Leptin Replacement Improves Cognitive Development

Abstract

Background

Leptin changes brain structure, neuron excitability and synaptic plasticity. It also regulates the development and function of feeding circuits. However, the effects of leptin on neurocognitive development are unknown.

Objective

To evaluate the effect of leptin on neurocognitive development.

Methodology

A 5-year-old boy with a nonconservative missense leptin gene mutation (Cys-to-Thr in codon 105) was treated with recombinant methionyl human leptin (r-metHuLeptin) at physiologic replacement doses of 0.03 mg/kg/day. Cognitive development was assessed using the Differential Ability Scales (DAS), a measure of general verbal and nonverbal functioning; and selected subtests from the NEPSY, a measure of neuropsychological functioning in children.

Principal Findings

Prior to treatment, the patient was morbidly obese, hypertensive, dyslipidemic, and hyperinsulinemic. Baseline neurocognitive tests revealed slower than expected rates of development (developmental age lower than chronological age) in a majority of the areas assessed. After two years, substantial increases in the rates of development in most neurocognitive domains were apparent, with some skills at or exceeding expectations based on chronological age. We also observed marked weight loss and resolution of hypertension, dyslipidemia and hyperinsulinemia.

Conclusions

We concluded that replacement with r-metHuLeptin is associated with weight loss and changes in rates of development in many neurocognitive domains, which lends support to the hypothesis that, in addition to its role in metabolism, leptin may have a cognitive enhancing role in the developing central nervous system.

Trial Registration

ClinicalTrials.gov NCT00659828

About the Authors:

Gilberto J. Paz-Filho

Affiliations Department of Psychiatry and Behavioral Sciences, Center for Pharmacogenomics, University of Miami Miller School of Medicine, Miami, Florida, United States of America, SEMPR – Serviço de Endocrinologia e Metabologia da UFPR, Curitiba, Parana, Brazil

Talin Babikian

Affiliation: Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, United States of America

Robert Asarnow

Affiliation: Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, United States of America

Karin Esposito

Affiliation: Department of Psychiatry and Behavioral Sciences, Center for Pharmacogenomics, University of Miami Miller School of Medicine, Miami, Florida, United States of America

Halil K. Erol

Affiliation: Department of Psychiatry and Behavioral Sciences, Center for Pharmacogenomics, University of Miami Miller School of Medicine, Miami, Florida, United States of America

Ma-Li Wong

Affiliation: Department of Psychiatry and Behavioral Sciences, Center for Pharmacogenomics, University of Miami Miller School of Medicine, Miami, Florida, United States of America

Julio Licinio

* E-mail: [email protected]

Affiliation: Department of Psychiatry and Behavioral Sciences, Center for Pharmacogenomics, University of Miami Miller School of Medicine, Miami, Florida, United States of America

Introduction

Leptin, the product of the ob gene, is an adipocyte-derived hormone with multiple functions in reproduction [1], [2], glucose homeostasis [3], [4], bone formation [5], [6], tissue remodeling [7], and inflammation [8], as well as in other elements of the endocrine [9], [10] and immune systems [11], [12]. The most important function of leptin is the regulation of energy expenditure and food intake, due to its actions on the arcuate nucleus of the hypothalamus. In this area, leptin binds to its respective receptors, which are expressed in two different neuronal populations: those that express agouti-related peptide (AgRP) and neuropeptide Y (NPY), and those that express the peptide cocaine and amphetamine-related transcript (CART) and the large precursor peptide pro-opiomelanocortin (POMC). Leptin exerts anorexigenic effects by inhibiting the AgRP/NPY neurons and by stimulating the POMC/CART neurons. Among mice that are leptin-deficient (ob/ob) or leptin-resistant (db/db), hyperphagia is a constant and obesity, a hallmark.

The effects of leptin on body composition, bone metabolism and on immune, endocrine and metabolic parameters have already been well documented. It has also been shown that treatment with leptin in its synthetic form (recombinant methionyl human leptin; r-metHuLeptin) leads to structural [13] and functional changes within specific regions of the central nervous system [14], [15]. Other roles of leptin within the brain include effects on neuron excitability and on synaptic plasticity [16]–[18]. In addition, leptin maintains neural stem and progenitor cells, affects neural differentiation, promotes the migration of neuronal lineage cells to the cortical plate, and regulates the development of hypothalamic feeding circuits [19]–[21]. Taking all these actions together, it is feasible to hypothesize that leptin is also important for the development of neurocognition. There is no data in the literature addressing the effects of leptin on the development of neurocognition in humans. The evaluation of these effects in normal humans has many limitations, such as the ethical problems in administering exogenous leptin to normal children and the fact that the child's endogenous leptin is an evident confounding factor.

Our group has previously described the phenotypic findings in the only leptin-deficient patients identified at adulthood to date. Concomitantly, we described the effects of leptin-replacement therapy in these unique patients [13], [14], [22]–[25]. These patients are two women and one man from a highly consanguineous extended Turkish pedigree, who carry a nonconservative missense leptin gene mutation (Cys-to-Thr in codon 105). These patients have benefited from a daily injection of recombinant methionyl human leptin (r-metHuLeptin) and have shown significant improvements regarding body weight, gonadal function and behavior. To our knowledge, 10 children with congenital leptin deficiency, also due to loss-of-function mutations in the gene encoding leptin, have been identified in the world [26]–[30].

Here we present a unique human model that overcomes the limitations of administering exogenous leptin to normal children, in order to evaluate its effects on cognition. We show, for the first time, the effects of replacement with r-metHuLeptin on neurocognition in a leptin-deficient boy from the aforementioned consanguineous Turkish family. Additional data on the anthropometric and metabolic parameters are described, before and during treatment.

Methods

The protocol for this n-of-1 trial and supporting CONSORT checklist are available as supporting information; see Protocol S1 and Checklist S1.

