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Brain metabolism--seminal article, 2017
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HD http://emboj.embopress.org/content/36/11/1474 DOI 10.15252/embj.201695810| Published
online 24.04.2017 FULL
Very informative
Brain metabolism in health, aging, and neurodegeneration
View ORCID Profile Simonetta Camandola, Mark
P Mattson
Abstract
Brain cells normally respond adaptively to
bioenergetic challenges resulting from ongoing activity in neuronal circuits,
and from
environmental energetic stressors such as food deprivation and physical
exertion. At the cellular level, such adaptive responses include the
“strengthening” of existing synapses, the formation of new synapses, and the
production of new neurons from stem cells. At the molecular level, bioenergetic challenges result in the
activation of transcription factors that induce the expression of proteins that
bolster the resistance of neurons to the kinds of metabolic, oxidative,
excitotoxic, and proteotoxic stresses involved in the pathogenesis of brain
disorders including stroke, and Alzheimer's and Parkinson's diseases. Emerging
findings suggest that lifestyles that include intermittent bioenergetic
challenges, most notably exercise
and dietary energy restriction, can increase the likelihood
that the brain will function optimally and in the absence of disease throughout life. Here, we provide an overview of cellular and
molecular mechanisms that regulate brain energy metabolism, how such mechanisms
are altered during aging and in neurodegenerative disorders, and the potential applications to brain
health and disease of interventions that engage pathways involved in neuronal
adaptations to metabolic stress. [UNDER their
MODEL, ENERGY RESTRICTION and intermittent fasting, Misses LOWERS EXPOSURE TO UFAs AND FRUCTOSE, use of
NEUROPSTEROIDS AMONG SENIORS, AND THE INCREASE IN AUTOPHAGY BY REDUCING INSULIN
RESISTANCE]
[They have missed the taking of drugs that
lower the production of ATP and thus metabolism, and the role of insulin
resistance and its EXTREME FORM type-2 diabetes. Lowering ATP production though
increased
mitochondrial dysfunction results in defective collagen, large lipid droplets,
and other processes function well below evolutionary design—jk]
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Introduction
The
higher cognitive functions of the human brain depend upon the expansion and increased
density and complexity of the neocortex during evolution (Rakic, 2009).
The enhanced abilities of the human brain to plan complex behaviors, make
decisions, and process emotional and social contexts came with hefty energy
requirements. Although it is only 2% of the total body weight, the brain
accounts for 20% of an individual's energy expenditure at rest (Kety, 1957;
Sokoloff, 1960).
Among brain cells, neurons expend 70–80% of the total energy, with the
remaining portion being utilized by glial cells (astrocytes, oligodendrocytes,
and microglia) (Harris et al, 2012;
Hyder et al, 2013).
Organisms allocate their available energy among the competing needs of
maintenance, growth, reproduction, and, particularly in primates, higher
cortical functions (communication, imagination, and creativity). A growing body
of evidence suggests that metabolic adaptations within the brain and whole body
played important roles in the expansion of the cerebral cortex during primate
evolution. Several studies comparing the expression of genes and regulatory
regions in brains of various primates have shown an up-regulation of genes and
metabolites involved in oxidative metabolism and mitochondrial functions in
human brains (Grossman et al, 2001, 2004;
Cáceres et al, 2003;
Uddin et al, 2004;
Haygood et al, 2007).
Furthermore, recent evidence indicates that an increase in metabolic rate,
coupled with a higher predisposition to deposit fat and changes in the
allocation of energy supplies, was crucial for the evolution of brain size and
complexity (Pontzer et al, 2016).
Understanding the metabolic signatures of different brain cells, and their
metabolic interactions, will not only advance our understanding of how the brain
functions and adapts to environmental demands, but may also elucidate the
propensity of the human brain to age-related neurodegenerative disorders. In
recent years, it has become evident that metabolic alterations strongly
influence the instigation and progression of many neurodegenerative disorders.
Decreases in glucose and oxygen metabolic rates of brain cells occur during
normal aging (Hoyer, 1982a)
and are further exacerbated in disorders such as Alzheimer's (AD), amyotrophic
lateral sclerosis (ALS), Parkinson's (PD), and Huntington's (HD) diseases
(Hoyer, 1982b).
In
this review article, we summarize the current knowledge of neural cell energy
metabolism in the contexts of normal brain function, adaptive neuroplasticity,
and the pathogenesis of neurodegenerative disorders.
Brain barriers and metabolite transporters
Neurons
in the adult brain rely mostly on glucose as an energy source (Kety, 1957;
Sokoloff, 1960).
However, in some circumstances neurons can use substrates other than glucose.
For example, ketone bodies are utilized during brain development and in the
adult during prolonged fasting periods (Owen et al, 1967;
Nehlig & Pereira de Vasconcelos, 1993),
while lactate utilization is increased during intense physical activity
(Dalsgaard et al, 2003;
van de Hall et al, 2009).
Given its high metabolic demands and negligible intrinsic energy stores, the
brain depends upon a continuous influx of substrates from the blood. In order
to protect the brain from fluctuations in the blood composition that could
impact its milieu and functions, the exchanges of molecules between blood and
cerebral fluids are regulated by the blood–brain barrier (BBB), and the
blood–cerebrospinal fluid barrier (BCSFB). The main function of the these
barriers is to limit the free diffusion of solutes between blood and brain fluids,
and to selectively transport essential nutrients, ions, and signaling
molecules, while removing metabolic waste products. The BBB separates the brain
interstitial fluid from the blood and is formed by capillary endothelial cells
interconnected by tight and adherens junctions, their underlying basement
membrane, pericytes, and the “end feet” of astrocytes (Fig 1).
The BBB controls the influx of metabolites such as glucose, amino acids, and
ketones from the blood into the brain, while preventing the access of
blood-borne molecules and cells (e.g., lymphocytes) that could be detrimental
for neuronal functions. The BCSFB is formed by the modified epithelial cells of
the choroid plexus which separates the peripheral blood from the CSF, and the
arachnoid epithelium separating the cerebral blood from the CSF. In addition to
filtering functions similar to the BBB, the epithelial cells of the BCSFB are
also responsible for producing the CSF.
Figure 1.
Nutrient transport
across the blood–brain barrier
The
blood–brain barrier is formed by capillary endothelial cells surrounded by
basement membrane, pericytes, and the astrocyte perivascular end feet. The
presence of tight junctions between the endothelial cells strongly inhibits the
penetration of water-soluble molecules. Passive diffusion is limited to gases
and small nonpolar lipids. All other nutrients require passive or active
mediated transporters. GLUT1-5, glucose transporter 1-5; MCT1-4, monocarboxylic
acid transporter 1-4.
The
modalities by which specific molecules cross through the BBB depend upon the
nature of the solutes (Fig 1).
Passive partition is limited to small nonpolar lipid-soluble molecules, and to
diffusible gases such as oxygen and carbon dioxide according to their
concentration gradients. The presence of tight junctions restricts paracellular
diffusion of polar molecules such as proteins (Zlokovic et al, 1985a,b;
Zlokovic & Apuzzo, 1997),
which cross the BBB by interacting with receptors or transporters expressed on
both the luminal and abluminal membranes, or selectively on one side
(Zloković et al, 1987;
Zlokovic et al, 1990;
Abbott et al, 2010).
Large peptides and proteins such as hormones, growth factors, and neuroactive
peptides are transferred via receptor-mediated, adsorptive-mediated, and
carrier-mediated transport (Zlokovic, 1995, 2008).
Based on the requirement or not to hydrolyze ATP to move the solute across the
membrane, two major families of transporters have been identified in the BBB:
the ATP-binding cassette (ABC) proteins and the solute carrier (SLC) proteins.
The ABC transporters include multidrug resistance-associated proteins (MRPs,
ABCB1-6), P-glycoprotein, and breast cancer resistance protein (BRPC)
(Begley, 2004).
These transporters function as efflux pumps that couple ATP hydrolysis to move
lipid-soluble molecules against their concentration gradient. The solute
carrier proteins comprise a large superfamily of more than 300 members; they
are instrumental for ensuring a stable supply of carbohydrates, amino acids,
monocarboxylic acids, nucleotides, fatty acids, and organic anions and cations
(Abbott et al, 2010).
