Engineering Chronic Disease Avoidance From Hyperinsulinemia to Bad

Engineering Chronic Disease Avoidance From Hyperinsulinemia to Bad Cholesterol ® Ivor Cummins BE(Chem) CEng 2017 MIEI Ivor PMP Cummins BE(Chem) CEng

PART 2 CHOLESTEROL - put into Context

The Human Machine: When Properly Maintained ! Very Low Insulin Levels Very Low Blood Glucose No Diabetic Physiology No Metabolic Syndrome -Hyperinsulinemia Syn No Hypertension No Central Obesity Great ω3 to ω6 Ratio Kitavans Too… “Coronary atherosclerosis in indigenous South American Tsimane: a cross-sectional cohort study” Lancet. 2017 Apr 29; 389(10080): 1730 -1739.

“Apolipoprotein B and non-high density lipoprotein cholesterol and the risk of coronary heart disease in Chinese ” Journal of Lipid Research Volume 48,

Google “Cholesterol Conundrum”

Atherosclerosis Decoded – LDL Versus Root Causes

1 2 3 4

Artery Wall Lumen 1 2 3 4 LDL Particles 1 2 3 4 Artery Wall

Red Blood Cell LDL’s 1 1 1 The Glycocalyx Platelet

Red Blood Cell LDL’s 1 The Glycocalyx 2 2 2 Endothelial Cell Platelet

Red Blood Cell LDL’s 1 The Glycocalyx 3 Endothelial Cell 2 3 3 Proteoglycans Sub. Endotheli al. Intima Platelet

Red Blood Cell LDL’s 1 2 4 HDL Efflux ! The Glycocalyx 4 Endothelial Cell 3 Proteoglycans Sub. Endotheli al. Intima Platelet

Red Blood Cell LDL’s 1 The Glycocalyx 1 2 2 Endothelial Cell 3 HDL Efflux ! 4 3 Proteoglycans Sub. Endotheli al. Intima Platelet

Red Blood Cell LDL’s 1 The Glycocalyx What governs or determines this 3 -layer leakage …and Efflux 1 2 2 Endothelial Cell 3 HDL Efflux ! 4 3 Proteoglycans Platelet Sub. Endotheli al. Intima ?

Layer 1 The GLYCOCALYX

RESPECT Your GLYCOCALYX

RESPECT Your GLYCOCALYX “Arterial glycocalyx dysfunction is the first step in the atherothrombotic Q J Med 2008; 101: 513– process” 518

Layer 1 - The GLYCOCALYX Red Blood Cell LDL’ s

- The GLYCOCALYX Red Blood Cell LDL’ s 400 Red Blood Cell 300 LDL’ s 200 100 cells 1 LDL Internalisation ng/106 Layer Control “Surface Determinants of Low Density Lipoprotein Uptake by Endothelial Cells” Atherosclerosis, 53 (1984) 21 -29

- The GLYCOCALYX Red Blood Cell LDL’ s 400 Red Blood Cell 300 LDL’ s 200 100 cells 1 LDL Internalisation ng/106 Layer Control Neuraminidas e “Surface Determinants of Low Density Lipoprotein Uptake by Endothelial Cells” Atherosclerosis, 53 (1984) 21 -29

- The GLYCOCALYX Red Blood Cell LDL’ s 400 Red Blood Cell 300 LDL’ s 200 100 cells 1 LDL Internalisation ng/106 Layer Control Cationized Ferritin

Layer 1 - The GLYCOCALYX High sugar / SAD diets Hypertension Red Blood Cell LDL’ s Red Blood Cell Oxidative Stress Oxidized LDL (not native LDL) Smoking Arterial Morphology Ischemia/reperfusion etc. LDL’ s

Layer 1 - The GLYCOCALYX Red Blood Cell LDL’ s Hyperinsulinemia Diabetic Physiology High Blood Glucose / Spikes Hypertension Metabolic Syndrome (Hyperinsulinemia Syn) Oxidative Stress Inflammation Smoking Etc. etc. Red Blood Cell LDL’ s

Layer 2 The ENDOTHELIUM

Layer 2 - The ENDOTHELIUM Lumen This is Transcytosis It Transports LDL to Intima Artery Wall

Layer 2 - The ENDOTHELIUM Lumen This is Transcytosis It Transports LDL to Intima Artery Wall “Receptor-Mediated Endocytosis and Intracellular Trafficking of Insulin and Low. Density Lipoprotein by Retinal Vascular Endothelial Cells” Investigative Ophthalmology & Visual Science, August 1994, Vol. 35, No. 9

