Brain metabolism during fasting

Effect of beta-hydroxybutyrate, a cerebral function improving agent, on cerebral hypoxia, anoxia and ischemia in mice and rats

Although improving energy metabolism in ischemic brain has been accepted for the treatment of cerebrovascular diseases, administration of glucose, as an energy substrate, would aggravate ischemic brain damage via activating anaerobic glycolysis, which leads to lactate accumulation. Beta-hydroxybutyrate (BHB) is one of the ketone bodies that can be utilized as an energy source during starvation. The purpose of our study was to define the protective effects of BHB on brain damage induced by hypoxia, anoxia and ischemia. The isotonic solution of BHB administered 30 min before the induction of ischemia at doses over 50 mg x kg(-1) x h(-1) showed remarkable protective effects against hypoxia and anoxia. BHB administered immediately after a bilateral carotid artery ligation at a dose of 30 mg x kg(-1) x h(-1) significantly suppressed the elevation of cerebral water and sodium contents as well as maintaining high ATP and low lactate levels. In contrast, glycerin, a hypertonic agent, substantially reduced the water content but did not show any significant effect on other parameters. We demonstrated that BHB, unlike glycerin, when used as an energy substrate in ischemic brain, has protective effects on cerebral hypoxia, anoxia and ischemia-induced metabolic change.

Contribution to glucose tolerance of insulin-independent vs. insulin-dependent mechanisms in mice

To study the contributions of insulin-dependent vs. insulin-independent mechanisms to intravenous glucose tolerance (K(G)), 475 experiments in mice were performed. An intravenous glucose bolus was given either alone or with exogenous insulin or with substances modulating insulin secretion and sensitivity. Seven samples were taken over 50 min. Insulin [suprabasal area under the curve (DeltaAUC(ins))] ranged from 0 to 100 mU. ml(-1). 50 min. After validation against the euglycemic hyperinsulinemic clamp, the minimal model of net glucose disappearance was exploited to analyze glucose and insulin concentrations to measure the action of glucose per se independent of dynamic insulin (S(G)) and the combined effect of insulin sensitivity (S(I)) and secretion. Sensitivity analysis showed that insulin [through disposition index (DI)] contributed to glucose tolerance by 29 +/- 4% in normal conditions. In conditions of elevated hyperinsulinemia, contribution by insulin increased on average to 69%. K(G) correlated with DI but was saturated for DeltaAUC(ins) above 15 mU. ml(-1). 50 min. Insulin sensitivity related to DeltaAUC(ins) in a hyperbolic manner, whereas S(G) did not correlate with the insulin peak in the physiological range. Thus glucose tolerance in vivo is largely mediated by mechanisms unrelated to dynamic insulin and saturates with high insulin.

Norepinephrine is required for the anticonvulsant effect of the ketogenic diet

Ketogenic diet (KD) is a high fat, low carbohydrate diet used to treat children with epilepsy that are refractory to conventional antiepileptic drugs (AEDs). The anticonvulsant mechanism of the KD is unknown. To determine if the noradrenergic system has a role in mediating the anticonvulsant action of the KD, dopamine beta-hydroxylase knockout (Dbh -/-) mice that lack norepinephrine (NE) and Dbh +/- littermates that have normal NE content were fed either a standard rodent chow or the KD. When exposed to the convulsant flurothyl, Dbh +/- mice fed the KD had significantly longer latencies to myoclonic jerk (MJ) and generalized clonic-tonic (CT) seizures than Dbh +/- mice fed normal chow. In contrast, Dbh -/- mice fed the KD had seizure latencies to both MJ and CT comparable to Dbh -/- mice fed normal chow. These results suggest that an intact, functional noradrenergic nervous system is required for the KD to exert an anticonvulsant effect.

Corneal temperature reversal after storage in Chen medium compared with Optisol GS

PURPOSE

To compare corneal endothelial cell function by measuring corneal thickness during temperature reversal between corneas stored in two different storage media, Optisol GS and Chen Medium (CM).

METHODS

Twenty paired corneas from 10 human donors were randomly assigned for storage at 4 degrees C in Optisol GS (10 corneas) or CM (10 corneas). The storage media were masked, and measurements were done in a masked fashion. After storage for 48 hours, corneal thickness was measured by ultrasonic pachymetry at 2-hour intervals for 12 hours, during which time the corneas were perfused with BSS (balanced salt solution) Plus at 37 degrees C. Scanning electron microscopy of two pairs of corneas from two donors was performed to assess ultrastructural change after 12 hours of warming.

RESULTS

Corneal thickness decreased during the first 4 hours of the warming period and then increased during the 6-to 12-hour warming period. These changes in corneal thickness over time were similar for the two storage media (p = 0.212). Scanning electron microscopy showed greater amounts of endothelial cell disruption in Optisol GS-stored corneas than those stored in CM after 12 hours of warming and perfusion.

CONCLUSIONS

The endothelial pump of corneas stored in CM appear to be as well-preserved as those stored in Optisol GS, although greater endothelial disruption may be present with Optisol GS by scanning electron microscopy. Further studies are required to compare the clinical effectiveness of these two media.