Among
the SLC carriers, those that transport hexose and pentose sugars (glucose
transporters; GLUTs) and monocarboxylates (monocarboxylic acid transporters;
MCTs) are particularly important for brain metabolism. The intake of glucose
into the brain is mediated by GLUT1, which is expressed as a 55-kD isoform in
endothelial cells of the BBB. A second 45-kD GLUT1 isoform ensures delivery of
glucose to glia, ependymal cells, and the choroid plexus. GLUT3 mediates uptake
of glucose in neurons; GLUT3 is mainly concentrated in axons and dendrites.
GLUT3 has a higher glucose affinity and transport capacity compared to other
transporters, and so ensures that neurons receive a constant supply of glucose
even when interstitial glucose concentrations are low. Other members of the
glucose transporter family are expressed at much lower levels compared to GLUT1
and GLUT3 in specific cell types and/or in specialized brain regions. For
example, the insulin-sensitive GLUT4 is present in astrocytes, neurons, and
endothelial cells (Kobayashi et al, 1996),
and GLUT8 is located in the cytoplasm of neurons mostly in the hippocampus,
amygdala, cerebellum, and hypothalamus (Reagan et al, 2001;
Ibberson et al, 2002).
GLUT2 is expressed in a subset of glutamatergic neurons in the hypothalamus and
has recently been identified as a brain glucose sensor that triggers sugar
seeking behavior under hypoglycemic conditions (Labouèbe et al, 2016).
GLUT6 has been detected in neurons (Doege et al, 2000)
and GLUT7 in astrocytes (Maher et al, 1994).
In microglia, the most abundant transporter is GLUT5 which has a very low
affinity for glucose and mostly fluxes fructose (Mantych et al, 1993).
The
predominant roles of GLUT1 and GLUT3 in efficiently moving glucose from the
blood across the BBB and into neurons have been clearly demonstrated in studies
of gene knockout mice. GLUT1+/− mice have
a reduced brain size and abnormal motor behavior (Wang et al, 2006),
reminiscent of the phenotypes observed in human GLUT1 deficiency syndrome
patients (De Vivo et al, 1991).
GLUT3+/− mice exhibit abnormal spatial learning and
working memory, in addition to perturbed social behavior (Zhao et al, 2010).
GLUT8-null homozygous mice have modest reductions of hippocampus volume
(Membrez et al, 2006),
and locomotion (Schmidt et al, 2008).
In addition to facilitative glucose transporters, the endothelial cells of the
BBB also express sodium-dependent unidirectional transporters that are members
of the solute carrier 5 family (SGLT) 1 and 2. These carriers couple the sodium
electrochemical gradient to transfer glucose against its concentration gradient
across the membrane. Their role under physiological conditions is not clear,
but they appear to be functional during conditions of oxygen/glucose
deprivation or ischemia (Yu et al, 2010).
Because GLUT1 and GLUT3 transporters are constitutively located on the plasma
membrane and do not respond to stimulation with insulin, brain glucose uptake
is believed to be insulin-independent.
There
are 14 MCTs with particular affinities for one or more substrates. MCTs 1–4 are
expressed in cells of the BBB (Fig 1)
and are responsible for bidirectional passive proton-linked transport of
lactate, ketone bodies (i.e., acetoacetate and 3-β-hydroxybutyrate), and
pyruvate. MCT1 has high affinity for pyruvate and also transports lactate and
ketone bodies; it is present in endothelial cells (Gerhart et al, 1997),
astrocytes[1]
(Bröer et al, 1997),
oligodendrocytes (Lee et al, 2012),
and microglia (Moreira et al, 2009).
Only a few specific subsets of hypothalamic neurons express MCT1
(Carneiro et al, 2016).
MCT2 is the major transporter in neurons (Pierre et al, 2002),
and compared to MCT1 has an overall higher affinity for all the substrates
(Bröer et al, 1997).
MCT2 is concentrated in dendritic spines where it associates with postsynaptic
density proteins, as well as the AMPA receptor subunit Glur2 (Bergensen et al, 2005).
MCT3 transports lactate and is only expressed in the retinal epithelium and the
choroid plexus epithelium (Philp et al, 2001).
MCT4 carries lactate and is exclusively expressed in astrocytes (Pellerin et al, 2005).
The specific cell distribution patterns and substrate affinities of MCTs in the
brain suggest that MCTs play fundamental roles in shuttling energy substrates
among different brain cell types.
Glucose metabolic pathways in neurons and
astrocytes
The
metabolic fate of glucose in the brain depends upon the cell type and the
selective expression of metabolic enzymes. Neurons are predominantly oxidative,
while astrocytes are mostly glycolytic (Hiden & Lange, 1962;
Hamberger & Hyden, 1963).
In addition to the production of adenosine-5′-triphosphate (ATP), glucose is
also used to generate metabolic intermediates for the synthesis of fatty acids
and other lipids required for membrane and myelin synthesis (Ramsey et al, 1971;
Jones et al, 1975);
amino acids for protein synthesis and neurotransmitter production (Vrba et al, 1962;
Gaitonde & Richter, 1966);
and 5-carbon sugars for the synthesis of nucleotides (Gaitonde et al, 1983);
and to produce glycogen in astrocytes.
In
neurons, each molecule of glucose is oxidized via glycolysis, the pentose
phosphate pathway (PPP), the tricarboxylic acid (TCA) cycle, and oxidative
phosphorylation, with the production of carbon dioxide, water, and 30–36
molecules of ATP depending upon the rates of proton leakage in the mitochondria
(Fig 2).
The glycolytic process metabolizes glucose to pyruvate, which can be actively
transported into the mitochondria where it is converted to acetyl coenzyme A
(acetyl-CoA). Acetyl-CoA is complexed with citrate which undergoes a series of
regenerative enzymatic reactions producing reduced nicotinamide adenine
dinucleotide (NADH) and flavin adenine dinucleotide (FADH2) in the TCA cycle.
The NADH and FADH2 produced during glycolysis and the TCA cycle are
subsequently re-oxidized in the electron transport chain (ETC). ETC. utilizes
the energy produced by the transfer of electrons through its various complexes
to transport protons across the inner mitochondrial membrane into the intermembrane
space. The flux of protons back into the mitochondrial matrix is mediated by
the enzyme ATP synthase, which utilizes the energy to generate ATP from ADP.
Once inside the cell, glucose is irreversibly converted to glucose-6-phosphate
(G6P) by hexokinase (HK). G6P can then be further metabolized via glycolysis or
the pentose phosphate pathway (PPP) or can be used for glycogen synthesis.
Figure 2.