2 - The ENDOTHELIUM Lumen 100 LDL location at 1 hr Layer “Receptor-Mediated Endocytosis and Intracellular Trafficking of Insulin and Low. Density Lipoprotein by Retinal Vascular Endothelial Cells” Investigative Ophthalmology & Visual Science, August 1994, Vol. 35, No. 9 77. 1 % 50 This is Transcytosis It Transports LDL to Intima Artery Wall 22. 9% Within Cells Transferred Across Cells

Layer 2 - The ENDOTHELIUM Lumen This is Transcytosis It Transports LDL to Intima Artery Wall “Visualization of the binding, endocytosis, and transcytosis of low density lipoprotein in the arterial endothelium in situ” THE JOURNAL OF CELL BIOLOGY • VOLUME 96 JUNE 1983 1677 -1689

Layer 2 - The ENDOTHELIUM Lumen This is Transcytosis It Transports LDL to Intima Artery Wall “TNF-α promotes early atherosclerosis by increasing transcytosis of LDL across endothelial cells: Crosstalk between NF-κB and PPAR-γ” Investigative Ophthalmology & Visual Science, August 1994, Vol. 35, No. 9

Layer 2 - The ENDOTHELIUM Lumen This is Transcytosis It Transports LDL to Intima Brain “A New Function for the LDL Receptor: Transcytosis of LDL across the Blood–Brain Barrier” The Journal of Cell Biology, Volume 138, Number 4, August 25, 1997 877– 889

Layer 2 - The ENDOTHELIUM Lumen C-reactive protein Oxidised LDL Oxidant Induction ROS -Reactive Oxygen This is Transcytosis Species TNFα –Tumor Necrosis It Transports LDL to Intima Factor Artery Wall Lipopolysaccharide Ingress

Layer 2 - The ENDOTHELIUM Lumen Hyperinsulinemia Diabetic High. Physiology Blood Glucose / Spikes Metabolic Syndrome This is Transcytosis It Transports LDL to Intima Artery Wall (Hyperinsulinemia Syn) Hypertension Oxidative Inflammatory Stress Drivers Smoking etc.

Layer 2 - The ENDOTHELIUM Lumen This is Paracellular Transport - It “Leaks” LDL into the Intima Artery Wall

Layer 2 - The ENDOTHELIUM Lumen This is Paracellular Transport - It “Leaks” LDL into the Intima Artery Wall “Endothelial Barrier and Its Abnormalities in Cardiovascular Disease” Front. Physiol. 6: 365.

2 - The ENDOTHELIUM Lumen This is Paracellular Transport - It “Leaks” LDL into the Intima Artery Wall LDL Permeability Layer “The role of apoptosis in LDL transport through cultured endothelial cell monolayers” Atherosclerosis. 2010 February ; 208(2): 335.

- The ENDOTHELIUM LDL Permeability 2 Lumen This is Paracellular Transport - It “Leaks” LDL into the Intima Artery Wall LDL Permeability Layer “The role of apoptosis in LDL transport through cultured endothelial cell monolayers” Atherosclerosis. 2010 February ; 208(2): 335. Increasing TNFα = Increasing Endothelial Cell Death = Increasing Paracellular Flux of LDL

Layer 2 - The ENDOTHELIUM Lumen TNFα –Tumor Necrosis Factor This is Paracellular Transport - It “Leaks” LDL into the Intima Artery Wall Angiotensin II Interleukin-17 Any insult to Endothelial Cells…

Layer 2 - The ENDOTHELIUM Lumen This is Paracellular Transport - It “Leaks” LDL into the Intima Artery Wall Hyperinsulinemia Diabetic High. Physiology Blood Glucose / Spikes Metabolic Syndrome (Hyperinsulinemia Syn) Hypertension Oxidative Inflammatory Stress Drivers Smoking etc.