Patient

The patient is a 7-year-old male born to a highly consanguineous Turkish family. His parents are first-degree cousins. Due to excessive weight gain beginning at age 3 months, and to familial history of leptin deficiency caused by a mutation in the leptin gene, that gene was genotyped when he was 2 years old.

Genotyping

The nucleotide sequence of the ob gene was analyzed in the proband and his first-degree relatives by direct sequencing. The patient was homozygous for a missense leptin gene mutation (Cys-to-Thr in codon 105), whereas the parents and the sister were heterozygous for the same mutation.

Leptin administration and dose

Leptin replacement therapy was started at age 5y1m. Recombinant methionyl human leptin (r-metHuLeptin) was supplied initially by Amgen, Inc. (Thousand Oaks, CA, USA), and subsequently by Amylin Pharmaceuticals, Inc., (San Diego, CA, USA). The drug has been uninterruptedly administered once a day in the evening (18:00–20:00), with a starting dose of 1.36 mg/day SQ. Dosage was initially calculated to achieve a peak serum leptin concentration of 70 ng/ml, which is equivalent to 10% of the child's predicted normal serum leptin concentration (based on age, sex, and body composition) [31], [32]. Due to his decreased food intake and subsequent weight loss, dosage was progressively reduced to 0.45 mg/day, which is the current dose, at age 7y5m. We chose daily evening administration to model the normal circadian variation of endogenous leptin, which is characterized by a pulsatile circadian rhythm with a marked nocturnal rise [33].

Neurocognitive evaluations

The patient underwent a neurocognitive evaluation pre-treatment (T1, at age 5y1m) and twice following the initiation of leptin treatment (T2, at age 6y0m; T3, at age 7y2m). A fluent Turkish-speaking clinician who was familiar with all test items translated the test instructions and language based measures. The clinician was familiar to the patient and had established good rapport. The patient generally showed interest in the tasks and readily participated but showed inconsistent attention. In order to maintain cooperation and interest in the test items, M&M candies were offered as needed to the patient at the T1 and T2 test sessions but were not necessary at T3.

The following neurocognitive assessments were administered: 1) Differential Ability Scales (DAS), a measure of general verbal and nonverbal functioning; and 2) selected subtests from the NEPSY, a measure of neuropsychological functioning in children. Both measures are standardized, commercially available instruments that are used for clinical and research purposes. Although both the DAS and the NEPSY are normed on a representative sample based on the US population census and on English speaking children only, careful consideration was given to selecting instruments (and subtests from these instruments) that tap into general skills and are least likely to be affected by cultural factors. We are fully aware that language and cultural differences may have introduced biases to the test results. Nonetheless, the longitudinal design was a strength in the study as it allowed us to use within subject analyses (with the patient's pre-treatment performance serving as his own control) to describe changes in cognitive functioning after the initiation of leptin treatment. Therefore, any aspects of culture or language status that may have affected the test results would have a similar effect on the patient's performance at all three time points and therefore cancel out in the analyses.

We assumed that the level of cognitive functioning at the pre-treatment evaluation was representative of the patient's cognitive functioning from birth until the baseline evaluation. This assumption seemed reasonable given that the effect of leptin on brain development likely began in utero. Rates of development were computed for each of the three sets of time points: T1) from birth to 61 months (pre-treatment), T2) from 61 months to 72 months (one year post-treatment), and T3) from 72 months to 86 months (two years post-treatment). To assess changes in cognitive functioning pre- and post-treatment, age equivalencies (based on typical performance for a given age or age range) were derived using normative data from the test manuals. For example, at age 4, performance at the level of a 4-year-old would yield a rate of development of 1 (4/4). Therefore, a ratio of “1” indicates typical development. In contrast, at age 4, a performance at the level of a 3-year-old would yield a developmental rate of 0.75 (3/4). Subsequently, a score of <1 indicates performance (developmental age) below that expected for chronological age. Rates above “1” indicate development above expected levels.

In addition to the cognitive measures, parent report measures assessing behavioral/emotional problems (Achenbach Child Behavior Checklist, CBCL) and behavioral regulation/executive functioning (Behavioral Rating Inventory of Executive Function, BRIEF) were orally translated and administered to the patient's mother.

Hormonal and metabolite assays

Blood samples were obtained after overnight fasting and analyzed for TSH, free T4, T3, cholesterol, triglycerides, HDL cholesterol, LDL cholesterol, glucose, and insulin, using standard assays, at T1 and T3.

Food intake

At T1 and T2, the General Clinical Research Center at the University of California, Los Angeles (UCLA GCRC) provided food ad libitum. During these visits, intake was calculated by subtracting content of uneaten food and beverage items from initial content of each item served. All food and beverages provided to the patient were recorded by weight (in grams, to nearest 0.1 g) with a precision balance (Mettler-Toledo Inc., Columbus, OH). The patient's mother was also instructed to keep dietary records, which were carefully reviewed by the GCRC Senior Dietician. Nutrient intake was calculated using a nutrition analysis software (Nutritionist Pro, First DataBank, Inc., San Bruno, CA). At T3, meals were not provided by the GCRC, as the participant was evaluated as an outpatient. Nevertheless, he was allowed to eat ad libitum, and dietary intake was assessed through food records kept by his mother. The software Food Processor SQL (Esha Research, Salem, OR, USA) was used for nutritional analysis in 2007.

Research ethics

At T1 and T2, the study took place at the General Clinical Research Center at the University of California, Los Angeles (UCLA GCRC). The study protocol was approved by the Food and Drug Administration and by the UCLA Institutional Review Boards. At T3, the study site was relocated to the University of Miami, where new approvals from the local Institutional Review Boards were obtained. Informed parental consent/patient assent (at age 7) were obtained for all studies. Written informed consent for publication was given by the mother.

