J Physiol Sci
DOI 10.1007/s12576-012-0221-z

ORIGINAL PAPER

Improvement of diabetic or obese patients’ erythrocyte
deformability by the program of the brain-oriented obesity
control system (BOOCS)
K. Saito • K. Odashiro • T. Maruyama •K. Akashi • S. Mawatari • T. Fujino

Received: 23 April 2012 / Accepted: 25 June 2012Ó The Physiological Society of Japan and Springer 2012

Abstract Diabetes is characterized by absolute or
relative insulin deficiency complicated with microangiopathy, whereas obesity stems from insulin resistance. A
psychosomatic approach to obesity and diabetes has beenhighlighted, including the brain-oriented obesity control
system (BOOCS). Impaired deformability of erythrocytes
in obese or diabetic patients is closely linked to disturbed
microcirculation, and improvement of abnormal erythrocyte rheology is a prerequisite for the prevention andtreatment of microangiopathy. Therefore, erythrocyte filterability, whole cell deformability defined as flow rate oferythrocyte suspension relative to that of saline, wasassessed by the nickel-mesh-filtration technique. Subjects
included healthy controls (group A, n = 14), diabetic, nonobese participants (group B, n = 29), and non-diabetic,
obese participants (group C, n = 32) in the 6-month
BOOCS program, and most patients in groups B and C(86.9 %) completed this program. Baseline mean erythrocyte filterabilities were 89.4 ± 1.7 % in group A, 82.8 ±5.2 % in group B, and 84.1 ± 5.6 % in group C, showing

K. Saito  T. Fujino
BOOCS Clinic Fukuoka, Fukuoka 812-0025, JapanK. Odashiro  K. Akashi
Department of Medicine and Biosystemic Science,
Kyushu University Graduate School of Medical Sciences,
Fukuoka 812-8582, Japan
T. Maruyama (&)
Institute of Health Science, Kyushu University,
Kasuga Kohen 6-1, Kasuga 816-8580, Japane-mail: maruyama@ihs.kyushu-u.ac.jp
S. Mawatari  T. Fujino
Institute of Rheological Function of Foods Co. Ltd.,
Hisayama 811-2501, Japansignificant intergroup differences (p \ 0.001). This program significantly improved (p \ 0.001) the impaired
erythrocyte filterability in groups B (87.9 ± 4.4 %) and C(88.5 ± 3.7 %). Declines in HbA1c (p = 0.387) and bodymass index (p = 0.479) were not correlated to thisimprovement. These findings indicate that the mechanismsof BOOCS-induced improvement of diabetic or obese
patients’ erythrocyte deformability are multifactorial, andthat the BOOCS program for these patients is a holistic,
cost-effective, and highly compliant approach possibly
ameliorating microcirculation.
Keywords BOOCS  Deformability  Diabetes Erythrocytes  Obesity

Introduction
It is well known that microcirculation is impaired in diabetes
mellitus, which is characterized by absolute or relative insulin
deficiency causing hyperglycemia, glucosuria, and various
diabetic complications including microangiopathy. This diabetic environment has a harmful rheological impact on circulating erythrocytes. Human erythrocytes have a diameter
greater than the smallest capillary network, and hence intact
erythrocytes cannot pass through the microvascular network
without any physiologic deformation. Therefore, deformability of erythrocytes plays a key role in fluent microcirculation[1]. We have investigated erythrocyte filterability, a surrogateof whole cell deformability, using the highly sensitive andreproducible nickel-mesh-filtration technique, which is usefulfor assessing the physiological bending deformation of intact
circulating erythrocytes [2–4].
Our recent study clarified the impaired filterability of
diabetic rat and human erythrocytes quantitatively [4]. This123

