Obesity is a worldwide epidemic increasing at an alarming rate among youth who are facing similar health problems as adults. Sleep Apnea Syndrome (SAS) is an underdiagnosed comorbidity of obesity, characterized by repetitive nocturnal interruptions in breathing. Obesity is associated with delayed skeletal maturation in overweight youth, but mechanisms contributing to this problem are unclear. Obesity and SAS both have been shown to disrupt regulatory hormones and cytokines that influence bone accretion during adolescence. PURPOSE: The purpose of this study was to assess the combined effects of excess body weight and SAS on bone mineral density (BMD) and content (BMC), bone turnover, and on the regulatory hormones leptin and IGF-1 known to potentially influence bone accretion during adolescence. METHODS: Men aged 18-28 years were assigned to groups as follows: normal weight controls (CON: AHI <3, n=8); overweight without SAS (OWT: BMI < 26 kg/m2 and AHI <3, n=9); and overweight with SAS (SAS: BMI >26 kg/m2 and AHI >5, n=8). The apnea/hypopnea index (AHI) expresses the score for disrupted nighttime breathing events/hr and was obtained in this study with results from a home sleep screening test. Health history and Epworth Sleepiness Scale (ESS) questionnaires also were administered. Bone mineral parameters and body composition variables were measured with dual-energy X-ray absorptiometry. Serum osteocalcin, leptin, IGF-1, and NTx-1 were measured, respectively, by radioimmunoassay and enzyme-linked immunoabsorbent assay. RESULTS: Fat-free mass, intra-abdominal fat, and fat mass were higher in the SAS and OWT groups (p<0.03). ESS scores revealed that SAS individuals were sleepier than CON and OWT groups (p<0.009). Total body and site-specific BMD and BMC values (lumbar spine, hip, and forearm) were similar between groups and did not relate to the estimated AHI score. Serum OC and NTx-1 did not differ between groups. Leptin levels were 30% higher in OWT and SAS than in the CON group (p<0.02), but did not correlate with the AHI score. Across all subjects (n=25), only lumbar spine BMC (p<0.005) was correlated to AHI (r=-.52; p<0.01). The preponderance of this relationship between AHI and lumbar spine BMC was attributable to the close inverse association of these two variables within the SAS group (r = -.81; p<0.001). CONCLUSION: The effects of SAS were not influenced by the amount of whole-body, intra-abdominal adiposity or lean body mass. Neither leptin nor IGF-1 predicted bone status across all groups. Daytime fatigue and sleepiness, a cardinal symptom of SAS, combined with overweight may contribute to lower lumbar BMC by chronically reducing weight-bearing physical activity and thereby reduce exposure time for mechanical loading of the spine in affected individuals. Further research is needed to explore the biochemical, physiological, and apparently the physical activity implications of SAS on skeletal status and turnover. / Master of Science

Abstract The extracellular matrix is not just a scaffold for cells and tissues, but rather a dynamic part of the human body. Characteristics of collagens, the major protein components of the extracellular matrix, are determined already during synthesis and mutations in genes encoding collagens, unbalance of regulators or dysfunction of collagen modifying enzymes, for instance, can lead to severe clinical complications. Certain hydroxylysine residues formed by lysyl hydroxylases (LHs) function in collagens as precursors of collagen cross-links that stabilize collagenous structures and thereby tissues. In humans, a deficiency of LH1, which is known to hydroxylate lysines in the helical regions of collagen polypeptides, causes Ehlers-Danlos syndrome VIA (EDS VIA). It is characterized e.g. by progressive kyphoscoliosis and hypermobile joints. Mutations in LH2, which is known to hydroxylate lysines in the telopeptides of collagen polypeptides, cause Bruck syndrome type 2 (BS2). BS2 patients suffer from fragile bones and congenital joint contractures, for instance, but the syndrome is usually not lethal. In this work we have generated and analyzed genetically modified LH1 and LH2 null mouse lines to study the in vivo functions and roles of these enzymes. Analyses concentrated also on collagen cross-links