, Volume 52, Issue 12, pp 2612–2615

Link between plasma ceramides, inflammation and insulin resistance: association with serum IL-6 concentration in patients with coronary heart disease

  • V. D. F. de Mello
  • M. Lankinen
  • U. Schwab
  • M. Kolehmainen
  • S. Lehto
  • T. Seppänen-Laakso
  • M. Orešič
  • L. Pulkkinen
  • M. Uusitupa
  • A. T. Erkkilä
Short Communication



Ceramides and IL-6 have a role in immune–inflammatory responses and cardiovascular diseases, and are suggested to be involved in insulin and glucose metabolism. We sought to assess the associations of circulating levels of IL-6, TNF-α and high-sensitivity C reactive protein (hsCRP), which are inflammatory markers related to insulin resistance (IR), with the plasma lipid metabolites ceramides and diacylglycerols (DAG) in patients with CHD.


Cross-sectional analyses were carried out on data from 33 patients with CHD. Serum levels of the inflammatory markers and plasma lipid metabolites (lipidomics approach performed by ultra-performance liquid chromatography coupled to electrospray ionisation MS) were measured at the same time point as insulin resistance (IR) (HOMA-IR index).


Serum circulating levels of IL-6 were strongly correlated with plasma ceramide concentrations (r = 0.59, p < 0.001). Adjustments for serum TNF-α or hsCRP levels, smoking, BMI, age, sex or HOMA-IR did not change the results (p < 0.001). After adjustments for the effect of serum inflammatory markers (TNF-α or hsCRP), HOMA-IR and BMI the correlation between plasma DAG and serum IL-6 (r = 0.33) was also significant (p < 0.03). In a linear regression model, circulating levels of both ceramides and TNF-α had a significant independent influence on circulating levels of IL-6, altogether accounting for 41% of its variation (p < 0.001).


Our results strongly suggest that the link between ceramides, IR and inflammation is related to the inflammatory marker IL-6. Ceramides may contribute to the induction of inflammation involved in IR states that frequently coexist with CHD.

Trial registration:

ClinicalTrials.gov NCT00720655


The study was supported by the Finnish Cultural Foundation, the North-Savo Regional Fund of the Finnish Cultural Foundation, the Yrjö Jahnsson Foundation, the Sigrid Juselius Foundation, the Juho Vainio Foundation, the Kuopio University Hospital (grant 510RA07), the Academy of Finland (Projects 117844 and 118590) and by the Nordic Centre of Excellence on ‘Systems biology in controlled dietary interventions and cohort studies’ (SYSDIET), Project 070014.


Cardiovascular disease Ceramides Diacylglycerols IL-6 Inflammation Insulin resistance Lipidomics 



C-reactive protein


Cardiovascular disease




High-sensitivity C-reactive protein


Insulin resistance


The sphingolipid ceramide has emerged as an important signal transduction metabolite, with a role in immune–inflammatory responses and with a potential role as an antagonist of insulin signalling [1]. The proinflammatory cytokines IL-6 and TNF-α are associated with insulin resistance (IR) and the metabolic syndrome [2]. These inflammatory markers are known to be involved in the hepatic production of inflammatory proteins such as C-reactive protein (CRP), which has been shown to increase the risk of type 2 diabetes mellitus and cardiovascular disease (CVD) [3, 4]. Other lipid metabolites, such as diacylglycerols (DAG), are related to IR, a core feature of type 2 diabetes [5].

Therefore, we sought to assess the association of circulating levels of IL-6, CRP and TNF-α with total plasma content of ceramides and DAG in patients with CHD, in whom IR is commonly present [6]. These individuals had participated in a previous dietary intervention and lipidomics study [7, 8].


Individuals (n = 33) who were part of this cross-sectional study had volunteered originally for a study investigating the effect of fatty or lean fish on cardiovascular risk markers [7]. Briefly, patients who had been admitted to Kuopio University Hospital because of myocardial infarction or unstable ischaemic attack during the previous 3–36 months participated in the study. They gave written consent for participation in the study, which was approved by the Research Ethics Committee, Hospital District of Northern Savo.