J Physiol Sci

impairment is closely associated with diabetic microangiopathy in that undeformable erythrocytes may increase theshear stress, elevate vascular resistance, and cause cardiac
overload and renal dysfunction. In our study, the impairment of diabetic erythrocyte filterability was closely linked
to glycemic stress on erythrocytes quantified by glycatedhemoglobin (HbA1c). Therefore, we anticipated that
reduction of HbA1c may contribute to improvement of theimpaired diabetic erythrocyte filterability. For glycemic
control in diabetic patients, self-promoting management
supported by healthcare professionals is important, andpositive healthy emotion protects patients from distress anddepression observed in long-term anti-diabetic treatment[5].
Diabetes is often associated with obesity which ischaracterized by insulin resistance. Obesity is a target ofcurrent psychosomatic approaches [6, 7], one of whichstems from the theory that stress-induced so-called ‘brainfatigue’ leads to taste resetting and dysfunction, which lead
to abnormal eating behaviors such as overeating and eatingof oily, pungent food. Therefore, psychosocial stress
reduction causes natural taste recovery and body weight
reduction without any calorie restriction. This kind ofholistic medicine actually provided a better understandingof the psychobiological aspects of obesity and reliableweight reduction among participants. This program wastermed the brain-oriented obesity control system (BOOCS)[8]. Therefore, we hypothesized that this BOOCS program
may be helpful not only for diabetic subjects but also forobese patients, and may improve the impaired erythrocyte
filterability in these subjects. The present study was
designed to test this hypothesis.

Methods
Subjects
This study design was approved by the internal ethics
committee of The Institute of Rheological Function ofFoods Co. Ltd. (Hisayama, Fukuoka, Japan), and performed according to the Declaration of Helsinki (2001),
that is, signed informed consent was obtained from subjects
prior to enrollment on the BOOCS program and, then, tothis study design. Subjects included healthy volunteers(group A, n = 14, mean age 46.7 ± 9.4 years), non-obese,
diabetic participants (group B, n = 29, mean age
47.2 ± 8.8 years), and obese, non-diabetic participants(group C, n = 32, mean age 49.6 ± 9.5 years) for the
6-month BOOCS program. In our recent study, diabetes
and obesity synergistically deranged erythrocyte filterability [4]. Therefore, patients with concomitant diabetes andobesity were excluded from this study to evaluate the123

individual rheological effects of these two common diseases. Diabetes mellitus was defined as HbA1c (NGDP)[6.5 % and/or ongoing anti-diabetic medication, whereas
obesity was defined as body mass index (BMI) [25.
BOOCS programBecause the BOOCS program is not based on the balance
between calorie intake and energy expenditure, caloriecalculation, carbo-counting, and exercise energy consumption are not scheduled. Instead, the basic principle
consists of two paradoxical items as follows; (1) prohibition of hard practices that the participant does not like,even if they are favorable to a healthy life, and (2) promotion of pleasant practices that the participant likes, even
if they are believed unfavorable to a healthy life [8]. After
explaining the basic principle and practical methodologiesof this program, outpatients participated in this programvoluntarily. These participants were followed up monthly
in the BOOCS clinics (Fukuoka, Japan). Prescriptions ofthese participants were not altered during the study period.
Smoking, drinking, and physical activity in daily life were
not regulated according to the above principle.
Erythrocyte suspensions
Erythrocyte suspensions were prepared as described
elsewhere [4]. In detail, about 10 ml of venous blood
was drawn from the antecubital vein of subjects, using
21-gauge needles and disposable syringes (Terumo Japan,
Tokyo, Japan) filled with 1/10 volume of 3.8 % trisodium citrate as an anticoagulant. Venous blood sampling
was performed in the morning after an overnight fast.
Blood cell counting and hematocrit measurements werecarried out using a hemocytometer (Ace Counter, FLC240A; Fukuda Denshi, Tokyo, Japan). Concurrently,
HbA1c was estimated using a routine autoanalyzer(Sysmex model K-4500; Sysmex, Tokyo, Japan). Aftercentrifugation of venous blood at 1,300g for 10 min,supernatant was carefully aspirated to replace buffy coatand plasma with saline buffered with N-(2-hydroxyethyl)piperazine-N0 -2-ethanesulfonic acid (HEPES) sodium salt
(HEPES-Na). The composition of HEPES-Na-bufferedsaline (HBS) was NaCl 141 mM and HEPES-Na 10 mM.
Osmolality and pH of the HBS were 287 mOsm/kg H2O
and 7.4, respectively. The osmolality of the HBS was
measured using a freezing point depression-type
osmometer (Fiske Mark 3 Osmometer; Fiske Associates,
MA, USA). Erythrocytes were then washed three times
by repeated resuspension with HBS and centrifugation
at 800g, 600g, and 500g for 10 min, respectively. The
final hematocrit of human erythrocyte suspension was
adjusted to 3.0 %. These procedures were performed