Metabolic pathways
of glucose utilization in neurons and astrocytes
In
neurons after entering the cell via glucose transporter 3 (GLUT3), glucose is
phosphorylated by hexokinase (HK) to glucose-6-phosphate (G6P), which is
subsequently routed in the glycolytic pathway and the pentose phosphate pathway
(PPP). The end product of glycolysis is pyruvate that enters the mitochondria
where it is metabolized through the tricarboxylic acid (TCA) cycle and
oxidative phosphorylation in the electron transport chain (ETC.), generating
adenosine-5′-triphosphate (ATP) and carbon dioxide (CO2) while consuming
oxygen (O2). Pyruvate can also be generated from lactate dehydrogenase 1
(LDH1)-dependent conversion of lactate. In the PPP, G6P is converted to
6-phosphogluconate (6PG) that is transformed in ribulose-5-phosphate (R5P),
with the concomitant production of reduced nicotinamide adenine dinucleotide
phosphate (NADPH). NADPH is utilized to regenerate oxidized antioxidants such
as glutathione (GSH) and thioredoxin. Neurons are not able to store glucose in
the form of glycogen due to constitutive degradation of glycogen synthase (GS)
via glycogen synthase kinase 3 (GSK3) phosphorylation, and subsequent
ubiquitin-dependent proteasomal digestion mediated by the malin-laforin
complex. [Malin decreases glycogen accumulation by promoting the degradation of
protein targeting to glycogen Laforin
regulates autophagy via Mammalian target of rapamycin, which
is impaired in Lafora disease. Lafora
disease (LD) is an autosomal recessive neurodegenerative disease that results
in progressive myoclonus epilepsy and death. LD is caused by mutations in
either the E3
ubiquitin ligase malin or the dual specificity phosphatase laforin. Lafora
disease (LD), a fatal
neurodegenerative disorder characterized by the presence of intracellular
inclusions called Lafora bodies (LBs), is caused by loss-of-function mutations
in laforin or malin.] In
astrocytes, glucose is imported trough glucose transporter 1 (GLUT1) and
preferentially stored as glycogen, or metabolized via glycolysis. The pyruvate
generated is converted to lactate thanks to the expression of lactate
dehydrogenase 5 (LDH5), and pyruvate dehydrogenase kinase 4 (PDK4)-dependent
inhibition of pyruvate dehydrogenase (PDH). The presence of
6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase 3 (Pfkfb3) allows
astrocytes to generate fructose-2,6-bisphosphate (F2,6P) that acts as an
allosteric modulator of PKF1 boosting glycolysis. Abbreviations are as follows:
F6P, fructose-6-phosphate; PKF1, phosphofructokinase 1; F1,6P, fructose-1,6-diphosphate;
G3P, glyceraldehyde-3-phosphate; Mit, mitochondrion; PEP, phosphoenolpyruvate;
PKM1, pyruvate kinase M1; PKM2, pyruvate kinase M2; G1P, glucose-1-phosphate;
GP, glycogen phosphorylase; APC/C-Cdh1, anaphase-promoting complex
C/cytosome-Cdh1; MCT, monocarboxylic acid transporter.
Although
negligible compared to peripheral energy deposits, glycogen represents the
largest energy reserve in the brain. Glycogen metabolism is regulated by two
key enzymes, glycogen synthase (GS) and glycogen phosphorylase (GP). The reason
why glycogen is produced and stored exclusively in astrocytes
(Magistretti et al, 1993)
is because in neurons GS is maintained in a constitutively inactive state by
hyperphosphorylation via glycogen synthase kinase 3 (GSK3), and subsequent
ubiquitin-dependent proteasomal degradation mediated by the malin–laforin
complex (Vilchez et al, 2007)
(Fig 2 inset).
A similar degradation process also occurs for protein targeting to glycogen (PTG),
the regulatory subunit of protein phosphatase 1 that is able to activate GS by
dephosphorylation, thus preventing the accumulation of glycogen in neurons
(Vilchez et al, 2007).
The preferred route of G6P metabolism in neurons is the PPP, an anabolic
metabolic pathway that converts G6P into 5-carbon sugars utilized for the
biosynthesis of nucleotides with generation of reduced nicotinamide adenine
dinucleotide phosphate (NADPH). Based on the cellular requirements, a portion
of ribulose-5-phosphate (R5P) can be converted back into the glycolytic
intermediates fructose-6-phosphate (F6P) and glyceraldehyde-3-phosphate (G3P).
In neurons, this conversion is minimal, and NADPH is utilized as a cofactor for
synthesis of fatty acids and myelin, for neurotransmitter turnover, and to
maintain redox homeostasis. The maintenance of neuronal antioxidant potential
relies on the use of NADPH as cofactor to regenerate reduced glutathione (GSH)
(Fig 2)
and thioredoxin by glutathione and thioredoxin reductase, respectively.
The
balance between glycolysis and PPP rates in neurons is very important, and
diversion of glucose utilization toward exclusive glycolysis can result in
decreased availability of NADPH, increased oxidative stress and cell death
(Herrero-Mendez et al, 2009).
The preferential use of G6P in the PPP in neurons, as well as their inability
to up-regulate glycolysis, is due to the selective expression of enzymes
favoring such a metabolic route coupled with the absence of specific glycolysis
modulators. In addition to the HK step mentioned above, the glycolytic flux is
regulated by phosphofructokinase 1 (PKF1) and pyruvate kinase (PK) (Lowry &
Passonneau, 1964).
PKF1 catalyzes the phosphorylation of F6P to fructose-1,6-bisphosphate (F1,6P).
Its activity is inhibited by metabolites associated with a high energy state
(i.e., ATP, citrate) and enhanced by those resulting from high metabolic
activity (i.e., ADP, AMP, phosphate), as well as by fructose-2, 6-bisphosphate (F2,6P).
It was recently shown that neurons lack the enzyme responsible for the
generation of F2,6P, 6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase 3
(Pfkfb3) due to continuous ubiquitin-dependent proteasomal degradation
(Herrero-Mendez et al, 2009)
(Fig 2 inset).
While neurons lack Pfkfb3, they express pyruvate kinase M1 (PKM1) (Zhang et al, 2014),
a constitutively active enzyme with a very high affinity for
phosphoenolpyruvate (PEP), thereby favoring the generation of high levels of
pyruvate. This, in association with the expression in neurons of the
low-pyruvate-affinity isoform of lactate dehydrogenase (LDH1), prevents
pyruvate conversion to lactate and favors its entrance into the TCA cycle
(Fig 2).
Further metabolic bias toward the TCA cycle results from the lower levels of
expression in neurons of pyruvate dehydrogenase kinase 4 (PDK4) which controls
the activity of pyruvate dehydrogenase (PDH), and therefore the decarboxylation
of pyruvate to acetyl-CoA.
Astrocyte
utilization of glucose is complementary to that of neurons. A portion of G6P is
channeled into glycogen synthesis and PPP, but its predominant metabolism
occurs via glycolysis with production of lactate and very low rates of
mitochondrial oxidation (Itoh et al, 2003).
This metabolic phenotype of astrocytes is the result of their unique expression
of various enzymes and transporters. In contrast to neurons, astrocytes express
very high levels of Pfkfb3 which favors glycolysis via allosteric activation of
PFK by F2,6P (Herrero-Mendez et al, 2009).
Furthermore, under basal conditions the levels of PDH phosphorylation are high
(Halim et al, 2010)
thanks to elevated expression of PDK4 (Zhang et al, 2014),
efficiently limiting the conversion of pyruvate to acetyl-CoA (Fig 2).
Astrocytes also express low levels of mitochondrial aspartate/glutamate carrier
(AGC) decreasing the import of reduced equivalents (NADH) from the cytosol
(Ramos et al, 2003).
The expression of LDH5, which has a high affinity for pyruvate, rather than
LDH1, ensures its conversion to lactate with concomitant oxidation of NADH to
NAD+ thus maintaining high rates of NAD+/NADH that further favor aerobic glycolysis. The
presence of PKM2 instead of PKM1 also enables astrocytes to easily up-regulate
the rate of glycolysis to increase the production of lactate, if needed.
Monocarboxylic acid metabolism
Over
the past few decades, it has become clear that in addition to glucose, neurons
can utilize alternate fuels, namely lactate and ketone bodies. Seminal in vitro studies
of McIlwain in the 1950s demonstrated that in human cerebral cortex slices, both pyruvate
and lactate could replace glucose
to support respiration under basal conditions, and during electrical
stimulation (McIlwain, 1953).
Neurons in vitro have
a preference
for lactate over glucose when both substrates are provided
(Itoh et al, 2003;
Bouzier-Sore et al, 2006).
However, clear evidence for a role for lactate in brain metabolism in vivo has
been obtained only recently. The cell type-specific distribution of MCTs, and
the intrinsic metabolic properties of astrocytes and neurons, led to the hypothesis
that lactate is shuttled between the two cell types to support neuronal
metabolism (Pellerin & Magistretti, 1994)
(Fig 2).
Such metabolic coupling of astrocytes and neurons is supported by optogenetic
studies showing an in vivo lactate gradient
from astrocytes to neurons (Mächler et al, 2016).
Furthermore, pharmacological inhibition or genetic targeting of MCT2
irreversibly impairs long-term memory in mice (Newman et al, 2011;
Suzuki et al, 2011).
Long-term memory impairment can be reversed by intrahippocampal administration
of lactate, but not glucose, in MCT4-deficient mice (Suzuki et al, 2011).
