© 1999 American Heart Association, Inc.
Atherosclerosis and Lipoproteins |
Gender Difference in Postprandial Lipemia
Importance of Visceral Adipose Tissue Accumulation
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Abstract |
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Abstract—Insulin resistance, hyperinsulinemia, hypertriglyceridemia, and low HDL-cholesterol concentrations are common features of a plurimetabolic syndrome, which increases the risk of coronary artery disease. Although it has been proposed that the development of atherosclerosis through alterations in plasma lipid levels could be a postprandial phenomenon, most studies on gender differences in plasma lipoprotein-lipid concentrations have reported fasting levels. Therefore, the aim of our study was to examine the response of postprandial triglyceride-rich lipoproteins to a standardized meal in 63 men and 25 women. In addition to the measurement of fasting and postprandial plasma lipid levels, numerous physical and metabolic variables were assessed, including body composition by underwater weighing and body fat distribution by computed tomography. Although no gender difference was noted in total body fat mass, men were characterized by a preferential accumulation of abdominal adipose tissue as revealed by an increased waist circumference and a greater visceral adipose tissue accumulation (50% difference) compared with women (P<0.001). Men also showed a greater plasma triglyceride response (P<0.005) as well as increased postprandial insulin and free fatty acid levels compared with women (P<0.01). Visceral adipose tissue was significantly associated with the postprandial triglyceride response in both genders (men: r=0.49, P<0.0001; women: r=0.43, P<0.05). Finally, when men and women were matched for visceral adipose tissue accumulation, the gender difference in postprandial plasma triglyceride response was eliminated. Thus results of the present study suggest that the well known gender difference in visceral adipose tissue accumulation is an important contributing factor involved in the exaggerated postprandial triglyceride-rich lipoprotein response noted in men compared with women.
Key Words: postprandial lipemia • gender differences • visceral obesity • free fatty acids
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Introduction |
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Alterations in plasma lipoprotein-lipid concentrations are known to increase the risk of coronary artery disease (CAD) in both men and women.1 2 However, at all ages, the prevalence of CAD in women is lower than in men, and the gender difference in plasma lipoprotein-lipid levels as well as in the prevalence of type II diabetes are believed to be responsible, at least in part, for the higher CAD risk observed in men. Indeed, men are characterized by an overall less favorable plasma lipid profile, which includes high fasting triglyceride (TG) and low HDL-cholesterol concentrations compared with women.3 Men and women also show marked differences in indices of plasma glucose-insulin homeostasis.4 5 Furthermore, an increased visceral adipose tissue (AT) accumulation has been reported in men compared with women and this factor could also contribute to the gender difference in the CAD risk profile.6 7
Although the contribution of altered plasma lipoprotein-lipid levels to the increased risk of CAD is well known, most studies reporting such a relationship have examined fasting concentrations. However, Zilversmit8 has suggested that the development of atherosclerosis could be a postprandial phenomenon, and the renewed interest for postprandial studies has allowed the identification of various physiological conditions that influence postprandial lipoprotein metabolism. It has therefore been reported that age,9 10 diet,11 physical activity,12 13 14 non–insulin dependent diabetes mellitus15 16 as well as obesity,17 and body fat distribution18 19 20 21 all affect dietary fat clearance. In addition, a gender dimorphism has been reported in postprandial lipoprotein-lipid metabolism, as women generally show a lower postprandial triglyceride response to a dietary fat challenge compared with men.10 22 However, little is known about the physiological mechanisms responsible for this gender dimorphism.
Therefore, the aim of the present study was to examine the contribution of the gender difference in visceral AT accumulation to the variation in postprandial lipoprotein-lipid levels. For that purpose, 63 men and 25 women were investigated and their plasma triglyceride-rich protein (TRL) responses measured over a period of 8 hours after the ingestion of a standardized meal.