J Physiol Sci

ABC
Vertical Tube

DCPU
A/D Converter
AmplifierhTransducer

Refrigerated
Isothermobath
Nickel Mesh Filter

Fig. 1 a Scanning electron microscopic photograph of a nickelmesh-filter. Magnification of a single pore in nickel-mesh shows thesmooth transition into the pore interior (inset). b Schematic illustration of gravity-based, nickel-mesh-filtration system. Height of themeniscus within the vertical tube (h) was obtained by continuous
reduction of filtration pressure (P), specific gravity (q), andacceleration of gravity (g). Flow rate (Q) was calculated automatically by the first time derivatives of h (dh/dt) and internal crosssectional area of the vertical tube. D internal diameter of vertical tube.
c Photograph of computer screen showing P–Q (upper right) andh–t (lower) relationships

within 2 h after blood sampling for subsequent filtration
experiments.

the height of meniscus in vertical tube (h; mm). The tangent of the h–t curve determined by drawing points corresponding to different heights gives the rate of fall of themeniscus (dh/dt). Thereafter, by multiplying the rate of fallby the internal cross-sectional area of the vertical tube, thecomplete set of flow rates (Q; ml/min) and corresponding
P, the P–Q relationship, was obtained. This procedure wasautomatically performed by measurement software installed in a personal computer (Dell Latitude CS; Dell, Round
Rock, TX, USA) and monitored on the main window of thecomputer screen (Fig. 1c). Together with the start of dataacquisition, the measurement software displays theh–t curve continuously during the filtration process. Whenthe filtration has been completed, the software displays the
P–Q curve. The h–t and P–Q curves are shown on thecomputer screen and stored simultaneously in Microsoft
Office Excel 2003 for Windows XP (Microsoft, Tokyo,
Japan). Temperature of the specimens was kept at 25 °C by
circulating isothermal water through a water jacket surrounding the vertical tube (Fig. 1b). The percentage of theflow rate of erythrocyte suspension to that of HBS at
100 mmH2O was used as an index of erythrocyte
filterability.

Nickel-mesh-filter
Figure 1a shows an electron microscopic photograph of anickel mesh filter that was produced in accordance with our
specifications by a photofabrication technique (Dainippon
Printing, Tokyo, Japan). We specified that this filter shouldhave an outer diameter of 13 mm, a filtration area 8 mm indiameter, 11 lm thick, with an interpore distance of 35 lm(Tsukasa Sokken, Tokyo, Japan). The vertical and cylindrical pores were distributed regularly across the filter
without coincidence or branching. The pore entrances
exhibited round and smooth transition into the pore interior. Pore diameters were all exactly identical in a specificnickel-mesh-filter. Filters with a specific pore diameter
ranging from 3 to 6 lm were available to be selected
depending on the suspension materials. After repeating
preliminary experiments to choose an appropriate poresize, a nickel-mesh-filter with a pore diameter of 4.94 lm
was chosen for human erythrocyte suspensions.
Erythrocyte filterability

Erythrocyte shape
Filtration experiments were performed blindly using agravity-based nickel mesh filtration apparatus (Model
NOBU-II; Tsukasa Sokken) as shown in Fig. 1b. In brief,
the relationship between hydrostatic pressure (P; mmH2O)
and time (t; s) was obtained during continuous filtration by
gravity using a pressure transducer. P was transformed to

An aliquot of the erythrocyte suspension was fixed withisotonic 1.0 % glutaraldehyde solution containing
24.5 mM NaCl and 50 mM phosphate buffer (pH 7.4). The
shape of erythrocytes was then examined using a differential interference contrast microscope (Diaphoto 300;

123

J Physiol Sci

Nikon;, Tokyo, Japan) at 9400 magnification. Theseexperiments were performed at room temperature(22 ± 3 °C).