Targeted disruption of MCT1 and MCT2 impairs memory consolidation/reconsolidation
in cocaine-induced conditioned place preference and self-administration
(Zhang et al, 2016).
Heterozygous MCT1 knockout mice have impaired inhibitory avoidance memory
(Tadi et al, 2015).
Altogether, these results strongly suggest that the neuronal uptake of lactate
is important for the establishment of long-term memories. The overall
contribution of lactate to brain metabolism varies with its availability.
Studies in conscious humans have shown that under resting conditions, lactate
uptake by the brain provides about 8% of its energy requirements (van de
Hall et al, 2009).
The percentage increases up to 20% under conditions of high plasma levels of
lactate such as during intense exercise (van de Hall et al, 2009).
Furthermore, at various exercise intensities the metabolism of lactate in the
brain is higher in trained subjects compared to controls (Kemppainen et al, 2005).
This suggests the possibility of adaptive mechanisms allowing the brain to
respond to changes in substrate availability. Notably, in rodents acute
exercise induces brain region-specific up-regulation of MCTs (Takimoto &
Hamada, 2014)
and enhances oxidative capacity of cells in the motor cortex (McCloskey et al, 2001).
In
addition to lactate, brain cells can metabolize the ketone bodies 3-β-hydroxybutyrate
(3HB) and acetoacetate (AcAc). Ketones are recognized as an essential energy
substrate for the brain during development, delivering up to 30–70% of its
energy requirement (Nehlig, 2004);
compared to the adult, the immature brain has high activity and levels of MCTs
(Gerhart et al, 1997;
Pellerin et al, 1998).
Also, in rodents the brain activity of enzymes involved in ketone metabolism
increases steadily through the suckling period, and then drops after weaning
(Page et al, 1971;
Middleton, 1973).
The high level of ketone utilization during development is necessary to support
energy metabolism, as well as the amino acid and lipid biosynthesis required
for brain maturation (De Vivo et al, 1975;
Yeh et al, 1977).
In rats, incorporation of 3HB into amino acids is two- to threefold higher than
glucose during the nursing period (De Vivo et al, 1975).
Similarly, lipid synthesis, fundamental for myelination, is preferentially
sustained by the use of ketones as precursors during the suckling period
(Yeh et al, 1977).
In addition to anabolic functions, the oxidation of ketones is also important
during the early postnatal period (Fig 3).
Mice with succinyl-CoA-3-oxoacid CoA transferase (SCOT) deficiency have normal
prenatal development, but right after birth they become ketotic, with reduced
plasma levels of glucose and lactate (Cotter et al, 2011).
In the adult brain, the utilization of ketones is greatly reduced in the fed
state, but can increase considerably under conditions of limited glucose
availability as occurs during fasting, starvation, low carbohydrate/high fat
intake, and prolonged or intense exercise bouts (Fig 3).
Under such conditions, the liver generates ketone bodies from fatty acid and
ketogenic amino acid oxidation. Among brain cells, only astrocytes are equipped
to generate ketone bodies from fatty acid β-oxidation (Edmond, 1992),
but the rates of fatty acid transport are very low compared to those in the
liver. All brain cell types are, however, able to uptake ketones, mostly 3HB
and AcAc, via MCTs; the ketones are then metabolized to acetyl-CoA to support
the cell energy and biosynthetic needs (Fig 3).
In adults, the activity of ketone-metabolizing enzymes is high enough that it
would easily permit a complete switch from glucose to ketones to support brain
energy needs (Krebs et al, 1971).
Because ketones are never produced at saturating concentrations, the brain rate
of utilization is strictly regulated by their blood concentration
(Sokoloff, 1973).
Indeed, during ketosis the brain glucose utilization has been shown to decrease
by about 10% for each millimole of plasma ketones (LaManna et al, 2009).
During medically supervised starvation of obese patients, ketones provide up to
60% of the energy utilized by the brain (Owen et al, 1967).
Figure 3.
Schematic of ketone
body oxidative and anabolic utilization in brain
Under
conditions of reduced glucose availability such as low carbohydrates/high-fat
diet, exercise, or fasting, the liver utilizes fatty acids mobilized from
adipose tissue and ketogenic amino acids (i.e. leucine, lysine, phenylalanine,
isoleucine, tryptophan, tyrosine, threonine) to produce acetoacetate (AcAc),
3-β-hydroxybutyrate (3HB), and acetone (Ac). Acetone is considered to have
negligible metabolic significance and rapidly eliminated through urine and
lungs. Ketone bodies cross the blood–brain barrier via monocarboxylate
transporters (MCTs). Inside the cells, they may be directed toward anabolic or
oxidative pathways depending on the developmental stage and cellular
requirements. In the anabolic pathway taking place in the cytosol, acetoacetate
is converted into acetoacetyl-CoA (AcAc-CoA) by acetoacetyl-CoA synthase
(AACS). AcAc-CoA can be condensed with acetyl-CoA to generate the precursor of
sterols, 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA) by
3-hydroxy-3-methylglutaryl-CoA synthase 1 (HMGCS1). The acetyl-CoA produced
from AcAc-CoA by cytosolic β-ketothiolase (cBKD), or from citrate by
ATP-citrate lyase (ACLY), can be transformed in malonyl-CoA for fatty acid
synthesis. Amino acid can be synthesized utilizing intermediates of the TCA
cycle. Oxidation of ketones occurs in the mitochondria (Mit) where AcAc
directly taken up or generated from 3HB by 3-β-hydroxybutyrate dehydrogenase
(BDH) is transformed into acetyl-CoA via succinyl-CoA-3-oxoacid CoA transferase
(SCOT), and mitochondrial β-ketothiolase (mBKD). The complete oxidation of AcAc
yields 23 molecules of ATP, while 3HB generates 26 molecules of ATP.
Brain metabolism in aging INTERESTING
About 20–40% of healthy people between 60 and 78 years
old
experience discernable decrements in cognitive performance in several domains including
working, spatial, and episodic memory, and processing speed
(Mattay et al, 2006;
Glisky, 2007).
Semantic memory and knowledge show no decline until very late in life, while
emotional, automatic, and autobiographic memory are not impacted by aging
(Hedden & Gabrieli, 2004).
These cognitive alterations correlate with neuroanatomical changes, including
an age-dependent decrease in gray matter volume not related to pathological
conditions (Resnick et al, 2003).
This thinning of the cortex is not uniform, with some regions such as the
prefrontal cortex, medial temporal lobe, and hippocampus being more impacted by
aging; other regions, such as the cingulate gyrus and the occipital cortex,
remain relatively unaffected (Sowell et al, 2003).
The loss of gray matter does not appear to be the result of neuronal loss, but
instead involves a gradual decline of dendritic arborization and synapse numbers
(Nakamura et al, 1985;
Page et al, 2002).
Aging also reduces white matter density and increases the number of white matter
lesions (Guttmann et al, 1998),
mostly in the prefrontal cortex and the anterior corpus callosum (O'Sullivan et al, 2001).
By altering the interactions between prefrontal cortex and structures such as
the hippocampus and striatum, white matter abnormalities result in poor
performance in tasks requiring processing speed and immediate or delayed memory
(Glisky, 2007).
The brain undergoes a gradual decline in energy utilization during aging
(Hoyer, 1982a). Functional neuroimaging studies have
shown that glucose hypometabolism and mitochondrial dysfunction are early
indicators of age-related functional changes during normal brain aging
(De Leon et al, 1983;
Small et al, 2000:
Mosconi et al, 2008).
Positron emission tomography analyses of fluorodeoxyglucose uptake into brain
cells in human subjects of different ages have revealed age-related decrements
in glucose utilization in several different brain regions (Zuendorf et al, 2003).
Regional analyses revealed age-related metabolic declines in temporal, parietal,
and cerebral cortex, with a particularly rapid decline in the frontal cortex
(Kuhl et al, 1984a).
In rats, age-dependent reduction in brain cell energy metabolism (glucose
utilization) in the hippocampus and prefrontal cortex is associated with
impaired performance in learning and memory tests (Gage et al, 1984).