Results

Neurocognitive development

General cognitive ability was assessed by the DAS, which measures verbal, nonverbal, short-term memory, and pre-academic skills. The patient's pre- and post- treatment DAS verbal and nonverbal cluster scores were lower than the scores for age- matched controls from the normative sample. However, administration of r-metHuLeptin was followed by an upward trend in development, with scores generally normalizing by T3. Pre-treatment verbal and nonverbal scores were in the 4th percentile. At T2, verbal scores were in the 9th percentile while nonverbal scores were in the 6th percentile. In contrast, by T3, the patient's verbal scores were in the 14th percentile while his nonverbal scores were in the 30th percentile, both broadly within normal limits for his age. With one exception (“Recall of Objects”), Figure 1 reveals that the patient's pre-treatment rate of development was consistently lower than expected for all DAS subtests administered. Of note however, the patient's rate of development increased, especially by T3, and in several instances achieved levels generally within the expected range for his age (i.e., close to “1”).

[Figure omitted. See PDF.]

Figure 1. Rates of development for DAS subtests.

A rate of “1” (vertical axis) indicates typical development (i.e., developmental age equals chronological age). For example, at age 4, performance at the level of a 4 year old would yield a rate of development of 1 (4/4). In contrast, at age 4, a performance at the level of a 3 year old would yield a developmental rate of 0.75 (3/4). Subsequently, a score of <1 indicates performance (developmental age) below that expected for chronological age.

https://doi.org/10.1371/journal.pone.0003098.g001

Neuropsychological functioning was evaluated by the NEPSY, with results analyzed similarly to those of the DAS (described in Methods). Similar to his cognitive results, the patient's intra-treatment rate of development showed an increasing trend compared to his pre-treatment rate of development, with many T3 rates of development at or exceeding age expectations (e.g., Memory for Faces, Blocks). The NEPSY scores are illustrated in Figure 2.

[Figure omitted. See PDF.]

Figure 2. Rates of development for NEPSY subtests.

A rate of “1” (vertical axis) indicates typical development (i.e., developmental age matches chronological age). A score of <1 indicates performance (developmental age) below that expected for chronological age.

https://doi.org/10.1371/journal.pone.0003098.g002

Parental report of emotional problems and behavioral regulation resulted in scores that were within normal limits compared to age-matched peers on all three occasions. The patient's mother did not report any concerns except for his overall health and well-being.

Metabolic and anthropometric parameters

Ten months after initiation of therapy, his growth velocity was normal (5.7 cm/year), but it decreased slightly to 4.1 cm/year, when calculated between ages 5y11m and 7y2m. Figure 3 and Table 1 illustrate the changes in anthropometric parameters.

[Figure omitted. See PDF.]

Figure 3. Patient before replacement with r-metHuLeptin at age 5y1m and during treatment at age 7y2m.

https://doi.org/10.1371/journal.pone.0003098.g003

[Figure omitted. See PDF.]

Table 1. Weight, height and BMI before and after treatment initiation, correlated with percentiles for same sex and age.

https://doi.org/10.1371/journal.pone.0003098.t001

On baseline clinical examination, the patient's blood pressure measured 110/70, slightly above the 90th percentile for his age [34]. At age 7y2m, his blood pressure was normal, at 101/66 mmHg. Other vital signs were normal at all times and, besides obesity, there were no other abnormalities. At baseline, the patient had normal liver and renal functions and was euglycemic at all times, but presented with hyperinsulinemia before treatment. This was normalized as his weight started to decrease. Also, there were decreases in triglycerides, total cholesterol and LDL cholesterol, and an increase in HDL cholesterol. Thyroid function was normal at all times (Table 2).

[Figure omitted. See PDF.]

Table 2. Lipid profile, glucose and insulin before and after treatment initiation.

https://doi.org/10.1371/journal.pone.0003098.t002

Caloric intake

Before treatment, average caloric intake was 2,709±370 kcal/day (54.3±2.5% from carbohydrate, 32.6±1.6% from fat and 13.1±1.1% from protein). In the 4th week of treatment, average caloric intake decreased to 1,751±475 kcal/day (56.0±5.9% from carbohydrate, 32.6±2.9% from fat and 11.5±3.2% from protein). One year after treatment initiation, average daily caloric intake was 2,594±346 kcal (55.8±5.6% from carbohydrate, 31.0±3.5% from fat and 13.2±2.8% from protein). Two years after treatment initiation, average daily caloric intake was 2,194±292 kcal (64.5±3.12% from carbohydrate, 16.6±3.0% from fat and 15.1±5.16% from protein), which is 106% of the recommended caloric intake for a boy this age, height and weight.

Discussion

In this n-of-1 trial, we observed that leptin was associated with an improved rate of development in various aspects of neurocognitive functioning. As evidence that leptin replacement was beneficial to the patient, we documented resolution of hypertension, dyslipidemia and hyperinsulinemia, in the context of decrease in food intake and weight loss. To the best of our knowledge, this is the first longitudinal study that shows that leptin has a cognitive enhancing role in the developing CNS of humans. To achieve that result, we employed the only possible human model: a leptin-deficient child under leptin replacement therapy. Treatment of leptin-sufficient children poses many ethical issues, and results are contaminated by the fact that these children are already under the effects of their endogenous leptin. Due to the leptin-naïve status of the patient, we were able to evaluate the effects of leptin on the developing CNS.

To compute rates of development at different time points, we inferred a steady rate from birth to 61 months (pre-leptin treatment) because we did not have two pretreatment baselines. The inferred rate of development was much slower from birth to 61 months (T1), suggesting developmental age below expectations for chronological age, than the rate of development observed during the treatment phase (T1 to T3) on most of the neurocognitive measures administered. By T3 (two years after initiation of leptin therapy), developmental relative chronological age ratios increased on all but one subtest compared to the baseline evaluation, and in many cases, approached or exceeded chronological age expectations. Because the patient had not experienced any environmental changes that would affect his neurocognitive abilities (i.e., starting school, receiving tutoring) between T1 and T2, we cautiously attribute the increased rate of development to leptin treatment and its subsequent effects on the CNS. However, the patient had completed the first year of school in his home country by the time of the third evaluation, which may partly have contributed to the apparent increase in rate of development between T2-T3. Nonetheless, these improvements are consistent with the finding that leptin replacement tends to normalize certain brain structures in leptin deficient mice. It would be instructive to compute correlations between rates of change in cognitive scores and rates of change in brain volume pre- and post-treatment to further support this assertion. Nonetheless, initial results suggest that in this leptin deficient patient, leptin may have had a cognitive enhancing role.