(p = 0.007) reduction of HbA1c obtained by the fulfillment of the BOOCS program.
Outcome of obesity

Data analyses

Results
BOOCS program
The incentive of the participants in the 6-month BOOCS
program was obviously weight reduction and possible
diabetic control. Totals of 27 non-obese, diabetic patients(group B) and 26 obese, non-diabetic patients (group C)
completed this program. Final levels of compliance withthis program were 93.1 and 81.3 % in groups B and C,
respectively. Overall compliance was 86.9 % and, hence,the drop-out rate was 13.1 %. Interviews to the compliant
participants (n = 53) revealed that fundamental life-style
was not changed in that they continued smoking anddrinking which may have affected on erythrocyte filterability if they liked, and that they did not controlled
physical activity in daily life. Importantly, many of themconfessed that they preferred to low-calorie, natural foodrather than to oily pungent food according to the progression of this program.
Outcome of diabetes
HbA1c in diabetic patients prior to the enrollment was
7.20 ± 1.40 %, whereas HbA1c after the completion ofthis program was 6.87 ± 1.41 %. There was a significant

123

As in our prior intervention with the BOOCS program forobese subjects [8], mean body weight was decreased significantly (p \ 0.001) from 74.1 ± 9.6 to 69.0 ± 8.8 kg
after completion of this program. Similarly, mean BMI was
reduced significantly (p \ 0.001) from 27.4 ± 2.6 to25.6 ± 2.5 kg/m2.
Erythrocyte filterability
Mean erythrocyte filterability in the subjects of group A(n = 14) was 89.4 ± 1.7 %. Before starting BOOCS program, the filterabilities in the groups B (n = 27) and C(n = 26) were 82.8 ± 5.2 and 84.1 ± 5.6 %, respectively.
Baseline filterability showed a significant difference among
the three groups (p \ 0.001). After the completion of the
6-month BOOCS program, the filterabilities in groups B
and C were 87.9 ± 4.4 and 88.5 ± 3.7 %. Significant
improvement of erythrocyte filterability was observed inboth groups B and C by the fulfillment of the BOOCS
program (p \ 0.001). These results are summarized inFig. 2, and the improvements of individual erythrocyte
filterability in groups B and C are detailed in Figs. 3 and 4.
The association of HbA1c (y) with erythrocyte filterability (x) was investigated in pooled data of groups B andC. As shown in Fig. 5, linear regression analysis with the
92.0
90.0
88.0

RCF (%)All data are expressed as mean ± SD. Because the distributions of HbA1c (p \ 0.001) and erythrocyte filterability(p \ 0.001) assessed by Kolmogorov–Smirnov test were
not normal, comparison of these variables between two
groups was conducted with Mann–Whitney test, and thatamong more than three groups was performed using
Kruskal–Wallis test. The assumptions used for power calculations required a sample size of more than 27 patients ingroups B and C, assuming a drop-out rate of 15 %, toprovide 90 % power to detect a 5.0 % difference oferythrocyte filterability [4], with a 5 % type I error rate fora two-sided test. Practical computation was performed
using Predictive Analytics Software (PASW) 18.0 version
for Windows (SPSS, Chicago, IL, USA). Because missing
values during the data acquisition are completely random(missing rate of 7.4 %), no specific treatment according to
the SPSS Missing Value AnalysisTM was attempted. Differences with a two-sided p \ 0.050 were consideredsignificant.

86.0
84.0
82.0
80.0
78.0

group A

group B(pre)group B
(post)

group C(pre)group C
(post)

Fig. 2 Mean erythrocyte filterability in groups A (control subjects,
n = 14), B (non-obese, diabetic patients, n = 29), and C (obese, nondiabetic patients, n = 32). Baseline filterability showed a significant(p \ 0.001) difference among the groups of A, B (pre), and C (pre).
Erythrocyte filterability was significantly improved in group B(p \ 0.001) and group C (p \ 0.001) after the fulfillment of the
BOOCS program. Columns and bars indicate means and standard
errors, respectively. RCF red cell filterability (%). *p \ 0.001
indicates a significant difference in baseline RCF among the threegroups, and #p \ 0.001 denotes a significant improvement of RCF
within a group