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Methods |
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Subjects
Sixty-three men (mean age±SD: 45.0±10.0 years) and twenty-five premenopausal women (41.6±10.9 years) were recruited through the media and selected to cover a wide range of body fatness values. All women were tested during the follicular phase (between days 5 and 12) of their menstrual cycle. None of the women were using oral contraceptives. Subjects gave their written consent to participate in the study, which was approved by the Medical Ethics Committee of Laval University. Subjects with diabetes or with coronary heart disease were excluded from the present study. None of the subjects were on medication known to affect insulin action or plasma lipoprotein levels.
Anthropometric and Body Composition Measurements
Body weight, height, waist, and hip circumferences were measured
following standardized procedures,23 and the waist-to-hip
ratio was calculated. Body density was measured by the hydrostatic
weighing technique.24 The mean of 6 measurements was used
in the calculation of percent body fat from body density using the
equation of Siri.25 Fat mass was obtained by multiplying
body weight by percent body fat.
Computed Tomography
Visceral AT accumulation was assessed by CT, which was performed
on a Siemens Somatom DRH scanner using previously described
procedures.26 27 Briefly, the subjects were examined in
the supine position with both arms stretched above the head. The scan
was performed at the abdominal level (between L4 and L5 vertebrae)
using an abdominal scout radiograph to standardize the position of the
scan to the nearest millimeter. The total AT area was calculated by
delineating the abdominal scan with a graph pen and then computing the
AT surface with attenuation range of -190 to -30 Hounsfield
units.26 27 28 The abdominal visceral AT area was measured
by drawing a line within the muscle wall surrounding the abdominal
cavity. The abdominal subcutaneous AT area was calculated by
subtracting the visceral AT area from the total abdominal AT area.
Oral Lipid Tolerance Test
After a 12-hour overnight fast, an intravenous
catheter was inserted into a forearm vein for blood sampling. Each
participant was given a test meal containing 60g
fat/m2 body surface area.18 The meal
consisted of eggs, cheese, toasts, peanut butter, peaches, whipped
cream, and milk. The meal provided 64% of calories from fat, 18% from
carbohydrates, and 18% from protein. The test meal was well tolerated
by all subjects. After the meal, subjects were not allowed to eat for
the 8 hours after meal intake but were given free access to water.
Blood samples were drawn before the meal and every 2 hours after the
meal over an 8-hour period.
Fasting and Postprandial Plasma Lipoprotein Concentrations
Plasma was separated immediately after blood collection by
centrifugation at 3000 rpm for 10 minutes at 4°C.
Triglyceride and cholesterol concentrations in
total plasma were determined enzymatically on a RA-500
Auto-Analyzer (Bayer Corporation Inc), as previously
described.29 Each plasma sample (4 mL) was then subjected
to a 12-hour ultracentrifugation (50 000 rpm) in a
Beckman 50.3Ti rotor at 4°C in 6 mL Beckman Quickseal tubes, which
yielded 2 fractions: the top fraction containing TRL (d<1.006 g/mL;
total) and the bottom fraction consisting of
triglyceride-poor lipoproteins (d>1.006 g/mL). Using the
distilled water layering technique and modified method of Ruotolo et
al,30 the total-TRL fraction was further separated by a
5-minute spin (40 000 rpm) at 4°C using the same tubes and rotor into
3 subclasses of TRL namely: large, medium, and small. A small volume
(100 µL) of a d=1.019 g/mL saline solution was added to the total-TRL
fraction to facilitate water layering. The large-TRL fraction was
collected by tube slicing and made up to a final volume of 1 mL with
0.15 mol/L NaCl. The next 3 mL of the middle layer were collected by
aspiration as medium-TRL, and the final 2 mL were considered as the
small-TRL fraction. Large-TRL consist of lipoproteins of
Sf>400, whereas the medium- and small-TRL are
within a spectrum of particles of Sf 20 to
400.30 Furthermore, in a pilot study (n=5) conducted in
our laboratory (Bergeron et al, unpublished observations, 1998)
in which apo B-48 and apo B-100 concentrations were measured, it was
found that although the protein concentration of the fraction
designated large-TRL is very low, it is predominantly rich in apo B-48,
with a minor contribution of apo B-100 particles. In contrast, the
predominant apolipoprotein found in the fraction designated small-TRL
was apo B-100 (>95% of total apo B). Finally, the fraction designated
medium contained both apo B-48 and apo B-100. HDL particles were
isolated from the bottom fraction (d>1.006 g/mL) after precipitation
of apo B–containing lipoproteins with heparin and
MnCl2.31 The
triglyceride and cholesterol contents of each
fraction, ie, large-, medium-, and small-TRL, as well as HDL, were
quantified on the Auto-Analyzer. All lipoprotein isolation
procedures were completed within 2 to 3 days of the fat load. Plasma
free fatty acid (FFA) levels were also measured at 0, 2, 4, 6,
and 8 hours using an enzymatic method.32 Total apo B
concentration was measured in plasma by the rocket
immunoelectrophoretic method, as previously
described.33 The lyophilized serum standard for apo B
measurement was prepared in our laboratory and calibrated with
reference standards obtained from the Centers for Disease Control.