The current resolution of functional brain imaging is insufficient to establish
a temporal sequence between hypometabolism and neuroanatomical changes. It is
however tempting to speculate that the increased mitochondrial capacity and
oxidative metabolism that appear to have driven expansion of the cerebral
cortex during human evolution (Grossman et al, 2001, 2004;
Cáceres et al, 2003;
Uddin et al, 2004;
Haygood et al, 2007;
Pontzer et al, 2016)
may have also rendered the brain susceptible to cognitive decline in aging.
Synaptic spines are the site of neurotransmission, and thus fundamental for
forms of synaptic plasticity such as long-term potentiation and long-term
depression. Excitatory synapses are subcellular sites with very high rates of
energy consumption as large amounts of ATP are required to support the activities
of neurotransmitter transporters, and membrane Na+ and Ca2+ pumps that rapidly restore gradients of these
ions after synapse activation (Attwell & Laughlin, 2001;
Alle et al, 2009;
Harris et al, 2012;
Rangaraju et al, 2014).
Accordingly, when the ability of neurons to generate sufficient ATP is
compromised (e.g. aging, ischemia, and neurodegenerative disorders), synapses
are vulnerable to dysfunction and degeneration (Harris et al, 2012)
(Fig 4).
Many factors likely contribute to the age-dependent brain hypometabolism.
Clinical studies have shown a negative correlation between cerebral blood flow
and age (Schultz et al, 1999;
Fabiani et al, 2014).
In addition, the permeabilities of the BBB and BCSFB are greater in older
compared to younger individuals (Rosenberg, 2012).
Brain hypoperfusion and loss of BBB integrity can result in diminished import
of nutrients, and/or removal of toxins. Furthermore, a compromised BBB allows
the parenchymal accumulation of blood-derived proteins (e.g., fibrinogen,
immunoglobulins, albumin, thrombin, hemoglobin), and immune cells which can
cause inflammation (Zlokovic, 2011).
Studies of humans and animals have clearly shown reduced expression of glucose
transporters in the brain with aging (Ding et al, 2013),
as well as changes in the expression of key enzymes involved in glycolysis and
oxidative phosphorylation (Meier-Ruge et al, 1980;
Ulfert et al, 1982;
Bowling et al, 1993).
Studies of mice have shown that levels of ATP are reduced in white matter
during aging, in correlation with ultrastructural alterations in mitochondria,
and a reduced association of mitochondria with endoplasmic reticulum
(Stahon et al, 2016).
NAD levels are critical for mitochondrial function and ATP production
(Bai et al, 2011;
Pittelli et al, 2011).
An increase in the levels of NADH, with decreased total NAD and NAD+ levels,
has been shown in human brain during
normal aging (Zhu et al, 2015).
Experimental evidence supporting a causative role for hypometabolism in
cognitive impairment comes from recent studies showing that mice with reduced
GLUT1 levels display an age-dependent decrease in cerebral capillary density,
reduced cerebral blood flow and glucose uptake, and increased BBB leakage
(Winkler et al, 2015).
These metabolic and vascular alterations precede dendritic spine loss in CA1
hippocampal neurons, and associated behavioral impairments (Winkler et al, 2015).
Figure 4.
Age-related
cognitive decline as a result of neuroanatomical changes driven by decreased
energy supply
The
neuronal firing patterns that play an important role in normal cognitive
processing rely on the neurons' ability to exchange information across
synapses. Compared to young neurons (left), aging neurons (right) are
characterized by a significant reduction of the dendritic tree, as well as
changes in spines size, shape, density, and turnover. Age-dependent diminished
nutrient import, as well as changes in glycolytic and oxidative phosphorylation
efficiency, results in decreased ATP production. The reduced energy
availability impairs the ability of aging neurons to preserve synapse homeostasis.
The resulting structural changes lead to perturbations in neuronal function,
and impairments in memory and learning.
Although
we tend to think of age-related metabolic decline as a “malfunction” of the
brain, it is possible it represents an evolutionary adaptation. Human
physiology is the result of millions of years of evolution under challenging
environmental conditions and limited food availability. The drastic rapid
changes in the lifestyle of modern human societies have led to an increased
incidence of metabolic disorders (i.e., diabetes, obesity, metabolic syndrome,
hyperlipidemia) that may be explained from an evolutionary perspective by the
so-called thrifty genotype hypothesis (Neel, 1962).
The positive natural selection of genes that decreased metabolic rates while
maintaining cognitive efficiency would have allowed individuals to survive
times of limited food availability, but such genes may be detrimental when food
is abundant (Nesse & Williams, 1998).
Indeed, as described in the section on “healthy habits for a healthy brain”
below, the fundamental bioenergetic challenges that were a driving force for
brain evolution (i.e., fasting/starvation, and physical mental exertion) are
exactly those that engage adaptive signaling pathways that promote optimal
brain health, and resistance to brain injury and neurodegenerative disorders in
modern humans.
Altered metabolism in neurodegenerative disorders interesting
Neurodegenerative brain
disorders are a
broad spectrum of fatal conditions characterized by progressive neuronal
dystrophic structural changes and loss of function. AD and PD are the most
common neurodegenerative disorders, with ALS and HD being less prevalent. These
diseases share several mechanistic similarities at the subcellular levels
including atypical protein aggregation, failure of protein degradation
pathways, impaired axonal transport, mitochondrial dysfunction, and programmed
cell death (Mattson et al, 1999).
Increasing evidence suggests that
metabolic alterations strongly influence the initiation and progression of
neurodegenerative disorders. Positron emission tomography imaging studies have
documented reduced glucose utilization in brain regions affected in patients
with AD, PD, ALS, and HD (Hoyer, 1982b).
Epidemiological studies indicate that diabetes, obesity, high blood pressure,
and atherosclerosis are all risk factors for dementia (Kivipelto et al, 2006).
Because each of the latter disorders involves impaired energy metabolism,
and/or adverse changes in the cerebral vasculature, reduced energy availability
to neurons in the brain may contribute to increased vulnerability of the brain
to cognitive impairment and dementia. Considerable evidence suggests that the
BBB [blood brain barrier] integrity is compromised in AD patients
(Glenner, 1979, 1985;
Powers et al, 1981;
Zipser et al, 2007;
Zlokovic, 2011).
In patients with mild cognitive impairment, or early stages of AD, the
age-dependent changes of the BBB permeability are accelerated compared to
neurological normal individuals (Montagne et al, 2015;
van de Haar et al, 2016).
This suggests that neurovascular dysfunction may be an early occurrence in the
pathogenesis of AD. Additionally, changes in nutrient transporter and metabolic
enzyme expression levels, and/or activities, have been reported in AD. For
example, levels of GLUT1 and GLUT3 are reduced in the brains of AD patients
(Simpson et al, 1994;
Harr et al, 1995)
and correlate with diminished brain glucose uptake and subsequent cognitive
decline (Landau et al, 2010).
A precipitous loss of activities of phosphofructokinase (PFK), phosphoglycerate
mutase, aldolase, glucose-6-phosphate isomerase, and lactate dehydrogenase
occurs in brain tissue samples of AD patients compared to age-matched controls
(Iwangoff et al, 1980).
The activities of pyruvate dehydrogenase complex (Perry et al, 1980;
Sorbi et al, 1983),
cytochrome oxidase (Kish et al, 1992),
and α-ketoglutarate dehydrogenase complex (Gibson et al, 1988)
are also decreased in the brains of AD patients. In mouse models of AD, reduction
of GLUT1 levels worsens amyloid
pathology, neurodegeneration, and cognitive function (Winkler et al, 2015), while
ketone and nicotinamide supplementation reduces Aβ and p-Tau
pathologies and improves behavioral outcomes (Kashiwaya et al, 2013;
Liu et al, 2013).
Glucose
hypometabolism in the brains of patients with PD has been documented using magnetic
resonance imaging and positron emission tomography methods (Kuhl et al, 1984b;
Borghammer et al, 2010).
Decreased levels of the PPP key enzymes glucose-6-phosphate dehydrogenase and
6-phosphogluconate dehydrogenase occur at early stages in the putamen and
cerebellum of PD patients (Dunn et al, 2014).