J Physiol Sci

Fig. 3 Individual improvement of erythrocyte filterability in group B(non-obese, diabetic patients). Closed symbols indicate erythrocyte
filterability (%) prior to the participation in the BOOCS program, andopen symbols mean the filterability after the completion of thisprogram. RCF red cell filterability (%)

Fig. 5 Relationship between HbA1c (y) and erythrocyte filterability(x) showing linear equation of y = 0.022 x ? 5.178 (r = 0.083), but
yielding no significance (p = 0.387). RCF red cell filterability (%)

shape changes at the stage before starting the program. The
same was true at the stage of completing this program.
Follow-up study
Most diabetic (n = 25 in group B) or obese (n = 23 ingroup C) patients who completed the BOOCS program
continued this program for the purpose of weight or diabetic control after the study periods. Re-exacerbation ofdiabetes in group B and body weight cycling (so-called‘rebound’ phenomenon) in group C were not observed, atleast in these participants (n = 48) during the follow-up
period ranging from 1 to 6 years (2.8 ± 1.0 years).

Discussion
Fig. 4 Individual improvement of erythrocyte filterability in group C(obese, non-diabetic patients). Closed symbols indicate erythrocyte
filterability (%) prior to the participation in the BOOCS program, andopen symbols mean the filterability after the completion of thisprogram. RCF red cell filterability (%)

least square method was applied, and the linear equation
was y = 0.022x ? 5.178 (r = 0.083), yielding no statistical significance (p = 0.387). Likewise, the relationshipbetween BMI and erythrocyte filterability was not significant (p = 0.479).
Erythrocyte shape
Erythrocyte morphology in the control subjects (group A)
did not demonstrate any outstanding abnormalities. Likewise, erythrocytes obtained from participants of the
BOOCS program (groups B and C) showed no discernible

The main finding of this study is an improvement of obese
or diabetic human erythrocyte filterability assessed by thenickel-mesh-filtration technique after completion of the
6-month BOOCS program. Circulating intact humanerythrocytes show physiological deformability to maintainfluent microcirculation. Erythrocyte filterability is considered to reflect whole cell deformability, and evaluation offilterability strictly depends on the filter property. The
nickel-mesh-filtration technique is highly sensitive, quantitative, and reproducible by assessing the physiologicalbending deformation of intact erythrocytes passing bygravity through the uniform, smooth, and regularly distributed pores in the nickel-mesh-filter without erythrocyte
trapping or stagnation [9–11]. This technique recently
clarified the impaired diabetic erythrocyte filterability [4],which was difficult in filtration experiments using conventional filters [12].

123J Physiol Sci

An increasing prevalence of obesity in the modern world
is an urgent healthcare problem. The BOOCS program forthe treatment of obesity is based on the ‘brain-fatigue’
hypothesis. Psychosocial stress in industrialized countries
causes human taste resetting and resultant oily, pungent
food preference and overeating, which leads to obesity andpossibly diabetes. To prevent this sequence, the BOOCS
program affirms patients’ own native appetite and denies
the patients’ stoicism for eating. On the other hand, thisprogram promotes healthy activities that the participant can
do and likes. Therefore, this program is a ‘low-tech’ psychosomatic approach without any drug or device interventions. Consequently, this program attenuates psychosocial
stress, restores natural taste sensing, and reduces bodyweight without any calorie restriction. This may be attributed to preference to the natural, low-calorie food after thedisappearance of taste resetting and abnormal eating
behaviors. High compliance of this program obtained bythis study (86.9 %) is considered to be due to its simple andcost-effective nature that is suitable for Japanese [8].
Microcirculatory dysfunction is already present in nondiabetic obese subjects [13]. Impaired diabetic erythrocyte
deformability is closely linked to the disturbed microcirculation [14], and underlies diabetic microangiopathy [15], such as
retinopathy [16], nephropathy [17], and neuropathy [18].
Although the present study demonstrated the improvement of
the impaired obese or diabetic human erythrocyte deformability by completion of the BOOCS program (Figs. 2, 3, 4),
the cause of this amelioration remains unknown. However,some possibilities can be postulated. From the hemorheological viewpoint, erythrocyte deformability is regulated bythree factors, namely, internal viscosity, geometry, andmembrane property of intact circulating erythrocytes [1, 10].
Internal viscosity of erythrocytes is evaluated by mean corpuscular hemoglobin concentration and strictly regulated inphysiological range. Microscopic observation showed no
discernible changes of erythrocyte shape (geometry). Furthermore, impaired filterability showed no direct correlation
with glycation of hemoglobin (Fig. 5). Therefore, this rheological effect may have been mediated by miscellaneous
factors which were improved by BOOCS program but notevaluated by this study design, i.e., psychosomatic stress
reduction alters neuroendocrine system that influences lipid
profile [19], feeding behavior, energy consumption [20], andblood pressure regulation [21].
Circulating erythrocytes as physiological oxygen carriers are the main target of oxidant stress. Oxidant stress isintroduced by hyperglycemia and obesity [22, 23], andderanges erythrocyte membrane integrity by lipid peroxidation and protein degradation, reduces the membrane
fluidity, and impairs deformability profoundly, which was
confirmed by this nickel-mesh-filtration technique [24–26].
Human redox status depends on high-calorie intake, and,123