Glucose and Insulin Concentrations
Fasting and postprandial plasma glucose concentrations were
determined using the glucose oxidase assay34 (SIGMA).
Plasma insulin levels were measured by a commercial double antibody
radioimmunoassay (LINCO Research) that shows little cross-reactivity
(<0.02%) with proinsulin.35
Statistical Analyses
Pearson product-moment correlation coefficients were used to
quantify associations between variables. Differences between men
and women were tested for significance using the Student's
t test. The different areas under the curve of TG, FFA,
insulin, and glucose concentrations were determined by the trapezoid
method. Multiple regression analyses were performed to quantify
the independent contributions of age, gender, fat mass, abdominal
visceral, and subcutaneous AT to the variance of postprandial plasma
triglyceride response. Fasting TG,
HDL-cholesterol, insulin, and FFA levels, as well as
postprandial insulin and FFA responses, were also included in the
statistical model. All analyses were conducted on the SAS
statistical package (SAS Institute).
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Results |
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Physical characteristics and fasting metabolic profiles of men and women are presented in Table 1
. Although both genders had the same
amount of total body fat, there were significant differences in body
fat distribution. Indeed, men were characterized by an increased
abdominal AT accumulation as expressed by higher waist circumference
and waist-to-hip ratio values compared with women. Furthermore, men
displayed a greater amount of visceral AT than women. In contrast,
significantly higher levels of abdominal subcutaneous AT were noted in
women compared with men. Gender differences in the fasting
metabolic risk profile were also observed as men were
characterized by increased plasma cholesterol,
triglyceride, and glucose levels, as well as by decreased
plasma HDL-cholesterol concentrations compared with women.
Men also showed higher fasting plasma insulin levels than women, but
this difference did not reach statistical significance.
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Figure 1 illustrates plasma TG as well as
the triglyceride content of the various TRL subfractions of
men and women throughout the entire postprandial period. Men showed
significantly higher triglyceride levels at all times
compared with women. These higher plasma triglyceride
levels noted during the postprandial period resulted in a greater
triglyceride response in men compared with women and were
also reflected by significantly higher TG levels in all TRL fractions
(total, large, medium, small) at all time points. Furthermore, gender
differences were also observed in postprandial insulin and FFA
concentrations, as men displayed higher postprandial insulin and FFA
levels compared with women (Figure 2).
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P<0.01; 
P<0.005.
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In both genders, increased adiposity was associated with a greater
postprandial lipemia, as body fat mass as well as abdominal visceral
and subcutaneous AT were positively correlated with the plasma
triglyceride response (Figure 3). In addition, we noted that for a
similar accumulation of abdominal subcutaneous AT, women had a lower
postprandial triglyceride response compared with men
(Figure 3B). However, the relationship of visceral AT to
plasma triglyceride response did not appear to differ
between men and women (Figure 3C). We also found that in men,
abdominal visceral AT, but not subcutaneous AT, was positively
associated with the postprandial FFA response (Figure 4). However, this association was not
observed in women.