The glycolytic enzyme glucose-6-phosphate isomerase that catalyzes the
conversion of G6P to F6P has been recently identified as a conserved modifier
of dopamine metabolism, protein aggregation, and neurodegeneration in Caenorhabditis
elegans, Drosophila melanogaster, and
murine neurons (Knight et al, 2014).
Furthermore, it was recently shown that plasma levels of α-synuclein regulate
glucose uptake in adipocytes (Rodriguez-Araujo et al, 2013).
Importantly, mutations in multiple genes that cause early-onset inherited forms
of PD (α-synuclein, Parkin, PINK1, LRRK2, DJ-1) result in mitochondrial
dysfunction (Pickrell & Youle, 2015).
Moreover, interventions that bolster
mitochondrial bioenergetics can ameliorate neuropathology and motor deficits in
animal models of PD (Tieu et al, 2003; Yang et al, 2009).
ALS patients
are hypercatabolic and
have increased energy expenditure at rest (Desport et al, 2001; Funalot et al, 2009).
Glucose intolerance (Pradat et al, 2010), insulin resistance (Reyes et al, 1984), and hyperlipidemia (Dupuis et al, 2008) have all been reported in ALS
patients. At a cellular
level, ALS patients exhibit altered
endothelial transporter proteins (Niebroj-Dobosz et al, 2010),
astrocyte end feet degeneration (Miyazaki et al, 2011),
increased permeability of the BBB/BCSFB resulting in abnormal levels of blood
proteins in the CSF (Leonardi et al, 1984;
Annunziata & Volpi, 1985),
and IgG and complement deposits in the spinal cord and motor cortex
(Donnenfeld et al, 1984).
In superoxide dismutase 1 mutant mice and rats, BBB/BCSFB breakdown occurs
prior to motor neuron degeneration and inflammation (Garbuzova-Davis et al, 2007;
Zhong et al, 2008;
Nicaise et al, 2009;
Miyazaki et al, 2011).
Collectively, these findings strongly
suggest that altered metabolic homeostasis plays a major role in ALS insurgence
and progression.
HD [huntington’s
disease] is a genetic disorder caused by trinucleotide repeat (CAG) expansions
in the huntingtingene that causes early
degeneration of
medium spiny neurons in the striatum, resulting in continuous involuntary motor
movements. Striatal metabolism is decreased well prior to atrophy, and the
progression of the disease is more strongly correlated with glucose
hypometabolism than the number of CAG repeats (Mazziotta et al, 1987;
Grafton et al, 1992;
Antonini et al, 1996).
HD patients at early stages of striatum degeneration have normal total levels
of glucose transporters (Gamberino & Brennan, 1994),
but diminished glucose uptake in the brain (Kuhl et al, 1982;
Ciarmiello et al, 2006).
Immunohistochemical analysis utilizing antibody raised against an extracellular
epitope of GLUT3 recently showed a diminished cell surface expression in the
striatum and cortex of HD mice compared to wild-type mice (McClory et al, 2014).
The diminished ability of neurons to uptake glucose can explain the
characteristic hypometabolism that precedes neuronal loss. Interestingly,
higher copy numbers of SLC2A3 (Glut3) delay the age of onset in
HD patients (Vittori et al, 2014).
In fruit fly models of HD, overexpression of GLUT3, PFK, and G6PD protects
against HD phenotypes and increases survival (Vittori et al, 2014;
Besson et al, 2015).
Evidence suggests that the
lysine deacetylases sirtuin 1 (SIRT1) and sirtuin 3 (SIRT3) can preserve
mitochondrial function and protect striatal neurons against dysfunction and
degeneration (Jeong et al, 2011;
Jiang et al, 2011;
Fu et al, 2012).
Agents that increase SIRT1 activity (e.g., SRT2104) attenuate degeneration of
striatal neurons and improve functional outcome in huntingtin mutant mice
(Jiang et al, 2014).
It was also reported that an agent that increases SIRT3 levels (viniferin)
protects neural cells against the toxicity of mutant huntingtin (Fu et al, 2012).
Collectively, the emerging data suggest that interventions that bolster
neuronal bioenergetics may delay disease onset or slow the progression
of HD.
Healthy habits for a healthy brain INTERESTING
In
the not too distant past, our ancestors were regularly challenged to locate and
acquire food, while avoiding hazards. Assumedly, individuals whose brains and bodies
functioned well/optimally when they were in a fasted state (i.e. when they had
to make critical decisions on how to acquire food) had a survival advantage
over those whose brains functioned less well in a state of prolonged negative
energy balance. This bioenergetic challenge-based hypothesis of
brain evolution is supported by empirical evidence that dietary energy
restriction/fasting and exercise enhance synaptic plasticity, neurogenesis, and
cognitive performance in animals (Mattson, 2015a).
For example, running wheel exercise and food restriction each increase
dendritic spine density in hippocampal neurons, and the combination of food
restriction and running results in even greater increases of spine density
(Stranahan et al, 2009).
Hippocampal neurogenesis is also increased in response to exercise and
intermittent fasting (van Praag et al, 1999;
Lee et al, 2002).
In Drosophila melanogaster, associative learning is
performed in fasted animals. One single training is sufficient for the flies to
create a “pleasant” association between a certain scent and food. However,
sequential multiple trainings are needed to establish an “aversive” association
between an odorant and an unpleasant stimulus (electric shock). Fasting before
training has been shown to increase long-term memory formation for both
“pleasant” and “aversive” experiences (Hirano et al, 2013). The duration of fasting appears to
be crucial in determining the ability of the brain to prioritize the type of
memory to establish/consolidate, based on the available energy and the most
pressing survival need. Short-term fasting results in increased long-term
memory (Hirano et al, 2013), while protracted fasting prevents
“aversive”, but not “pleasant”, memory formation (Hirano et al, 2013;
Placais & Preat, 2013).
From an evolutionary point of view, it makes sense that starving flies would
channel their remaining energy in finding food, ignoring aversive/safety issues.
These findings support the idea that intermittent bioenergetic challenges are
beneficial for brain performance.
In this section of our article, we
highlight the importance of “cerebro-bioenergetic resiliency”, the ability of
the brain to respond adaptively to bioenergetic challenges, in promoting
optimal brain function and resistance to stress, injury, and disease throughout
life.
Cells
and organisms have evolved the ability to respond adaptively to stress by
activating intra- and intercellular signaling pathways that increase their
resistance to that specific type of stress, and stress in general. This
property of biological systems is fundamental to the concept of “hormesis”
which is defined by a biphasic dose–response curve in which low doses induce a
stimulatory/beneficial response, while high doses are damaging/toxic
(Mattson, 2008, 2015b).
Numerous studies have shown that when neurons and the organism in which they
reside are subjected to mild metabolic challenges, brain function is improved
and resistance to dysfunction and degeneration is increased compared to those
that are unchallenged. For example, when cultured neurons are first subjected
to a mild metabolic stress (e.g., glutamate, 2-deoxyglucose, or mitochondrial
uncoupling agents), they become resistant to subsequent exposure to a high
level of stress (e.g., metabolic, excitotoxic, or oxidative stressor) that
would have killed them had they not been previously exposed to the mild stress (Marini
& Paul, 1992;
Lee et al, 1999;
Liu et al, 2015).
A classic example
of neuroprotection via hormesis in vivo is
ischemic
preconditioning in which rats or mice that are subjected to a mild cerebral
ischemia prior to full-blown ischemic stroke exhibit reduced brain cell damage
and improved functional outcome compared to animals not subjected to the
preconditioning ischemia (Dirnagl et al, 2009).
Similar to ischemic preconditioning, treatment of mice or rats with
2-deoxyglucose, an analog of glucose that induces cellular metabolic stress,
can protect neurons in the brain and improve functional outcome in models of ischemic
stroke, excitotoxic seizures, and PD (Duan & Mattson, 1999;
Lee et al, 1999;
Yu & Mattson, 1999).
Lifestyle
factors appear to be crucial to determine how healthily our brain will age.