importantly, feeding behavior is altered by completion of
the BOOCS program, that is, participants of this program
prefer natural, low-calorie Japanese food rather thanWestern food spontaneously [8]. This trend may contributeto attenuate the systemic oxidant stress and, hence, toimprove the erythrocyte filterability.
In conclusion, although this single-center, small-sample
study did not evaluate the subjects’ lipid profile, nutritional
background, or redox status, it indicates that diabetic orobese human erythrocyte deformability is impaired, that the
BOOCS program, a psychosomatic, cost-effective approach
to lifestyle per se, ameliorates the impaired erythrocyte
deformability in these patients, and that the nickel-meshfiltration technique is useful to evaluate subtle but significant alterations of human erythrocyte deformability.
Acknowledgments The authors would like to thank staff of the
BOOCS clinic (Fukuoka, Japan) for clinical assistance, and staff ofthe Institute of Rheological Function of Foods Co. Ltd. (Hisayama,
Fukuoka) for technical assistance. We lost our collaborator,
Dr. Nobuhiro Uyesaka (Department of Physiology, Nippon Medical
University), during the preparation of this manuscript, and dedicate
this work to honor his memory.
Conflict of interest The authors declare that there are no conflictsof interest in relation to this manuscript.

References
1. Mohandas N, Chasis JA (1993) Red cell deformability, membrane material properties and shape: regulation by transmembrane, skeletal and cytosolic proteins and lipids. Semin Hematol
30:171–192
2. Ejima J, Ijichi T, Ohnishi Y, Maruyama T, Kaji Y, Kanaya S et al(2000) Relationship of high-density lipoprotein cholesterol andred blood cell filterability: cross-sectional study of healthy subjects. Clin Hemorheol Microcirc 22:1–7
3. Ariyoshi K, Maruyama T, Odashiro K, Akashi K, Fujino T,
Uyesaka N (2010) Impaired erythrocyte filterability of spontaneously hypertensive rats: investigation by nickel mesh filtration
technique. Circ J 74:129–136
4. Saito K, Kokawa Y, Fukata M, Odashiro K, Maruyama T, Akashi
K, Fujino T (2011) Impaired deformability of erythrocytes indiabetic rat and human: investigation by the nickel-mesh-filtration technique. J Biorheol 25:18–26
5. Robertson SM, Stanley MA, Cully JA, Naik AD (2012) Positive
emotional health and diabetes care: concepts, measurement, andclinical implications. Psychosomatics 53:1–12
6. Brown J, Wimpenny P (2011) Developing a holistic approach toobesity management. Int J Nurs Pract 17:9–18
7. Kitzmann KM, Dalton WT, Stanley CM, Beech BM, Reeves TP,
Buscemi J, Egli CJ, Gamble HL, Midgett EL (2010) Lifestyleinterventions for youth who are overweight: a meta-analytic
review. Health Psychol 29:91–101
8. Fujino T (1999) Proposal of a new hypothesis for the psychosomatic treatment of obesity and its application. Fukuoka Acta
Med 90:353–364
9. Rodgers GP, Dover GJ, Uyesaka N, Noguchi CT, Schechter AN,
Nienhuis AW (1993) Augmentation by erythropoietin of theJ Physiol Sci