that were determined from several null or heterozygous mouse tissues. In the present work we also studied the effects of known BS2 mutations on recombinant human LH2 polypeptides to understand the molecular pathology of the syndrome. As an animal model for human EDS VIA, LH1 null mice had certain characteristics typical for EDS VIA, such as muscular hypotonia, but generally the symptoms were milder. Like EDS VIA patients, the mice have an increased risk of arterial ruptures and ultrastructural changes can be seen in the wall of the aorta, explained by inadequate helical lysine hydroxylation accompanied by a changed cross-linking state of tissues. Similarly, analysis of the LH2 null mouse line demonstrated the importance of the enzyme in cross-link formation. We showed that even a reduced amount of LH2 in adult mice changes the cross-linking pattern in tissues and a total lack of the enzyme leads to embryonic lethality. Furthermore, we demonstrated that LH2 is particularly important in tissue structures supporting blood vessels in the developing mouse embryo or in extraembryonic tissues. Finally, our in vitro studies with recombinant human LH2 polypeptides revealed that the known BS2 mutations severely affect the activity of the enzyme thus explaining the clinical symptoms of the patients, but the mutations do not lead to a total inactivation of the enzyme, which may be critical for the survival of patients. / Tiivistelmä Solunulkoinen matriksi ei ole ainoastaan soluja ja kudoksia tukeva rakenne, vaan se on dynaaminen osa ihmiskehoa. Kollageenien, solunulkoisen matriksin yleisimpien proteiinien ominaisuudet määräytyvät jo kollageenien synteesivaiheessa ja mutaatiot kollageeneja koodittavissa geeneissä, säätelytekijöiden epätasapaino tai esimerkiksi kollageeneja muokkaavien entsyymien toimintahäiriöt voivat johtaa vaikeisiin kliinisiin komplikaatioihin. Tietyt lysyylihydroksylaasien (LH) muodostamat hydroksilysiinitähteet toimivat kollageeneissa kollageeniristisidosten esiasteina. Ristisidokset vakauttavat kollageenirakenteita ja siten myös kudoksia. LH1 hydroksyloi lysiinejä kollageenipolypeptidien kolmoiskierteisellä alueella ja ihmisellä entsyymin puutos aiheuttaa tyypin VIA Ehlers-Danlosin syndrooman (EDS VIA), jossa potilailla on esimerkiksi etenevää kyfoskolioosia ja yliliikkuvat nivelet. Mutaatiot LH2-entsyymissä, joka hydroksyloi lysiinejä kollageenipolypeptidien telopeptidialueilla, aiheuttavat tyypin 2 Bruckin syndrooman (BS2). BS2-potilaat kärsivät mm. luiden hauraudesta ja niveljäykkyydestä, mutta syndrooma ei yleensä ole letaali. Tässä työssä loimme ja analysoimme geneettisesti muunnellut LH1 ja LH2 hiirilinjat, joiden kyseinen LH-geeniaktiivisuus on hiljennetty. Linjojen avulla halusimme tutkia näiden entsyymien toimintaa ja merkitystä in vivo. Analyysit keskittyivät myös kollageeniristisidoksiin, joita tutkittiin useista poistogeenisten tai heterotsygoottisten hiirten kudoksista. Ymmärtääksemme BS2:n molekyylipatologiaa, tutkimme tässä työssä myös tunnettujen BS2-mutaatioiden vaikutuksia ihmisen LH2-rekombinanttiproteiinissa. EDS VIA:n eläinmallina LH1 poistogeenisillä hiirillä on joitakin ominaisuuksia, kuten lihashypotonia, jotka ovat tyypillisiä EDS VIA:lle, mutta yleisesti oireet ovat lievempiä. Kuten EDS VIA-potilailla, hiirillä on kohonnut valtimoiden repeytymisriski ja aortan seinämän ultrarakenteessa voidaankin havaita muutoksia. Oireita voidaan selittää riittämättömällä kollageenien kolmoiskierteisen alueen lysiinien hydroksylaatiolla, joka muuttaa kollageenien ristisidostilaa kudoksissa. Myös LH2-hiirilinjan analysointi osoitti kyseisen entsyymin tärkeyden ristisidosten muodostamisessa. Jo alentunut LH2:n määrä aikuisissa hiirissä muuttaa kudosten kollageeniristisidoksia ja täydellinen entsyymin puuttuminen johtaa sikiön kuolemaan. Lisäksi osoitimme, että LH2 on erityisen tärkeä kudosrakenteissa, jotka tukevat kehittyvän hiiren sikiön tai sikiön ulkopuolisten kudosten verisuonia. In vitro-tutkimukset ihmisen LH2-rekombinanttiproteiinilla paljastivat, että tunnetut BS2-mutaatiot vaikuttavat erittäin haitallisesti entsyymin toimintaan, mikä selittää potilaiden kliiniset oireet, mutta mutaatiot eivät kuitenkaan aiheuta entsyymin täydellistä inaktivaatiota, mikä voi olla kriittistä potilaiden selviytymisen kannalta.