After the initiation of r-metHuLeptin, we observed a slower rate of development at T2 relative to T1 on a few subtests (“Recall of Objects,” “Memory for Faces,” and “Blocks”). However, scores at T2 were no more than 20% lower than scores predicted for age and in most cases, not clinically different. The few exceptions to the general pattern of increase in developmental rate may in part be within the error variance of the instrument. These normal variations in performance are difficult to characterize given that there is only subject in the study.

Leptin has a role in the central nervous system beyond its regulatory function through the hypothalamus on food intake and energy balance. Leptin is expressed in the brain, including the cerebellum, pyriform cortex, cerebral cortex, thalamus, hippocampus, amygdala, olfactory tract and substantia nigra [35]. It may improve cognition by the selective enhancement of N-methyl D-aspartate (NMDA) receptors, facilitating long-term potentiation (LTP) [36]. In low frequency stimulation, leptin inhibits hippocampal neurons, regulating hippocampal excitability [35], [37]. In adult mice, leptin increases hippocampal neurogenesis, both in vitro and in vivo [38]. Hippocampal synaptic plasticity is also regulated by leptin. Animals with leptin receptor mutations (db/db mice or fa/fa rats) present deficits in hippocampal-specific memory tasks [39], impairments in hippocampal LTP, and long-term depression [36]. Leptin is also an important hormonal signal in the developing CNS. In adult leptin deficient (ob/ob) or leptin resistant (db/db) mice, for example, leptin deficiency leads to lower brain weight and protein content [21], [40], [41]. Many of these effects normalize after postnatal administration of leptin [35]. In addition, brain myelin [42], neuronal soma size [43], and several synaptic proteins are reduced [35]. Growth-associated proteins in the neocortex, striatum and hippocampus are elevated, and dendritic orientation is altered [44].

In humans, normal neonates have two to three times higher serum leptin levels, when compared to adults [45]. Elevated circulating leptin levels are originated from the maternal and the neonatal adipose tissue, as well as from the placenta. Moreover, the increased adipose leptin mRNA expression in fetal adipose tissue, and the delayed onset of synthesis of leptin prior to the maturation of its receptor also explain the high levels of leptin [46]. Several maternal, placental and neonatal factors are potentially associated with production and functions of leptin in early life, and have been reviewed by Alexe et al. [47]. Leptin does not appear to regulate food intake and body weight during neonatal life [48], and the metabolically irrelevant surge of leptin may act as a developmental signal [49], which coincides with the development of major hypothalamic feeding circuits [50]. This neurodevelopmental activity of leptin is limited to a neonatal window of maximum sensitivity, corresponding to a period of elevated leptin secretion [51]. However, in adults, leptin can still affect brain plasticity by causing synaptic rearrangement of excitatory and inhibitory inputs on arcuate neurons [18], suggesting that these circuits remain relatively plastic throughout life.

In abnormal conditions, low levels of leptin at birth are seen in small for gestational age infants [52], but the neurodevelopmental consequences of this alteration have not been evaluated. The neurodevelopmental actions of leptin are not restricted to the hypothalamus: it has been demonstrated that cortical and hippocampal development can also be influenced by leptin [53], [54]. It is known that, besides its effects on the components of feeding circuits, leptin also acts as a cognitive enhancer in the hippocampus and on excitatory synaptic strength, which may regulate the processes involved in learning and memory 17, 36. These processes would be explained, at the cellular level, by the leptin-mediated modulation of hippocampal synaptic plasticity, leading to the conversion of hippocampal short-term potentiation (STP) into LTP, via enhancing NMDA receptor function [55]. In the hippocampus, leptin also regulates neuronal excitability via its ability to activate the large conductance Ca2+-activated K+ (BK) channels. Leptin can also evoke a novel form of NMDA receptor-dependent LTD in the CA1 region of the hippocampus, but this is only apparent under conditions of enhanced excitability [56], [57]. The signaling processes underlying these effects involve activation of a phosphatidylinositol 3-kinase-dependent process [35]. Activation of mitogen-activated protein kinases and Src tyrosine kinases has also been implicated in this pathway.

Morphological studies in adult humans with genetic leptin deficiency suggest that leptin effect on the CNS extends beyond the hypothalamic nuclei. Six months of leptin replacement treatment for these three genetically leptin-deficient adults produced increased gray matter concentration in the anterior cingulate gyrus, inferior parietal lobule, and the cerebellum, findings that were maintained for 18 months following treatment [13].

The most marked effect of leptin replacement is weight loss, which is primarily achieved through reducing caloric intake. Leptin also leads to weight loss by increasing resting energy expenditure (REE) in animals [58], but not in humans [29]. In this study, we did not evaluate the effects of leptin on REE, which prevents us from stating that weight loss was entirely attributed to the decrease in energy intake. Following weight loss, we observed a mild deceleration in growth. Height changed from the 50th percentile to the 25th percentile between the first and the second year under treatment. Growth will be monitored and adequate hormonal parameters will be assessed in the next follow-up visit. Subsequent to losing weight, hypertension, dyslipidemia and hyperinsulinemia were reversed. We believe these changes are attributable to weight loss, but we cannot exclude a direct effect of leptin on these parameters, independent of weight loss. In particular, it is known that leptin directly affects the pancreatic beta cells to decrease insulin secretion [59], but it is problematic to evaluate whether these changes are caused by leptin alone, by weight loss or both.