Blood samples for the serum markers and lipidomics analyses were drawn after a 12 h overnight fast. High-sensitivity ELISA kits were used for IL-6 and TNF-α measurements (Quantikine; R&D Systems, Minneapolis, MN, USA). High-sensitivity CRP (hsCRP) was determined by an image immunochemistry system (Immulite 2000 DPC; Los Angeles, CA, USA). Serum insulin and plasma glucose were analysed as previously described [7]. Data on plasma ceramides and DAG were assessed by lipidomics analyses using ultra-performance liquid chromatography coupled to electrospray ionisation MS, described in more detailed elsewhere [8]. An internal standard mixture containing ten lipid classes was used. The lipids were extracted with chloroform/methanol (2:1 [vol./vol.], 100 μl to 50 μl plasma) and measurements were done in replicate.

The mean ± SD age, BMI, fasting plasma glucose concentration, serum total cholesterol and LDL- and HDL-cholesterol, and median (interquartile range) triacylglycerols, fasting serum insulin concentration, and HOMA of IR (HOMA-IR) index [9] of the patients were respectively: 61.0 ± 5.8 years, 27.2 ± 2.6 kg/m2, 5.80 ± 0.63 mmol/l, 4.05 ± 0.82 mmo/l, 2.15 ± 0.60 mmo/l, 1.36 ± 0.41 mmo/l, 1.09 mmol/l (0.75–1.94), 73.6 pmol/l (43.8–99.3), and 2.77 (1.58–3.81). All the participants were using beta blockers and statins. Further details of patients’ medication use and other clinical and biochemical variables are described elsewhere [7].

Statistical analyses

Correlations were performed using Pearson’s correlation coefficient (r) adjusted by partial correlation for serum concentrations of TNF-α or hsCRP, HOMA-IR, BMI, age, sex or smoking. Multivariate linear regression analyses were carried out for testing the independent effect of plasma ceramides and other independent variables on IL-6 circulating levels. Except for HOMA-IR, variables associated with serum IL-6 and TNF-α, and also BMI, age, sex and smoking were tested one by one together with ceramides as independent variables in the models. The final explanatory variables were selected if their effects were significant at p < 0.10. Variables with a skewed distribution were log10 transformed before the analyses and are presented as medians (interquartile range). p < 0.05 was considered to be statistically significant. Analyses were performed using SPSS software version 14.0 (SPSS, Chicago, IL, USA).


In the population studied, the median (interquartile range) for IL-6, TNF-α and hsCRP serum concentrations were 1.20 pg/ml (0.99–2.15), 1.22 pg/ml (0.94–1.51) and 0.72 mg/l (0.43–2.73), respectively. The mean ± SD for total ceramides and DAG were respectively 3.82 ± 1.27 μmol/l and 4.54 ± 1.74 μmol/l. The subspecies of serum ceramides detected were d18:1/C23:0 and d18:1/C24:1. Their respective concentrations (median, interquartile range) were 1.36 μmol/l (0.94–1.72) and 2.58 μmol/l (1.70–3.02).

Circulating levels of both plasma ceramides and serum IL-6 correlated with HOMA-IR (r = 0.33, p = 0.06 and r = 0.37, p = 0.04, respectively). As described in Table 1, serum IL-6 concentration correlated with both TNF-α and hsCRP levels. Interestingly, serum IL-6, but not TNF-α or hsCRP, correlated with plasma ceramides. Although the correlation between serum IL-6 levels and plasma DAG did not reach conventional statistical significance, after adjustments for the effect of serum inflammatory markers (TNF-α or hsCRP), HOMA-IR or BMI the correlation was significant (Table 1). No correlation was found between TNF-α or hsCRP levels and plasma DAG (p > 0.50). Because ceramides subspecies d18:1/C23:0 and d18:1/C24:1 were highly correlated (r = 0.80, p < 0.000001), and did not differ in respect of their association with the outcomes of interest (data not shown), we used the total plasma ceramides for our analyses.
Table 1

Correlations (r) among serum inflammatory markers and plasma ceramide and DAG concentrations in patients with CHD (n = 33)


Serum IL-6

Serum TNF-α

Serum hsCRP


p value


p value


p value

























aAdjustments for age, sex, BMI, smoking, hsCRP, TNF-α or HOMA-IR did not alter the results

bp < 0.03 after adjustment for BMI, HOMA-IR, hsCRP or TNF-α

We hypothesised that plasma ceramide concentrations could influence serum IL-6 levels. Because production of hsCRP is influenced by IL-6 and correlates with TNF-α concentration, hsCRP was not considered in the models for testing the independent effect of ceramides on IL-6. The circulating levels of ceramides and TNF-α independently influenced IL-6 concentrations, altogether accounting for 41% of its variation (ceramides: β = 0.47, p = 0.003; TNF-α: β = 0.31, p = 0.04; HOMA-IR: β = 0.13, p = 0.40; R2 = 0.41, p = 0.001). The results were not different when HOMA-IR was taken out of the model or if a step-wise regression model approach was used, considering also BMI, age, sex and smoking as independent variables (ceramides: β = 0.51, p = 0.002; TNF-α: β = 0.33, p = 0.02; R2 = 0.41, p = 0.001). When analysed according to tertiles of plasma ceramide concentrations, individuals who had higher ceramide levels had higher serum IL-6 concentrations (Fig. 1).
Fig. 1