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As shown in Table 2, some variables
of the fasting metabolic profile were associated more
closely with the postprandial plasma triglyceride response
than adiposity indices. Indeed, increased fasting plasma
triglyceride and insulin levels were predictive of a
greater triglyceride response in both men and women. We
also found that low fasting HDL-cholesterol levels were
associated with an increased triglyceride response and that
elevated fasting apo B concentrations were correlated with higher
postprandial triglyceride levels. However, these latter
relationships were only noted in men.
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To further examine the importance of visceral AT accumulation to the
gender difference in postprandial lipemia, we matched men and women on
the basis of visceral AT (Table 3)
regardless of total body fat mass and examined their respective
postprandial triglyceride responses. Despite having
identical levels of visceral AT, women were characterized by increased
overall adiposity and abdominal subcutaneous AT accumulation. After the
matching procedure, the difference in postprandial plasma
triglyceride levels was no longer significant between men
and women (Figure 5). We also compared
the plasma triglyceride responses of men and women who were
matched for total body fat mass and abdominal subcutaneous AT. These
comparisons revealed a greater postprandial plasma
triglyceride response in men than in women (Figure 5). We also examined the impact of matching subjects for
visceral AT on the triglyceride responses in the various
TRL subfractions (Figure 6). We found no
significant difference in total-, large-, and medium-TRL
triglyceride responses between men and women. On the other
hand, the matching procedure failed to eliminate the difference in
small-TRL levels as women were characterized by a lower
triglyceride response in this subfraction compared with
men. Matching men and women for visceral AT also affected postprandial
plasma glucose and insulin responses as shown both genders were
characterized by similar glucose and insulin responses after pairing
men and women for visceral AT accumulation (Figure 7). However, women were still
characterized by a lower FFA response after the fat load compared with
men.
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Finally, we conducted multiple regression analyses to quantify
the independent contributions of age, gender, and adiposity indices, as
well as fasting and postprandial metabolic profile
variables to the variance of the postprandial plasma
triglyceride response (Table 4). Fasting
triglyceride concentration was by far the best predictor of
plasma triglyceride response, accounting for more than 61%
of its variance (Model 1). However, when fasting TG level was removed
from the model (Model 2), fasting apo B level showed the greatest
contribution to the plasma triglyceride response (37%). In
Model 3, both fasting TG and apo B levels were excluded on purpose from
the statistical model. In this restricted model, 27% of the variance
of the plasma triglyceride response was attributed to
visceral AT accumulation. It seems important to point out that, in all
models, postprandial FFA response and fasting insulin concentration
were significant predictors of the postprandial plasma
triglyceride response. However, gender per se did not
contribute to the variation in postprandial triglyceride
levels after control for visceral AT accumulation and related fasting
metabolic variables (TG, apo B, FFA, and insulin).
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Discussion |
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Gender differences in fasting plasma lipoprotein-lipid concentrations have already been reported.3 36 In the present study, we also found that men were characterized by increased fasting plasma cholesterol and triglyceride levels as well as by decreased HDL-cholesterol concentrations compared with women. In addition, men also displayed higher fasting plasma glucose and insulin levels than women, although the gender difference in fasting insulinemia did not reach statistical significance. These metabolic alterations are considered as features of the insulin-resistance syndrome.37 On the other hand, it has been suggested that differences in adiposity, especially in body fat distribution, between men and women may be involved in the gender dimorphism noted in plasma lipoprotein-lipid levels. Indeed, men are known to present a preferential accumulation of AT in the abdominal visceral depot, whereas women are characterized by a more peripheral AT distribution.38 In the present study, we found that despite having similar levels of total body fat in kg compared with women, men were characterized by an increased abdominal fat accumulation as indicated by higher waist circumference and visceral AT values.