We acknowledge that our study has some limitations. First, the significance of our findings is hard to judge, due to the fact that we report the findings on only one patient. To our knowledge, eleven leptin-deficient children have been identified in the world thus far (including our patient). Neurocognitive evaluations of these children are warranted, preferably at early ages, and while leptin-naïve. Second, we did not have an age-, sex-, weight- and cultural background-matched control group. To compensate for this limitation, we gave careful consideration to our choice of measurement instruments so as to select tests and subtests that are less culturally biased and measure general skills. Further, we considered a strength of the study to the fact that we have longitudinal evaluation, which in essence allowed us to use the patient's baseline performance as his own control for subsequent evaluations. Although this is an n-of-1 trial, we chose not to conduct additional leptin-free evaluations (other than those performed at T1) because we believe that the absence of leptin would be harmful to the child's development.

In conclusion, treatment of a leptin-deficient child with r-metHuLeptin was beneficial, leading to improvements in neurocognition, substantial weight loss, decrease in caloric intake and normalization of the parameters of metabolic syndrome. Further studies need to confirm these neurocognitive findings additional in leptin-deficient patients across the life span. Additional findings may support a rationale for the development of further studies to test the hypothesis that the effects of leptin replacement may improve cognition in leptin-sufficient patients with delay or decline of cognitive function.

Supporting Information

[Figure omitted. See PDF.]

Protocol S1.

Trial Protocol.

https://doi.org/10.1371/journal.pone.0003098.s001

(0.80 MB DOC)

Checklist S1.

CONSORT Checklist.

https://doi.org/10.1371/journal.pone.0003098.s002

(0.06 MB DOC)

Acknowledgments

During the course of this study, Amgen, Inc. and Amylin Pharmaceuticals, Inc. graciously provided r-MetHuLeptin. Neither Amgen, Inc., nor Amylin Pharmaceuticals, Inc. contributed to the design, analysis, or writing of this study. The authors are also grateful to the members of the UCLA GCRC, the University of Miami GCRC, the University of Miami Behavioral Medicine Research Center, to Drs. João Vicente Busnello and Luciana Ribeiro for their contributions to the clinical care of the leptin-deficient patients and to Arie Zakaryan for his assistance in the preparation of this manuscript.

Author Contributions

Conceived and designed the experiments: GPF TB RA KE MLW JL. Performed the experiments: GPF TB RA KE HKE MLW JL. Analyzed the data: GPF TB RA KE MLW JL. Contributed reagents/materials/analysis tools: RA MLW JL. Wrote the paper: GPF TB RA KE MLW JL.

Citation: Paz-Filho GJ, Babikian T, Asarnow R, Esposito K, Erol HK, Wong M-L, et al. (2008) Leptin Replacement Improves Cognitive Development. PLoS ONE3(8): e3098. https://doi.org/10.1371/journal.pone.0003098

References

1. Bluher S, Mantzoros CS (2007) Leptin in reproduction. Curr Opin Endocrinol Diabetes Obes 14: 458–464.S. BluherCS Mantzoros2007Leptin in reproduction.Curr Opin Endocrinol Diabetes Obes14458464

2. Chan JL, Mantzoros CS (2005) Role of leptin in energy-deprivation states: normal human physiology and clinical implications for hypothalamic amenorrhoea and anorexia nervosa. Lancet 366: 74–85.JL ChanCS Mantzoros2005Role of leptin in energy-deprivation states: normal human physiology and clinical implications for hypothalamic amenorrhoea and anorexia nervosa.Lancet3667485

3. Ceddia RB (2005) Direct metabolic regulation in skeletal muscle and fat tissue by leptin: implications for glucose and fatty acids homeostasis. Int J Obes (Lond) 29: 1175–1183.RB Ceddia2005Direct metabolic regulation in skeletal muscle and fat tissue by leptin: implications for glucose and fatty acids homeostasis.Int J Obes (Lond)2911751183

4. Brennan AM, Mantzoros CS (2007) Leptin and adiponectin: their role in diabetes. Curr Diab Rep 7: 1–2.AM BrennanCS Mantzoros2007Leptin and adiponectin: their role in diabetes.Curr Diab Rep712

5. Karsenty G (2006) Convergence between bone and energy homeostases: leptin regulation of bone mass. Cell Metab 4: 341–348.G. Karsenty2006Convergence between bone and energy homeostases: leptin regulation of bone mass.Cell Metab4341348

6. Cock TA, Auwerx J (2003) Leptin: cutting the fat off the bone. Lancet 362: 1572–1574.TA CockJ. Auwerx2003Leptin: cutting the fat off the bone.Lancet36215721574

7. Barouch LA, Berkowitz DE, Harrison RW, O'Donnell CP, Hare JM (2003) Disruption of leptin signaling contributes to cardiac hypertrophy independently of body weight in mice. Circulation 108: 754–759.LA BarouchDE BerkowitzRW HarrisonCP O'DonnellJM Hare2003Disruption of leptin signaling contributes to cardiac hypertrophy independently of body weight in mice.Circulation108754759

8. Otero M, Lago R, Lago F, Casanueva FF, Dieguez C, et al. (2005) Leptin, from fat to inflammation: old questions and new insights. FEBS Lett 579: 295–301.M. OteroR. LagoF. LagoFF CasanuevaC. Dieguez2005Leptin, from fat to inflammation: old questions and new insights.FEBS Lett579295301

9. Ahima RS (2006) Adipose tissue as an endocrine organ. Obesity (Silver Spring) 14: Suppl 5242S–249S.RS Ahima2006Adipose tissue as an endocrine organ.Obesity (Silver Spring)14Suppl 5242S249S

10. Chan JL, Heist K, DePaoli AM, Veldhuis JD, Mantzoros CS (2003) The role of falling leptin levels in the neuroendocrine and metabolic adaptation to short-term starvation in healthy men. J Clin Invest 111: 1409–1421.JL ChanK. HeistAM DePaoliJD VeldhuisCS Mantzoros2003The role of falling leptin levels in the neuroendocrine and metabolic adaptation to short-term starvation in healthy men.J Clin Invest11114091421