Serum IL-6 concentration (mea ± SD of log10 values) according to tertiles of plasma ceramides concentration. First tertile (n = 11), 1.7–2.9 μmol/l; second tertile (n = 11), 3.0–4.4 μmol/l; third tertile (n = 11), 4.5–5.9 μmol/l. The respective medians (interquartile range) of IL-6 for each ceramide tertile were: first tertile, 1.09 pg/ml (0.84–1.43); second tertile, 1.19 pg/ml (1.03–1.69); and third tertile, 2.12 pg/ml (1.28–4.48). General linear model univariate analysis: p = 0.02. *p = 0.02 for third vs first tertile after Bonferroni post hoc test. All statistical analyses were adjusted for serum TNF-α concentration


Our results clearly show a strong association between circulating levels of IL-6 and plasma ceramide concentrations in patients with established CHD. As far as we know, no data on this association have been reported earlier. Although a causal link between circulating IL-6 and CVD or type 2 diabetes is not yet established, our findings are of relevance because serum IL-6 concentration has been suggested as a risk factor for diabetes, and one of the putative links between obesity, IR, CVD and the metabolic syndrome [2]. IL-6 is involved in the hepatic production of CRP, which is associated with increased risk of type 2 diabetes and CVD [3, 4]. Moreover, animal studies suggest that ceramides can induce IR [1], and in humans have been associated with insulin sensitivity [10].

The present results suggest that the proposed adverse effect of IL-6 on IR and type 2 diabetes per se and possibly through its role in enhancing hepatic production of CRP could be initiated by ceramides. The sphingomyelin pathway and ceramides themselves are reported to play a role in the regulation of IL6 gene expression [11], probably through the activation of transcription factors such as the nuclear factor kappa-B (NFκB) [11, 12]. Ceramides can act as inducers of proinflammatory cytokines through the activation of kinases (e.g. I-kappaB-kinase β [IKKβ]), which enables the activation of transcription factors such as NFκB [1]. Upregulation of ceramides and NFκB seem to work sequentially to promote the production of inflammatory molecules such as IL-6. Moreover, a role for NFκB and IKKβ in the development of IR and type 2 diabetes has been described and has been linked to inflammation [13].

Increased ceramide synthesis in response to excessive TNF-α is associated with an inhibition of insulin signalling [1]. TNF-α is known to be involved in the regulation of IL-6 production [12]. We did not observe any association between the circulating levels of TNF-α and ceramides. Conversely, recent findings showed an association between TNF-α circulating levels and plasma concentration of ceramide subspecies [10]. This observation was made in obese type 2 diabetes patients in whom IR is much more exacerbated. In our study only 15% of the participants were obese (BMI > 30 kg/m2), their serum levels of TNF-α were lower, and all were on statin therapy.

We found an association between total plasma DAG and IL-6 concentrations, which was stronger after adjustments for IR, BMI or serum inflammatory levels. DAG have been implicated in the development of IR via activation of specific protein kinase C (PKC) isoforms [5]. PKC is known to induce IL-6 synthesis [14]. However, ceramides seemed to be more strongly associated with IL-6 levels than DAG, independently of the degree of IR as assessed by HOMA-IR index.

The lack of a prospective arm might limit the generalisation of the present results. As this study is cross-sectional, we cannot assess any causal links based on the observed results. The small sample size could limit the statistical power for detecting significant results. Nonetheless, this is a homogeneous group of patients, which is important to better characterise the population under study. Because all participants were using statins, which lower plasma levels of hsCRP, correlation data involving this marker should be interpreted with caution.

In conclusion, we suggest that the link between ceramides, IR and inflammation is related to the inflammatory marker IL-6. Ceramides may contribute to the induction of inflammation involved in IR states that frequently coexist with CHD.


Duality of interest

The authors declare that there is no duality of interest associated with this manuscript.