Layer 3 The INTIMA PROTEOGLYCANS

en - The INTIMA PROTEOGLYCANS Lu m 3 Ar t W ery al l Layer

en - The INTIMA PROTEOGLYCANS Lu m 3 Ar t W ery al l Layer Increased LDL Reactivity and Binding with Proteoglycans

- The INTIMA PROTEOGLYCANS en Blood from MI Patients Lu m 3 Ar t W ery al l Layer Blood from Insulin Resistant Blood from Type 2 Diabetics Small Dense / Oxidized LDL - higher Apo. CIII content - plus much higher affinity T 1 Diabetic Murine Experiments (8. 1 times more retention vs control) Etc. Increased LDL Reactivity and Binding with Proteoglycans

en - The INTIMA PROTEOGLYCANS Lu m 3 Ar t W ery al l Layer Hyperinsulinemia Diabetic Physiology High Blood Glucose / Spikes Metabolic Syndrome (Hyperinsulinemia Syn) Hypertension Oxidative Stress Inflammatory Drivers Smokin etc. g Increased LDL Reactivity and Binding with Proteoglycans

Layer 4 HDL Efflux Issues

m en - HDL Efflux Issues Lu 4 HDL Efflux ! Ar t W ery al l Layer HDL Efflux !

4 - HDL Efflux Issues HDL Efflux ! Ar t W ery al l Lu m en Layer HDL Efflux ! “Macrophage-specific cholesterol efflux capacity has been directly and “HDL Cholesterol Efflux Capacity and Incident Cardiovascular Events” N Engl J Med causally linked to the prevention of 2014; 371: 2383 -93. atherosclerosis in animal

Layer 4 - HDL Efflux Issues Hazard Ratio Coronary Events 1. 0 0. 8 0. 64 0. 32 0. 12 High HDL “HDL Cholesterol Efflux Capacity and Incident Cardiovascular Events” N Engl J Med 2014; 371: 2383 -93. HDL Efflux Capacity (Adj) HDL Efflux (HR for Stroke)

Layer 4 - HDL Efflux Issues Hazard Ratio Coronary Events 1. 0 0. 8 0. 64 0. 2 High HDL “HDL Cholesterol Efflux Capacity and Incident Cardiovascular Events” N Engl J Med 2014; 371: 2383 -93. HDL Efflux Capacity

Layer 4 - HDL Efflux Issues Hazard Ratio Coronary Events 1. 0 0. 8 0. 64 0. 32 0. 12 High HDL “HDL Cholesterol Efflux Capacity and Incident Cardiovascular Events” N Engl J Med 2014; 371: 2383 -93. HDL Efflux Capacity (Adj) HDL Efflux (HR for Stroke)

4 - HDL Efflux Issues Hyperinsulinemia Diabetic High. Physiology Blood Glucose / Spikes Metabolic Syndrome (Hyperinsulinemia Syn) Hypertension Oxidative Stress Inflammatory Drivers Smokingetc. 1. 0 Hazard Ratio Coronary Events Layer 0. 8 0. 64 0. 32 0. 12 High HDL “HDL Cholesterol Efflux Capacity and Incident Cardiovascular Events” N Engl J Med 2014; 371: 2383 -93. HDL Efflux Capacity (Adj) HDL Efflux (HR for Stroke)

Red Blood Cell LDL’s 1 The Glycocalyx 1 2 2 Endothelial Cell 3 HDL Efflux ! 4 3 Proteoglycans Sub. Endotheli al. Intima Platelet

Red Blood Cell LDL’s 1 The Glycocalyx 1 2 4 Hyperinsulinemia Diabetic High. Physiology Blood Glucose / Spikes Metabolic Syndrome (Hyperinsulinemia Syn) Hypertension Oxidative Stress Inflammatory Drivers Smokingetc. Endothelial 2 Cell 3 HDL Efflux ! Platelet 3 Proteoglycans Sub. Endotheli al. Intima

Bonus Layer Oxidised LDL as Cause 0

Layer 0 - The OXIDISED LDL in PLASMA? “LOX-1 The Multifunctional Receptor Underlying Cardiovascular Dysfunction” Circ J 2009; 73: 1993 – 1999

Layer 0 “LOX-1 The Multifunctional Receptor Underlying Cardiovascular Dysfunction” Circ J 2009; 73: 1993 – 1999

Layer 0 - The OXIDISED LDL in PLASMA? Healthy Controls Hyperchol Patients “Low-Density Lipoprotein in Hypercholesterolemic Human Plasma Induces Vascular Endothelial Cell Apoptosis by Inhibiting Fibroblast Growth Factor 2 Transcription” Circulation 2003; 107: 2102 -2108