fetal-hemoglobin response to hydroxyurea in sickle cell disease.
N Engl J Med 328:73–80
10. Hiruma H, Noguchi CT, Uyesaka N, Schechter AN, Rodgers GP(1995) Contributions of sickle hemoglobin polymer and sickle
cell membranes to impaired filterability. Am J Physiol 268:
H2003–H2008
11. Oonishi T, Sakashita K, Uyesaka N (1997) Regulation of red
blood cell filterability by Ca2? influx and cAMP-mediated signaling pathways. Am J Physiol 273:C1828–C1834
12. Caimi G, Presti RL (2004) Techniques to evaluate erythrocyte
deformability in diabetes mellitus. Acta Diabetol 41:99–103
13. Kraemer-Aguiar LG, Laflor CM, Bouskela E (2008) Skin
microcirculatory dysfunction is already present in normoglycemic
subjects with metabolic syndrome. Metabolism 57:1740–1746
14. Diamantopoulos EJ, Kittas C, Charitos D, Grigoriadou M, IfantiG, Raptis SA (2004) Impaired erythrocyte deformability precedes
vascular changes in experimental diabetes mellitus. Horm Metab
Res 36:142–147
15. Shin S, Ku YH, Ho JX, Kim YK, Suh JS, Singh M (2007) Progressive impairment of erythrocyte deformability as indicator of
microangiopathy in type 2 diabetes mellitus. Clin Hemorheol
Microcirc 36:253–261
16. Huang SY, Jeng C, Kao SC, Yu JJ, Liu DZ (2004) Improved
haemorrheological properties by Ginkgo biloba extract (Egb 761)
in type 2 diabetes mellitus complicated with retinopathy. Clin
Nutr 23:615–621
17. Brown CD, Ghali HS, Zhao Z, Thomas LL, Friedman EA (2005)
Association of reduced red blood cell deformability and diabetic
nephropathy. Kidney Int 67:295–300

18. Young MJ, Bennett JL, Liderth SA, Veves A, Boulton AJ,
Douglas JT (1996) Rheological and microvascular parameters indiabetic peripheral neuropathy. Clin Sci (Lond) 90:183–187
19. Perez-Tilve D, Habbeger KM, Tschop MH, Hofmann SM (2011)
Neural regulation of cholesterol metabolism. Curr Opin Lipidol
22:283–287
20. Cha SH, Hu Z, Chohnan S, Lane MD (2005) Inhibition of
hypothalamic fatty acid synthase triggers rapid activation of fatty
acid oxidation in skeletal muscle. Proc Natl Acad Sci USA
102:14557–14562
21. Harshfield GA, Dong Y, Kapuku GK, Zhu H, Hanevold CD(2009) Stress-induced sodium retention and hypertension: areview and hypothesis. Curr Hypertens Rep 11:29–34
22. Vincent HK, Innes KE, Vincent KR (2007) Oxidative stress andpotential interventions to reduce oxidative stress in overweight
and obesity. Diabetes Obes Metab 9:813–839
23. Pennathur S, Heinecke JW (2007) Mechanisms for oxidative
stress in diabetic cardiovasc disease. Antioxid Redox Signal
9:955–969
24. Uyesaka N, Hasegawa S, Ishioka N, Ishioka R, Shio H, Schechter
AN (1992) Effects of superoxide anions on red cell deformability
and membrane proteins. Biorheology 29:217–229
25. Iwata H, Ukeda H, Maruyama T, Fujino T, Sawamura M (2004)
Effect of carbonyl compounds on red blood cells deformability.
Biochem Biophys Res Comm 321:700–706
26. Okamoto K, Maruyama T, Kaji Y, Harada M, Mawatari S, Fujino
T et al (2004) Verapamil prevents impairment in filterability ofhuman erythrocytes exposed to oxidative stress. Jpn J Physiol
54:39–46123