  1. 1.
    Summers SA (2006) Ceramides in insulin resistance and lipotoxicity. Prog Lipid Res 45:42–72CrossRefPubMedGoogle Scholar
  2. 2.
    van Gaal LF, Mertens IL, de Block CE (2006) Mechanisms linking obesity with cardiovascular disease. Nature 444:875–880CrossRefPubMedGoogle Scholar
  3. 3.
    Laaksonen DE, Niskanen L, Nyyssonen K et al (2004) C-reactive protein and the development of the metabolic syndrome and diabetes in middle-aged men. Diabetologia 47:1403–1410CrossRefPubMedGoogle Scholar
  4. 4.
    Pradhan AD, Ridker PM (2002) Do atherosclerosis and type 2 diabetes share a common inflammatory basis? Eur Heart J 23:831–834CrossRefPubMedGoogle Scholar
  5. 5.
    Holland WL, Knotts TA, Chavez JA, Wang LP, Hoehn KL, Summers SA (2007) Lipid mediators of insulin resistance. Nutr Rev 65:S39–S46CrossRefPubMedGoogle Scholar
  6. 6.
    Bressler P, Bailey SR, Matsuda M, DeFronzo RA (1996) Insulin resistance and coronary artery disease. Diabetologia 39:1345–1350CrossRefPubMedGoogle Scholar
  7. 7.
    Erkkilä AT, Schwab US, de Mello VD et al (2008) Effects of fatty and lean fish intake on blood pressure in subjects with coronary heart disease using multiple medications. Eur J Nutr 47:319–328CrossRefPubMedGoogle Scholar
  8. 8.
    Lankinen M, Schwab US, Erkkilä AT et al (2009) Fatty fish intake decreases lipids related to inflammation and insulin signaling—a lipidomics approach. PLoS ONE 4:e5258CrossRefPubMedGoogle Scholar
  9. 9.
    Matthews DR, Hosker JP, Rudenski AS, Naylor BA, Treacher DF, Turner RC (1985) Homeostasis model assessment: insulin resistance and beta-cell function from fasting plasma glucose and insulin concentrations in man. Diabetologia 28:412–419CrossRefPubMedGoogle Scholar
  10. 10.
    Haus JM, Kashyap SR, Kasumov T et al (2009) Plasma ceramides are elevated in obese subjects with type 2 diabetes and correlate with the severity of insulin resistance. Diabetes 58:337–343CrossRefPubMedGoogle Scholar
  11. 11.
    Wu D, Marko M, Claycombe K, Paulson KE, Meydani SN (2003) Ceramide-induced and age-associated increase in macrophage COX-2 expression is mediated through up-regulation of NF-κ B activity. J Biol Chem 278:10983–10992CrossRefPubMedGoogle Scholar
  12. 12.
    Vanden Berghe W, Vermeulen L, de Wilde G, de Bosscher K, Boone E, Haegeman G (2000) Signal transduction by tumor necrosis factor and gene regulation of the inflammatory cytokine interleukin-6. Biochem Pharmacol 60:1185–1195CrossRefPubMedGoogle Scholar
  13. 13.
    Yuan M, Konstantopoulos N, Lee J et al (2001) Reversal of obesity- and diet-induced insulin resistance with salicylates or targeted disruption of Ikkβ. Science 293:1673–1677CrossRefPubMedGoogle Scholar
  14. 14.
    Devaraj S, Venugopal SK, Singh U, Jialal I (2005) Hyperglycemia induces monocytic release of interleukin-6 via induction of protein kinase C-α and -β. Diabetes 54:85–91CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  • V. D. F. de Mello
    • 1
  • M. Lankinen
    • 1
    • 2
  • U. Schwab
    • 1
    • 3
  • M. Kolehmainen
    • 1
  • S. Lehto
    • 3
  • T. Seppänen-Laakso
    • 2
  • M. Orešič
    • 2
  • L. Pulkkinen
    • 1
  • M. Uusitupa
    • 1
  • A. T. Erkkilä
    • 4
  1. 1.Department of Clinical Nutrition/Food and Health Research Centre, School of Public Health and Clinical NutritionUniversity of KuopioKuopioFinland
  2. 2.VTT Technical Research Centre of FinlandEspooFinland
  3. 3.Department of Internal MedicineKuopio University HospitalKuopioFinland
  4. 4.Department of Public Health, School of Public Health and Clinical NutritionUniversity of KuopioKuopioFinland

Personalised recommendations