11. Lago F, Dieguez C, Gomez-Reino J, Gualillo O (2007) Adipokines as emerging mediators of immune response and inflammation. Nat Clin Pract Rheumatol 3: 716–724.F. LagoC. DieguezJ. Gomez-ReinoO. Gualillo2007Adipokines as emerging mediators of immune response and inflammation.Nat Clin Pract Rheumatol3716724

12. La Cava A, Matarese G (2004) The weight of leptin in immunity. Nat Rev Immunol 4: 371–379.A. La CavaG. Matarese2004The weight of leptin in immunity.Nat Rev Immunol4371379

13. Matochik JA, London ED, Yildiz BO, Ozata M, Caglayan S, et al. (2005) Effect of leptin replacement on brain structure in genetically leptin-deficient adults. J Clin Endocrinol Metab 90: 2851–2854.JA MatochikED LondonBO YildizM. OzataS. Caglayan2005Effect of leptin replacement on brain structure in genetically leptin-deficient adults.J Clin Endocrinol Metab9028512854

14. Baicy K, London ED, Monterosso J, Wong ML, Delibasi T, et al. (2007) Leptin replacement alters brain response to food cues in genetically leptin-deficient adults. Proc Natl Acad Sci U S A 104: 18276–18279.K. BaicyED LondonJ. MonterossoML WongT. Delibasi2007Leptin replacement alters brain response to food cues in genetically leptin-deficient adults.Proc Natl Acad Sci U S A1041827618279

15. Farooqi IS, Bullmore E, Keogh J, Gillard J, O'Rahilly S, et al. (2007) Leptin regulates striatal regions and human eating behavior. Science 317: 1355.IS FarooqiE. BullmoreJ. KeoghJ. GillardS. O'Rahilly2007Leptin regulates striatal regions and human eating behavior.Science3171355

16. Harvey J (2007) Leptin regulation of neuronal excitability and cognitive function. Curr Opin Pharmacol 7: 643–647.J. Harvey2007Leptin regulation of neuronal excitability and cognitive function.Curr Opin Pharmacol7643647

17. Harvey J, Shanley LJ, O'Malley D, Irving AJ (2005) Leptin: a potential cognitive enhancer? Biochem Soc Trans 33: 1029–1032.J. HarveyLJ ShanleyD. O'MalleyAJ Irving2005Leptin: a potential cognitive enhancer?Biochem Soc Trans3310291032

18. Pinto S, Roseberry AG, Liu H, Diano S, Shanabrough M, et al. (2004) Rapid rewiring of arcuate nucleus feeding circuits by leptin. Science 304: 110–115.S. PintoAG RoseberryH. LiuS. DianoM. Shanabrough2004Rapid rewiring of arcuate nucleus feeding circuits by leptin.Science304110115

19. Bouret SG, Simerly RB (2004) Minireview: Leptin and development of hypothalamic feeding circuits. Endocrinology 145: 2621–2626.SG BouretRB Simerly2004Minireview: Leptin and development of hypothalamic feeding circuits.Endocrinology14526212626

20. Udagawa J, Hashimoto R, Hioki K, Otani H (2006) The role of leptin in the development of the cortical neuron in mouse embryos. Brain Res 1120: 74–82.J. UdagawaR. HashimotoK. HiokiH. Otani2006The role of leptin in the development of the cortical neuron in mouse embryos.Brain Res11207482

21. Udagawa J, Nimura M, Otani H (2006) Leptin affects oligodendroglial development in the mouse embryonic cerebral cortex. Neuro Endocrinol Lett 27: 177–182.J. UdagawaM. NimuraH. Otani2006Leptin affects oligodendroglial development in the mouse embryonic cerebral cortex.Neuro Endocrinol Lett27177182

22. Licinio J, Milane M, Thakur S, Whelan F, Yildiz BO, et al. (2007) Effects of leptin on intake of specific micro- and macronutrients in a woman with leptin gene deficiency studied off and on leptin at stable body weight. Appetite 49: 594–599.J. LicinioM. MilaneS. ThakurF. WhelanBO Yildiz2007Effects of leptin on intake of specific micro- and macronutrients in a woman with leptin gene deficiency studied off and on leptin at stable body weight.Appetite49594599

23. Licinio J, Ribeiro L, Busnello JV, Delibasi T, Thakur S, et al. (2007) Effects of leptin replacement on macro- and micronutrient preferences. Int J Obes (Lond) 31: 1859–1863.J. LicinioL. RibeiroJV BusnelloT. DelibasiS. Thakur2007Effects of leptin replacement on macro- and micronutrient preferences.Int J Obes (Lond)3118591863

24. Williamson DA, Ravussin E, Wong ML, Wagner A, Dipaoli A, et al. (2005) Microanalysis of eating behavior of three leptin deficient adults treated with leptin therapy. Appetite 45: 75–80.DA WilliamsonE. RavussinML WongA. WagnerA. Dipaoli2005Microanalysis of eating behavior of three leptin deficient adults treated with leptin therapy.Appetite457580

25. Licinio J, Caglayan S, Ozata M, Yildiz BO, de Miranda PB, et al. (2004) Phenotypic effects of leptin replacement on morbid obesity, diabetes mellitus, hypogonadism, and behavior in leptin-deficient adults. Proc Natl Acad Sci U S A 101: 4531–4536.J. LicinioS. CaglayanM. OzataBO YildizPB de Miranda2004Phenotypic effects of leptin replacement on morbid obesity, diabetes mellitus, hypogonadism, and behavior in leptin-deficient adults.Proc Natl Acad Sci U S A10145314536

26. O'Rahilly S (2007) Human obesity and insulin resistance: lessons from experiments of nature. Biochem Soc Trans 35: 33–36.S. O'Rahilly2007Human obesity and insulin resistance: lessons from experiments of nature.Biochem Soc Trans353336