Significant gender differences were also noted in postprandial lipemia men being characterized by a greater postprandial plasma triglyceride response compared with women. This result is concordant with previous observations that reported higher postprandial triglyceride levels in men than in women.10 22 In the present study, gender differences in the postprandial triglyceride response profile were also noted. In men, plasma triglyceride levels peaked later during the postprandial period than in women. Because the increase in triglycerides (from 2 to 4 hours) after meal consumption mainly reflects dietary TG absorption, whereas the return to fasting levels (from 6 to 9 hours postprandially) is presumably a function of TRL clearance,11 our results of a delayed postprandial TG peak in men suggest an impaired postprandial clearance of TRL compared with women.
The strong association between fasting TG and the postprandial plasma
triglyceride response indicates that fasting
triglyceridemia is an important correlate of the gender
difference in postprandial lipemia. Indeed, on their entry into the
circulation, both newly synthesized and endogenous TRL
compete for lipoprotein lipase (LPL) to be hydrolyzed.39
Thus, in men, the increased quantity of TRL before the meal as
indicated by their fasting
hypertriglyceridemic state may contribute
to the delayed clearance of postprandial triglycerides from
the plasma. This accumulation of TRL related to the presumed
"saturation" of LPL would also postpone the postprandial peak
plasma triglyceride concentration. The gender difference in
TRL clearance after a meal could also be the result of an increase in
the contribution of hepatic TRL to total-TRL at the late stages of the
postprandial period. Under insulin-resistant conditions, the
antilipolytic effect of insulin on AT is very weak,40
which would explain the raised FFA levels observed postprandially in
subjects with visceral obesity.18 This increased flux of
FFA to the liver would promote the synthesis and secretion of VLDL.
This model is supported by results presented in Figure 2
. Indeed, we noted that, in men, there was a progressive
increase in plasma FFA levels, which resulted in 8-hour plasma FFA
concentrations that remained well above fasting values, whereas in
women, plasma FFA levels at the end of the postprandial period were
near fasting concentrations. Furthermore, our results are supported by
a previous study41 in which men and women had been shown
to differ significantly in the postprandial regulation of AT lipolysis.
Indeed, men were characterized by an AT nonesterified fatty acid
release that was more resistant to the postprandial
antilipolytic effect of insulin.41 On the other hand, the
increase in postprandial FFA concentrations may also be resulting from
an increased lipolysis of TRL by LPL paralleled by an inadequate
esterification of FFA into triglycerides by the
AT.42 However, the present study did not allow us to
quantify the contribution of both physiological
processes, ie, increased AT or TRL lipolysis, to the increased
postprandial FFA response in men. Further studies in this area are
clearly warranted.
Nevertheless, our results indicate that visceral AT accumulation plays a major role in the gender difference in postprandial lipemia. Accordingly, we found no difference in postprandial lipemia among men and women matched for visceral AT accumulation. We also have examined the impact of the matching procedure on the different TRL subclasses. We found that there was no difference in total- as well as in large- and medium-TRL triglyceride responses between men and women with similar levels of visceral AT. However, a gender difference remained in the small-TRL triglyceride response as men had higher 2-, 4-, and 6-hour small-TRL triglyceride concentrations compared with women matched for similar visceral AT accumulation. It is suggested that the remaining increased postprandial FFA response noted in men, after the matching procedure, may have contributed to their higher small-TRL triglyceride response compared with women. Particle size has also been suggested to affect the rate of TRL clearance, with large particles being better substrates for lipolysis by LPL than smaller particles.43 Our finding of a more prolonged accumulation of small-TRL triglycerides but not of large- and medium-TRL in men than women matched for visceral AT is concordant with this observation.
Multiple regression analyses revealed that the fasting triglyceride levels were by far the best predictors of the plasma triglyceride response to the fat load (Model 1). The contribution of apo B–containing lipoproteins to postprandial lipemia was also highlighted as fasting apo B concentration became the strongest predictor of plasma triglyceride response after fasting triglyceridemia was eliminated from the statistical model. Because apo B found in the fasting plasma is secreted through lipoproteins of hepatic origin, our results provide further support to the concept of a hepatic contribution to the delayed clearance of TRL in men.44 However, further studies are needed to support this notion and measurements of apo B-48 and apo B-100 containing TRL, which are respectively used as markers of TRL of intestinal and hepatic origin, will have to be performed in future studies.
