weeks of apoB ASO treatment, there was an increase in markers of ER stress in the apoB ASO-treated mice, but no evidence of an increase in the autophagy. After inhibition of autophagy, both ER stress and apoptosis were markedly increased in the livers of the apoB ASO-treated mice, indicating that autophagy protected the hepatocyte when apoB was knocked down. Thus, in this model of inhibition of apoB synthesis, with markedly reduced secretion of VLDL, TG that enters the ER gets trapped there and first induces ER stress. The ER stress response is unable to repair the defect, lipid accumulation in the ER continues to increase, and autophagy of the lipid-filled ER is induced, allowing the lysosome to act as an alternative pathway for oxidation of FA by the mitochondria. Our results suggest, therefore, that by stimulating autophagy, it may be possible to lower plasma TG levels by inhibiting VLDL secretion without causing hepatic steatosis. PPARgamma2, which has been previously shown to contribute to increased lipid accumulation through decreased TG turnover of the lipid droplets and increased DNL, is aberrantly expressed in hepatic steatosis. However, the basis for increased expression of the PPARgamma2 specific isoform in the liver is unknown. We used hepatocytes and in vivo models to study the relative effects of hyperinsulinemia and/or increased FA delivery on hepatic PPARgamma2 and PPARgamma1 expression. Hepatic PPARgamma2 expression is not increased by increased fatty acid delivery in the absence of hyperinsulinemia but is regulated by changes in insulin signaling. Since hyperinsulinemia often occurs in the presence of excess nutrients, including glucose and FA, expression of PPARgamma2 in the liver, with subsequent effects on hepatic lipid droplet formation and stability, may be a means of protecting hepatocytes from lipotoxicity.

Obesity alters metabolism including increasing insulin resistance and hepatic accumulation of triglycerides. Obesity also activates immune responses in adipose tissue (AT) including accumulation of adipose tissue macrophages (ATMs) (Weisberg, McCann et al. 2003, Xu, Barnes et al. 2003). AT releases chemokines that recruit circulating monocytes into AT which differentiate in ATMs. In a lipid-rich environment, ATMs accumulate lipid by mechanisms that have yet to be directly studied. (Prieur, Mok et al. 2011 , Cinti, Mitchell et al. 2005, Xu, Grijalva et al. 2013). Some work has implied that FFA are taken up by ATMs and re-esterified with glycerol to yield TG; others imply the direct release of triglycerides (TG) by select adipocytes in crown-like structures (Prieur, Mok et al. 2011 , Cinti, Mitchell et al. 2005, Xu, Grijalva et al. 2013). Nonetheless, obesity leads to the accumulation of neutral lipid in ATMs and induces lysosomal dependent lipid catabolism. The question my thesis tried to answer is how lipid is delivered to lysosomes. Autophagy of lipid droplets or lipophagy contributes to lipid catabolism in other cells, including hepatocytes and foam cells. We hypothesized that lipophagy would regulate lipid delivery for lysosomal dependent lipid catabolism in ATMs. Our data, however, demonstrated that lipophagy does not contribute to lysosomal dependent lipid catabolism in ATMs. Myeloid specific ablation of Atg7, a protein necessary for autophagosome formation, did not lead to alterations in lipid content of ATMs or in whole body metabolism. These finding suggested an endosomal-dependent delivery of lipid to lysosomes in ATMs. We found lipid in lipid vesicles, structures distinct from lipid droplets. These neutral lipid vesicles contain adipocyte specific proteins suggesting they are released from adipocytes. The adipocyte derived lipid vesicles also had the ability to differentiate bone marrow derived macrophages into ATM-like cells. Lipid vesicles provide a transport mechanism for lipids between adipocytes and ATMs, contributing to ATM differentiation. Our data suggest a complex interplay in lipid exchange between adipocytes and ATMs and a role for adipocyte derived vesicles in ATM differentiation.

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