27. Montague CT, Farooqi IS, Whitehead JP, Soos MA, Rau H, et al. (1997) Congenital leptin deficiency is associated with severe early-onset obesity in humans. Nature 387: 903–908.CT MontagueIS FarooqiJP WhiteheadMA SoosH. Rau1997Congenital leptin deficiency is associated with severe early-onset obesity in humans.Nature387903908

28. Strobel A, Issad T, Camoin L, Ozata M, Strosberg AD (1998) A leptin missense mutation associated with hypogonadism and morbid obesity. Nat Genet 18: 213–215.A. StrobelT. IssadL. CamoinM. OzataAD Strosberg1998A leptin missense mutation associated with hypogonadism and morbid obesity.Nat Genet18213215

29. Farooqi IS, Matarese G, Lord GM, Keogh JM, Lawrence E, et al. (2002) Beneficial effects of leptin on obesity, T cell hyporesponsiveness, and neuroendocrine/metabolic dysfunction of human congenital leptin deficiency. J Clin Invest 110: 1093–1103.IS FarooqiG. MatareseGM LordJM KeoghE. Lawrence2002Beneficial effects of leptin on obesity, T cell hyporesponsiveness, and neuroendocrine/metabolic dysfunction of human congenital leptin deficiency.J Clin Invest11010931103

30. Gibson WT, Farooqi IS, Moreau M, DePaoli AM, Lawrence E, et al. (2004) Congenital leptin deficiency due to homozygosity for the Delta133G mutation: report of another case and evaluation of response to four years of leptin therapy. J Clin Endocrinol Metab 89: 4821–4826.WT GibsonIS FarooqiM. MoreauAM DePaoliE. Lawrence2004Congenital leptin deficiency due to homozygosity for the Delta133G mutation: report of another case and evaluation of response to four years of leptin therapy.J Clin Endocrinol Metab8948214826

31. Butler MG, Moore J, Morawiecki A, Nicolson M (1998) Comparison of leptin protein levels in Prader-Willi syndrome and control individuals. Am J Med Genet 75: 7–12.MG ButlerJ. MooreA. MorawieckiM. Nicolson1998Comparison of leptin protein levels in Prader-Willi syndrome and control individuals.Am J Med Genet75712

32. Ellis KJ, Nicolson M (1997) Leptin levels and body fatness in children: effects of gender, ethnicity, and sexual development. Pediatr Res 42: 484–488.KJ EllisM. Nicolson1997Leptin levels and body fatness in children: effects of gender, ethnicity, and sexual development.Pediatr Res42484488

33. Mantzoros CS, Ozata M, Negrao AB, Suchard MA, Ziotopoulou M, et al. (2001) Synchronicity of frequently sampled thyrotropin (TSH) and leptin concentrations in healthy adults and leptin-deficient subjects: evidence for possible partial TSH regulation by leptin in humans. J Clin Endocrinol Metab 86: 3284–3291.CS MantzorosM. OzataAB NegraoMA SuchardM. Ziotopoulou2001Synchronicity of frequently sampled thyrotropin (TSH) and leptin concentrations in healthy adults and leptin-deficient subjects: evidence for possible partial TSH regulation by leptin in humans.J Clin Endocrinol Metab8632843291

34. National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents (2004) The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 114: 555–576.National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents2004The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents.Pediatrics114555576

35. Harvey J, Ashford ML (2003) Leptin in the CNS: much more than a satiety signal. Neuropharmacology 44: 845–854.J. HarveyML Ashford2003Leptin in the CNS: much more than a satiety signal.Neuropharmacology44845854

36. Li XL, Aou S, Oomura Y, Hori N, Fukunaga K, et al. (2002) Impairment of long-term potentiation and spatial memory in leptin receptor-deficient rodents. Neuroscience 113: 607–615.XL LiS. AouY. OomuraN. HoriK. Fukunaga2002Impairment of long-term potentiation and spatial memory in leptin receptor-deficient rodents.Neuroscience113607615

37. Harvey J (2003) Novel actions of leptin in the hippocampus. Ann Med 35: 197–206.J. Harvey2003Novel actions of leptin in the hippocampus.Ann Med35197206

38. Garza JC, Guo M, Zhang W, Lu XY (2008) Leptin increases adult hippocampal neurogenesis in vivo and in vitro. J Biol Chem 283: 18238–18247.JC GarzaM. GuoW. ZhangXY Lu2008Leptin increases adult hippocampal neurogenesis in vivo and in vitro.J Biol Chem2831823818247

39. Winocur G, Greenwood CE, Piroli GG, Grillo CA, Reznikov LR, et al. (2005) Memory impairment in obese Zucker rats: an investigation of cognitive function in an animal model of insulin resistance and obesity. Behav Neurosci 119: 1389–1395.G. WinocurCE GreenwoodGG PiroliCA GrilloLR Reznikov2005Memory impairment in obese Zucker rats: an investigation of cognitive function in an animal model of insulin resistance and obesity.Behav Neurosci11913891395

40. Ahima RS, Bjorbaek C, Osei S, Flier JS (1999) Regulation of neuronal and glial proteins by leptin: implications for brain development. Endocrinology 140: 2755–2762.RS AhimaC. BjorbaekS. OseiJS Flier1999Regulation of neuronal and glial proteins by leptin: implications for brain development.Endocrinology14027552762

41. Steppan CM, Swick AG (1999) A role for leptin in brain development. Biochem Biophys Res Commun 256: 600–602.CM SteppanAG Swick1999A role for leptin in brain development.Biochem Biophys Res Commun256600602

42. Sena A, Sarlieve LL, Rebel G (1985) Brain myelin of genetically obese mice. J Neurol Sci 68: 233–243.A. SenaLL SarlieveG. Rebel1985Brain myelin of genetically obese mice.J Neurol Sci68233243

43. Bereiter DA, Jeanrenaud B (1979) Altered neuroanatomical organization in the central nervous system of the genetically obese (ob/ob) mouse. Brain Res 165: 249–260.DA BereiterB. Jeanrenaud1979Altered neuroanatomical organization in the central nervous system of the genetically obese (ob/ob) mouse.Brain Res165249260