Lack of physical activity, excessive calorie intake, and cognitive apathy
negatively influence brain aging (Mattson, 2015a)
and are predisposing factors for neurodegenerative disorders, such as AD and PD
(Mattson, 2015a).
Conversely, healthy lifestyle habits including dietary energy restriction,
macro- and micronutrient diet composition, physical and mental exercise, and
reduction of life stress boost cognitive function (Mattson, 2015a).
Regular
aerobic exercise improves executive
function, attention processing, speed memory, and learning (Colcombe &
Kramer, 2003; Curlik & Shors, 2013; Dresler et al, 2013). Neuroimaging studies have shown that
exercise targets specific brain areas, namely prefrontal and medial temporal
cortices (Berchicci et al, 2013), and hippocampus (Kerr et al, 2010; Erickson et al, 2011, 2014). Elderly people that regularly
exercise have increased brain volumes in these critical network areas, compared
to sedentary subjects that instead undergo a significant volume decline
(Colcombe et al, 2006; Erickson et al, 2009; Kerr et al, 2010). Epidemiological
and interventional studies in humans have shown that exercise can increase
one's resistance to anxiety and depression, and possibly AD and PD; exercise
lessens symptoms in individuals suffering from these medical conditions
(Tordeurs et al, 2011;
Mattson, 2012;
Paillard et al, 2015). The results of studies of animal
models of anxiety, depression, AD, PD, stroke, and traumatic brain injury have
established broad preventative and therapeutic benefits of aerobic exercise
(Greenwood & Fleshner, 2008; Yuede et al, 2009; Egan et al, 2014; Mattson, 2014; Holland & Schmidt, 2015; Ryan & Kelly, 2016). The dysfunction
and degeneration of neurons in these different disorders involves impaired
neuronal bioenergetics, whose onset and progression varies markedly with regard
to severity and duration (insidious in AD and depression, and acute and
dramatic in stroke and traumatic brain injury) (Dirnagl et al, 2009;
Marazziti et al, 2011).
A
second lifestyle modification that promotes brain health is dietary energy
restriction that can be achieved by caloric restriction, or by intermittent
fasting (IF). IF
can be operationally defined as an eating pattern that includes extended
periods of time (e.g. 16 h daily or 24 h twice a week) during which
no or very little food is consumed. Most animal studies of IF have used
alternate-day fasting (ADF, alternating days of complete fasting and ad libitum
feeding). Mice or rats maintained on ADF exhibit reduced brain
neuropathology and improved functional outcomes in models of stroke, AD, PD,
HD, and epilepsy (Bruce-Keller et al, 1999;
Duan & Mattson, 1999;
Halagappa et al, 2007).
Age-related
cognitive decline can also be counteracted by interventions stimulating brain
activity. Engaging in intellectual challenges “exercises” and reinforces
neuronal circuitries. Different types of cognitive training
have been shown to improve specific cognitive aspects such as learning
(Bailey et al, 2010),
executive functions (Basak et al, 2008),
and fluid intelligence (Jaeggi et al, 2008).
In animal studies, environmental enrichment enhances cognitive performance by
promoting neurotrophin production, synaptogenesis, dendrite formation, and
arborization (van Praag et al, 2000;
Fratiglioni et al, 2004).
Neuroimaging studies in humans have shown that memory training increases
hippocampal volume (Engvig et al, 2012),
as well as the thickness of brain areas involved in decision-making processing
(i.e., lateral and fusiform orbitofrontal cortex) (Engvig et al, 2010).
The
importance of exercise, diet, and intellectual and social stimulation in brain
aging is emphasized by the results of a recent study showing that changes in
diet, exercise, and cognitive training slow cognitive decline in elderly
subjects (Ngandu et al, 2015).
An additional advantage of this healthy lifestyle habit is that their
combination appears to provide synergistic benefits (Schneider &
Yvon, 2013).
For example, adopting an exercise routine together with cognitive training
promotes memory performance (Fabre et al, 2002;
Oswald et al, 2006).
A recent study in elderly subjects exposed to either moderate aerobic exercise
or cognitive training, or to a combination of both, showed a greater
improvement in working memory, long-term memory, and reaction times in the
cohort exposed to both trainings (Shatil, 2013).
Studies
of cell culture and in vivo models of
bioenergetic stress-induced neuroprotection have begun to elucidate the
molecular pathways that bolster neuronal resilience. They include activation of
transcription factors such as cAMP response element-binding protein (CREB),
nuclear factor κB (NF-κB), and nuclear factor erythroid-derived 2 (NRF2) and
induction of the expression of genes encoding proteins that counteract cellular
stress at multiple subcellular sites, and by different mechanisms
(Mattson, 2012)
(Fig 5).
Figure 5.
Signaling pathways
mediating adaptive responses of neurons to bioenergetic challenges
Exercise
and fasting affect subcellular processes in neurons by brain-intrinsic
mechanisms mediated by increased neuronal network activity, and via signals
coming from the periphery including 3-β-hydroxybutyrate (3HB), cathepsin B, and
irisin. Intellectual challenges involve increased neuronal network activity and
consequent activation of calcium-responsive pathways. BDNF expression is
up-regulated by neuronal network activity, as well as 3HB, cathepsin B, and
irisin, and BDNF is known to mediate, at least in part, the enhancement of
neuronal plasticity and stress resistance by exercise, fasting, and
intellectual challenges. Exercise, fasting, and intellectual challenges result
in the activation of glutamate receptors at excitatory synapses, Ca2+ influx,
and activation of Ca2+ calmodulin-dependent protein kinase (CaMK)
which, in turn, activates the transcription factor cyclic AMP response
element-binding protein (CREB). CREB can directly and indirectly modulate
mitochondrial biogenesis via expression of several genes (i.e. BDNF, PGC-1α,
NRF1, PPARα, and TFAM). Activation of glutamate receptors also induces the
expression of the mitochondrial protein sirtuin 3 (SIRT3) which can protect
neurons by deacetylating superoxide dismutase 2 (SOD2) to increase its
enzymatic activity, and thus reduce mitochondrial oxidative stress, and by
inhibiting cyclophilin D (CycD), a protein involved in the formation of
membrane permeability transition pores (PTP). 3-β-Hydroxybutyrate (3HB) can
induce BDNF expression in neurons via the Ca2+–CREB pathway,
and a pathway involving mitochondrial reactive oxygen species (ROS) and
activation of the transcription factor nuclear factor κB (NF-κB). BDNF is
released from neurons and activates the receptor tropomyosin receptor kinase B
(TrkB), on the same neuron and adjacent neurons, engaging downstream intracellular
pathways which activate transcription factors that induce the expression of
genes encoding proteins involved in synaptic plasticity, learning and memory,
and neuronal stress resistance. Abbreviations are as follows: Pgc1a, peroxisome
proliferator-activated receptor gamma coactivator 1-alpha; NRF1, nuclear
regulatory factor 1; PPARα, peroxisome proliferator-activated receptor α; TFAM,
mitochondrial transcription factor A; GLUT3, glucose transporter 3; MCT2,
monocarboxylic acid transporter 2; PI3K, phosphoinositide 3 kinase; Akt,
protein kinase B; ERK, extracellular signal regulated kinase; ETC., electron
transport chain; ATP, adenosine-5′-triphosphate; APE1, apurinic/apyrimidinic
endonuclease 1.
Exercise
and IF can up-regulate the expression of various proteins including antioxidant
enzymes such as glutathione peroxidase, superoxide dismutase 2 (SOD2), and heme
oxygenase 1; anti-apoptotic proteins such as B-cell lymphoma 2 family members;
proteins involved in mitochondrial biogenesis and stress resistance; protein
chaperones such as heat-shock protein 70 and glucose-regulated protein 78;
neurotrophic factors such as brain-derived neurotrophic factor (BDNF); and
fibroblast growth factor 2 (Marosi et al, 2012;
Mattson, 2012).
Secreted neurotrophins can in turn activate cytoprotective signaling pathways
in adjacent or distant neurons, thereby propagating adaptive cellular stress
responses to cells that themselves had not experienced the same metabolic
stress (Madinier et al, 2013).