It is known that visceral obesity is associated with
metabolic abnormalities such as fasting
hypertriglyceridemia,
hyperinsulinemia, and increased apo B
concentrations as well as lower HDL-cholesterol
levels.6 45 Recently, we have reported that visceral obese
men are characterized by an impaired postprandial TRL clearance
compared with obese men with low levels of visceral AT.18
In the present study, when both fasting TG and apo B concentrations
were eliminated on purpose from the multiple regression
analyses, the amount of visceral AT was found to be the best
predictor of TRL triglyceride response. Furthermore, we
also quantified (data not shown) the independent contributions of total
body fat mass and AT distribution variables (including subcutaneous
abdominal fat measured by CT) to the fasting TG and apo B levels. In
both cases, visceral AT accumulation was the best and only significant
predictor of these metabolic variables. As women have
less visceral AT than men,39 we tested the hypothesis that
their preferential accumulation of subcutaneous AT would be associated
with a more favorable postprandial TRL metabolism. Results
of the present study provide further support to such an hypothesis.
Indeed, for a similar abdominal subcutaneous AT accumulation, women had
a lower postprandial triglyceride response compared with
men (Figure 3). Although we were not able to study the
physiological mechanisms responsible for this
phenomenon, previous results have indicated that subcutaneous AT may
have a greater capacity for FFA esterification into adipose cell TG
than omental AT.46 This peculiar metabolic
behavior of subcutaneous fat is concordant with the faster clearance of
TG-rich lipoproteins after a meal in women who have more subcutaneous
AT than men. However, results of the present study support the
notion that visceral AT may be more critical to the gender difference
in postprandial lipemia than subcutaneous AT. Indeed, when men and
women were matched on the basis of visceral AT accumulation, women
remained characterized by a substantially greater subcutaneous AT depot
compared with men (409 versus 234 cm2,
respectively). Thus, had subcutaneous AT had a greater impact on
postprandial lipemia than visceral AT, a significant difference in
postprandial TRL levels between men and women would have been expected
even after they were matched for visceral AT accumulation. In the
present study, such a difference in TRL response was minimal after
men and women were matched for visceral AT despite the fact that
matched women had more subcutaneous AT than matched men.
Although matching men and women for the level of visceral AT eliminated the gender difference in plasma triglyceride response, there was a tendency for men to display a greater triglyceridemic response compared with women. This gender difference was evident for the response of the small-TRL fraction. Other factors have been proposed to explain the lower postprandial lipemia in women than in men. For instance, estrogens have been suggested to have a favorable impact on postprandial triglyceridemia.47 Variation in LPL activity between men and women47 48 may also be implicated in the gender difference in postprandial lipemia. Once again, the greater accumulation of subcutaneous fat in women than in men could play a role in the gender difference noted in the clearance of TRL after a dietary fat challenge.
In summary, results from the present study indicate that there is a gender difference in postprandial lipemia as men show a greater postprandial triglyceridemic response to a meal than women. Although this difference is likely to result from the influence of several factors, our results suggest that the increased visceral AT accumulation in men makes an important contribution to this delayed dietary fat clearance. Concomitant impairment of postprandial FFA metabolism after meal consumption and a reduced ability to store lipids in subcutaneous AT may be responsible, at least in part, for this exaggerated lipemic response observed in men compared with women.
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Acknowledgments |
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This study was supported by the Medical Research Council of Canada and by the Québec Heart and Stroke Foundation. We would like to thank the staff of the Physical Activity Sciences Laboratory for data collection and the personnel of the Lipid Research Center for their excellent and dedicated work.
Received November 12, 1998; accepted February 22, 1999.
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