44. Bereiter DA, Jeanrenaud B (1980) Altered dendritic orientation of hypothalamic neurons from genetically obese (ob/ob) mice. Brain Res 202: 201–206.DA BereiterB. Jeanrenaud1980Altered dendritic orientation of hypothalamic neurons from genetically obese (ob/ob) mice.Brain Res202201206

45. Petridou E, Mantzoros CS, Belechri M, Skalkidou A, Dessypris N, et al. (2005) Neonatal leptin levels are strongly associated with female gender, birth length, IGF-I levels and formula feeding. Clin Endocrinol (Oxf) 62: 366–371.E. PetridouCS MantzorosM. BelechriA. SkalkidouN. Dessypris2005Neonatal leptin levels are strongly associated with female gender, birth length, IGF-I levels and formula feeding.Clin Endocrinol (Oxf)62366371

46. Kratzsch J, Schubring C, Stitzel B, Bottner A, Berthold A, et al. (2005) Inverse changes in the serum levels of the soluble leptin receptor and leptin in neonates: relations to anthropometric data. J Clin Endocrinol Metab 90: 2212–2217.J. KratzschC. SchubringB. StitzelA. BottnerA. Berthold2005Inverse changes in the serum levels of the soluble leptin receptor and leptin in neonates: relations to anthropometric data.J Clin Endocrinol Metab9022122217

47. Alexe DM, Syridou G, Petridou ET (2006) Determinants of early life leptin levels and later life degenerative outcomes. Clin Med Res 4: 326–335.DM AlexeG. SyridouET Petridou2006Determinants of early life leptin levels and later life degenerative outcomes.Clin Med Res4326335

48. Proulx K, Richard D, Walker CD (2002) Leptin regulates appetite-related neuropeptides in the hypothalamus of developing rats without affecting food intake. Endocrinology 143: 4683–4692.K. ProulxD. RichardCD Walker2002Leptin regulates appetite-related neuropeptides in the hypothalamus of developing rats without affecting food intake.Endocrinology14346834692

49. Ahima RS, Prabakaran D, Flier JS (1998) Postnatal leptin surge and regulation of circadian rhythm of leptin by feeding. Implications for energy homeostasis and neuroendocrine function. J Clin Invest 101: 1020–1027.RS AhimaD. PrabakaranJS Flier1998Postnatal leptin surge and regulation of circadian rhythm of leptin by feeding. Implications for energy homeostasis and neuroendocrine function.J Clin Invest10110201027

50. Bouret SG, Draper SJ, Simerly RB (2004) Formation of projection pathways from the arcuate nucleus of the hypothalamus to hypothalamic regions implicated in the neural control of feeding behavior in mice. J Neurosci 24: 2797–2805.SG BouretSJ DraperRB Simerly2004Formation of projection pathways from the arcuate nucleus of the hypothalamus to hypothalamic regions implicated in the neural control of feeding behavior in mice.J Neurosci2427972805

51. Bouret SG, Simerly RB (2007) Development of leptin-sensitive circuits. J Neuroendocrinol 19: 575–582.SG BouretRB Simerly2007Development of leptin-sensitive circuits.J Neuroendocrinol19575582

52. Ben X, Qin Y, Wu S, Zhang W, Cai W (2001) Placental leptin correlates with intrauterine fetal growth and development. Chin Med J (Engl) 114: 636–639.X. BenY. QinS. WuW. ZhangW. Cai2001Placental leptin correlates with intrauterine fetal growth and development.Chin Med J (Engl)114636639

53. Udagawa J, Hashimoto R, Suzuki H, Hatta T, Sotomaru Y, et al. (2006) The role of leptin in the development of the cerebral cortex in mouse embryos. Endocrinology 147: 647–658.J. UdagawaR. HashimotoH. SuzukiT. HattaY. Sotomaru2006The role of leptin in the development of the cerebral cortex in mouse embryos.Endocrinology147647658

54. Walker CD, Long H, Williams S, Richard D (2007) Long-lasting effects of elevated neonatal leptin on rat hippocampal function, synaptic proteins and NMDA receptor subunits. J Neurosci Res 85: 816–828.CD WalkerH. LongS. WilliamsD. Richard2007Long-lasting effects of elevated neonatal leptin on rat hippocampal function, synaptic proteins and NMDA receptor subunits.J Neurosci Res85816828

55. Shanley LJ, Irving AJ, Harvey J (2001) Leptin enhances NMDA receptor function and modulates hippocampal synaptic plasticity. J Neurosci 21: RC186.LJ ShanleyAJ IrvingJ. Harvey2001Leptin enhances NMDA receptor function and modulates hippocampal synaptic plasticity.J Neurosci21RC186

56. Durakoglugil M, Irving AJ, Harvey J (2005) Leptin induces a novel form of NMDA receptor-dependent long-term depression. J Neurochem 95: 396–405.M. DurakoglugilAJ IrvingJ. Harvey2005Leptin induces a novel form of NMDA receptor-dependent long-term depression.J Neurochem95396405

57. Harvey J, Solovyova N, Irving A (2006) Leptin and its role in hippocampal synaptic plasticity. Prog Lipid Res 45: 369–378.J. HarveyN. SolovyovaA. Irving2006Leptin and its role in hippocampal synaptic plasticity.Prog Lipid Res45369378

58. Pelleymounter MA, Cullen MJ, Baker MB, Hecht R, Winters D, et al. (1995) Effects of the obese gene product on body weight regulation in ob/ob mice. Science 269: 540–543.MA PelleymounterMJ CullenMB BakerR. HechtD. Winters1995Effects of the obese gene product on body weight regulation in ob/ob mice.Science269540543

59. Seufert J (2004) Leptin effects on pancreatic beta-cell gene expression and function. Diabetes 53: Suppl 1S152–158.J. Seufert2004Leptin effects on pancreatic beta-cell gene expression and function.Diabetes53Suppl 1S152158