BDNF may play a significant role in several neuronal activity-mediated effects
of exercise and IF on neuronal bioenergetics and stress resistance. BDNF
stimulates neuronal energy metabolism by increasing the expression of GLUT3,
sodium-dependent amino acid transport and protein synthesis (Burkahalter et al, 2003),
and ketone utilization via MCT2 (Robinet & Pellerin, 2010).
Furthermore, running and BDNF induce the expression of peroxisome
proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α) to increase
mitochondrial biogenesis (Steiner et al, 1985;
Cheng et al, 2012).
Interestingly, exercise, moderate levels of glutamate receptor activation, and
BDNF also induce the expression of the DNA repair enzyme apurinic/apyrimidinic
endonuclease 1 (APE1), which plays a critical role in repairing oxidatively
damaged DNA and protecting neurons against metabolic and excitotoxic stress
(Yang et al, 2010, 2014).
Peripheral
signals elicited in response to vigorous exercise and energy restriction/fasting
may mediate some of the effects of these bioenergetic challenges on
neuroplasticity and stress resistance. In addition to being used by neurons as
an energy substrate, the ketone body 3HB also boosts the function, plasticity,
and stress resistance of neurons in the brain by inducing the expression of
BDNF in vivo (Sleiman et al, 2016)
and in vitro (Marosi et al, 2016).
3HB mechanisms of action involve the generation of mitochondrial ROS and
activation of the transcription factor nuclear factor κB (NF-κB) (Marosi et al, 2016)
(Fig 5),
as well as the inhibition of histone deacetylases (Sleiman et al, 2016).
Metabolic challenges also trigger peripheral cells to release into the
circulation proteins that enter the brain where they elicit adaptive responses
in neurons. Levels of cathepsin B, a predominantly lysosomal protein, are
increased in skeletal muscle and plasma in response to running in mice
(Moon et al, 2016).
Cathepsin B induces the expression of BDNF in hippocampal neural progenitor
cells, and the abilities of running to induce hippocampal neurogenesis and
improve learning and memory performance are attenuated in cathepsin B-deficient
mice (Moon et al, 2016)
(Fig 5).
Another muscle-derived factor that has been suggested to mediate beneficial
effects of exercise on neuroplasticity is irisin, which was reported to
increase BDNF levels in the brain (Wrann et al, 2013).
It is therefore becoming clear that bioenergetic challenges educe a complex
array of brain-intrinsic and peripheral signaling mechanisms that coordinate
adaptive responses of neurons and neural progenitor cells so as to optimize
brain function and protect the brain against injury and disease.
It
seems unlikely that drugs can be developed that trigger the complex,
evolutionarily conserved mechanisms by which bioenergetic challenges promote
brain health. However,
preclinical findings and the results of some clinical trials suggest the
potential for pharmacological interventions able to activate some of signaling
pathways induced by exercise, fasting, and intellectual challenges. Ketogenic
diets, ketone precursors (medium chain triglycerides), and 3HB have been
reported in clinical studies of subjects with cognitive impairment, and AD
(Reger et al, 2004; Henderson et al, 2009; Rebello et al, 2015), or PD patients
(Vanitallie et al, 2005). It is not known whether
improvements in cognitive function in the latter studies result from the utilization
of 3HB as an energy substrate and/or the activation of adaptive stress response
signaling in neurons
[or both]. Caffeine, by stimulating Ca2+ release
from the endoplasmic reticulum and increasing cyclic AMP levels, activates CREB
(Connolly & Kingsbury, 2010)
and has been shown to enhance memory consolidation in humans (Borota et al, 2014).
Bitter chemicals that function as natural pesticides/antifeedants activate NRF2
and have demonstrated efficacy in animal models of stroke, AD, and PD; examples
include sulforaphane, curcumin, and plumbagin (Son et al, 2008, 2010;
Mattson, 2015b).
Randomized controlled trials of such chemicals in human subjects with
neurological disorders remain to be performed. Transcranial direct current or
magnetic stimulation modulates BDNF levels (Müller et al, 2000)
and can improve cognitive performance in healthy subjects and relieve symptoms
in patients with depression and AD (Hsu et al, 2015;
Brunoni et al, 2016).
Noninvasive brain stimulation is a very exciting area because of its safety and
potential for selective activation or inhibition of neuronal circuits in a
brain region-specific manner.
Although
promising, such approaches should not be considered as substitutes for
exercise, energy restriction, and intellectually challenging lifestyles. The
adaptive cellular and molecular responses to these physiological challenges are
finely tuned and are centrally and peripherally coordinated. They involve
metabolic stress that occurs predominantly in excitable cells—skeletal muscle,
cardiac myocytes, and neurons—and results in the activation or inhibition of
numerous signaling pathways in cells throughout the brain. There is much that
remains to be learned about these pathways: how they are activated, their
molecular components, and how they interact to promote neuroplasticity and
stress resistance. We also have little information concerning the intensities
and durations of exercise and energy restriction that promote optimal brain
health, nor how such regimens might vary depending upon one's age, metabolic
status, or neurological disorders.
Conclusions and future directions
Emerging findings suggest that optimal
brain health is promoted by intermittent bioenergetic challenges that increase
activity in neuronal circuits, including intellectual challenges, restriction
of energy intake, and physical exercise. Studies of animal and cell culture
models have shown that such intermittent bioenergetic challenges activate
signaling pathways in neurons that bolster mitochondrial health by, for
example, stimulating mitochondrial biogenesis and mitophagy. The neuronal
activity-dependent and cellular stress-responsive neurotrophic factor BDNF
appears to play key roles in the neuroplasticity-enhancing and neuroprotective
actions of bioenergetic challenges. Signals from peripheral organs to brain
cells may also contribute to the beneficial effects of exercise and fasting on
cognitive function and neuronal resilience. During normal aging, there are
decrements in the functionality of several energy metabolism-related pathways
in brain cells including glucose transport, mitochondrial electron transport, DNA
repair, and neurotrophic factor signaling. Epidemiological, clinical, and
experimental evidence points to important roles for impaired neuronal
bioenergetics and reduced adaptation to stress in normal aging, and preclinical
stages of neurodegenerative disorders such as AD and PD.
There
is considerable complexity in the signaling pathways that integrate cellular
energy metabolism with adaptive structural and functional responses of neuronal
circuits to neuronal network activity. Future studies should be aimed at
elucidating such intercellular and subcellular pathways. As new mechanisms
emerge, it will be important to determine whether and how environmental and
genetic factors that positively or negatively impact brain health influence
brain cell energy metabolism. Translational research on cellular energy
metabolism and brain health has been meager compared to efforts that focus on
individual disease-specific molecular targets. The drug development approach
has thus far failed for AD, PD, and stroke. Indeed, the number of individuals
living until they are in the age range for neurodegenerative disorders is
rapidly increasing. The kinds of evidence from preclinical studies and human
subjects described above provide a rationale for moving forward with randomized
controlled trials of intermittent bioenergetic challenges achieved
physiologically (e.g. intermittent fasting and exercise) or pharmacologically
(e.g. mitochondrial uncoupling agents) in humans at risk of or in the early
symptomatic stages of a neurodegenerative disorder, or during recovery from a
stroke. As elaborated elsewhere (Mattson, 2012),
it would also seem prudent to incorporate intermittent exercise and fasting
protocols into physician training and healthcare practice, for disease risk
reduction and early intervention in acute and chronic neurodegenerative
conditions.
Acknowledgements
This work was supported by
the Intramural Research Program of the National Institute on Aging.
[1]
Astrocytes are
characteristic star-shaped glial cells in
the brain and spinal cord.
They make from 20-40% of all gilia.
They perform
many functions, including biochemical support
of endothelial cells that form
the blood–brain
barrier, provision of
nutrients to the nervous tissue, maintenance
of extracellular ion balance, and a role in the repair and scarring process of
the brain and spinal cord following traumatic injuries.
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Oliver Wendel Holmes Senior said: If you throw all the medicines in the ocean it would be
better for mankind and worse for the fish. He also wrote: drugs are what you take while you wait for your body
to heal. That which made drugs bad in 1885, the profit incentive is still
the same, only the percentage take drugs has increased
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