Layer 0 - The OXIDISED LDL in PLASMA? L 1 L 2 L 3 Hyperchol Patients L 1 L 2 L 3 L 4 L 5 Cu Percentage Endothelial Cell Death Healthy Controls “Low-Density Lipoprotein in Hypercholesterolemic Human Plasma Induces Vascular Endothelial Cell Apoptosis by Inhibiting Fibroblast Growth Factor 2 Transcription” Circulation 2003; 107: 2102 -2108

Layer 0 - The OXIDISED LDL in PLASMA? Healthy Controls L 1 L 2 L 3 Hyperchol Patients L 1 L 2 L 3 L 4 L 5 “Low-Density Lipoprotein in Hypercholesterolemic Human Plasma Induces Vascular Endothelial Cell Apoptosis by Inhibiting Fibroblast Growth Factor 2 Transcription” Circulation 2003; 107: 2102 -2108

Layer 0 - The OXIDISED LDL in PLASMA? L 1 L 2 L 3 Hyperchol Patients L 1 L 2 L 3 L 4 L 5 Percentage Endothelial Cell Death Healthy Controls “Low-Density Lipoprotein in Hypercholesterolemic Human Plasma Induces Vascular Endothelial Cell Apoptosis by Inhibiting Fibroblast Growth Factor 2 Transcription” Circulation 2003; 107: 2102 -2108

Layer 0 - The OXIDISED LDL in PLASMA? L 1 L 2 L 3 Hyperchol Patients L 1 L 2 L 3 L 4 L 5 OX Percentage Endothelial Cell Death Healthy Controls “Low-Density Lipoprotein in Hypercholesterolemic Human Plasma Induces Vascular Endothelial Cell Apoptosis by Inhibiting Fibroblast Growth Factor 2 Transcription” Circulation 2003; 107: 2102 -2108

Layer 0 Healthy Controls L 1 L 2 L 3 and being in the highest quartiles of the ox. LDL: Apo. B ratio increased the probability of coronary artery disease among patients 60 years of age or younger (odds ratio, 16. 8; N Engl J Med 2005; 353: 46 -57. P<0. 001)” L 4 L 5 Cu Percentage Endothelial Cell Death Hyperchol Patients - The OXIDISED LDL in PLASMA? “The combined effect of hypercholesterolemia “Low-Density Lipoprotein in Hypercholesterolemic Human Plasma Induces Vascular Endothelial Cell Apoptosis by Inhibiting Fibroblast Growth Factor 2 Transcription” Circulation 2003; 107: 2102 -2108

Layer 0 Healthy Controls Percentage Endothelial Cell Death Hyperchol Patients - The OXIDISED LDL in PLASMA? “The combined effect of hypercholesterolemia L 1 L 2 L 3 and being in the highest quartiles of the ox. LDL: Apo. B ratio increased the probability of coronary artery disease among patients 60 years of age or younger (odds ratio, 16. 8; N Engl J Med 2005; 353: 46 -57. P<0. 001)” L 4 L 5 Cu ? “Low-Density Lipoprotein in Hypercholesterolemic Human Plasma Induces Vascular Endothelial Cell Apoptosis by Inhibiting Fibroblast Growth Factor 2 Transcription” Circulation 2003; 107: 2102 -2108

Red Blood Cell LDL’s 1 The Glycocalyx 1 2 2 Endothelial Cell 3 HDL Efflux ! 4 3 Proteoglycans Sub. Endotheli al. Intima Platelet

Red Blood Cell 0 LDL’s 1 The Glycocalyx 1 2 2 Endothelial Cell 3 HDL Efflux ! 4 3 Proteoglycans Sub. Endotheli al. Intima Platelet

Red Blood Cell 0 LDL’s 1 The Glycocalyx 1 2 4 Hyperinsulinemia Diabetic High. Physiology Blood Glucose / Spikes Metabolic Syndrome (Hyperinsulinemia Syn) Hypertension Oxidative Stress Inflammatory Drivers Smoking etc. Endothelial 2 Cell 3 HDL Efflux ! Platelet 3 Proteoglycans Sub. Endotheli al. Intima

Hi-LDLp Unhealthy Red Blood Cell 0 LDL’s 1 The Glycocalyx 1 2 2 Endothelial Cell 3 HDL Efflux ! 4 3 Proteoglycans Sub. Endotheli al. Intima Platelet

Hi-LDLp Unhealthy Red Blood Cell 0 LDL’s 1 The Glycocalyx 1 2 2 Endothelial Cell 3 HDL Efflux ! 4 3 Proteoglycans Sub. Endotheli al. Intima Platelet Hi-LDLp Healthy