Vagus nerve stimulation and the ketogenic diet

Antiepileptic drugs are the primary form of treatment for patients with epilepsy. In the United States, hundreds of thousands of people do not achieve seizure control, or have significant side effects, or both. Only a minority of patients with intractable epilepsy are candidates for traditional epilepsy surgery. Vagus nerve stimulation is now the second most common treatment for epilepsy in the United States. Additionally, the ketogenic diet has established itself as a valid treatment. This article discusses the history, mechanism of action, patient selection, efficacy, initiation, complications, and advantages of vagus nerve stimulation and the ketogenic diet.

Hypoglycemic brain injury

Hypoglycemia frequently occurs in newborn infants who previously have suffered asphyxia, who are offspring of diabetic mothers, or who are low birthweight for gestational age (IUGR). Many infants who are hypoglycemic do not exhibit clinical manifestations, while others are symptomatic and at risk for the occurrence of permanent brain damage. This review emphasizes the clinical, neuropathologic, and neuro-imaging features of hypoglycemia in newborn infants, especially those who are symptomatic. Neurologic morbidity occurs particularly in those infants who have suffered severe, protracted, or recurrent symptomatic hypoglycemia. Experimental observations emphasize the resistance of the immature brain to the damaging effect of hypoglycemia; such resistance occurs as a consequence of compensatory increases in cerebral blood flow, lower energy requirements, higher endogenous carbohydrate stores, and an ability to incorporate and consume alternative organic substrates to spare glucose for energy production. Hypoglycemia combined with hypoxia-ischemia (asphyxia) is more deleterious to the immature brain than either condition alone.

Expression of monocarboxylate transporter MCT1 in normal and neoplastic human CNS tissues

Expression of monocarboxylate transporter MCT1 was studied in archival tissues from human CNS using antibodies to the carboxyl-terminal end of MCT1. Sections of neocortex, hippocampus and cerebellum of brains from 10 adult autopsy patients who died from other than CNS disease, and from archival surgical biopsy specimens of 83 primary CNS and eight non-CNS tumors were studied. MCT1 immunoreactivity was present in microvessels and, ependymocytes of normal CNS tissues similar to that reported for MCT1 expression in rat brains. MCT1 immunoreactivity was strongest in ependymomas, hemangioblastomas and high grade glial neoplasms, and weakest in low grade gliomas. Increased MCT1 expression in high grade glial neoplasms may provide a potential therapeutic target for treatment of some CNS neoplasms.

Cognitive performance and its relationship with postprandial metabolic changes after ingestion of different macronutrients in the morning

The effect of carbohydrate, protein and fat ingestion on simple as well as complex cognitive functions and the relationship between the respective postprandial metabolic changes and changes in cognitive performance were studied in fifteen healthy male students. Subjects were tested in three sessions, separated by 1 week, for short-term changes in blood variables, indirect calorimetry, subjective performance and different objective performance tasks using a repeated-measures counterbalanced cross-over design. Measurements were made after an overnight fast before and hourly during 3 h after test meal ingestion. Test meals consisted of either pure carbohydrates, protein or fat and were served as isoenergetic (1670 kJ) spoonable creams with similar sensory properties. Most aspects of subjective performance did not differ between test meals. For all objective tasks, however, postprandial cognitive performance was best after fat ingestion concomitant with an almost constant glucose metabolism and constant metabolic activation state measured by glucagon:insulin (G:I). In contrast, carbohydrate as well as protein ingestion resulted in lower overall cognitive performance, both together with partly marked changes in glucose metabolism and metabolic activation. They also differently affected specific cognitive functions in relation to their specific effect on metabolism. Carbohydrate ingestion resulted in relatively better short-term memory and accuracy of tasks concomitant with low metabolic activation, whereas protein ingestion resulted in better attention and efficiency of tasks concomitant with higher metabolic activation. Our findings support the concept that good and stable cognitive performance is related to a balanced glucose metabolism and metabolic activation state.

Cell-specific localization of monocarboxylate transporters, MCT1 and MCT2, in the adult mouse brain revealed by double immunohistochemical labeling and confocal microscopy

Recent evidence suggests that lactate could be a preferential energy substrate transferred from astrocytes to neurons. This would imply the presence of specific transporters for lactate on both cell types. We have investigated the immunohistochemical localization of two monocarboxylate transporters, MCT1 and MCT2, in the adult mouse brain. Using specific antibodies raised against MCT1 and MCT2, we found strong immunoreactivity for each transporter in glia limitans, ependymocytes and several microvessel-like elements. In addition, small processes distributed throughout the cerebral parenchyma were immunolabeled for monocarboxylate transporters. Double immunofluorescent labeling and confocal microscopy examination of these small processes revealed no co-localization between glial fibrillary acidic protein and monocarboxylate transporters, although many glial fibrillary acidic protein-positive processes were often in close apposition to elements labeled for monocarboxylate transporters. In contrast, several elements expressing the S100beta protein, another astrocytic marker found to be located in distinct parts of the same cell when compared with glial fibrillary acidic protein, were also strongly immunoreactive for MCT1, suggesting expression of this transporter by astrocytes. In contrast, MCT2 was expressed in a small subset of microtubule-associated protein-2-positive elements, indicating a neuronal localization. In conclusion, these observations are consistent with the possibility that lactate, produced and released by astrocytes (via MCT1), could be taken up (via MCT2) and used by neurons as an energy substrate.

Terminal nutrition: framing the debate for the withdrawal of nutritional support in terminally ill patients

Nutrition and hydration have long been considered to be life-sustaining therapies that are associated with comfort and relief of suffering. This belief is largely based on our own experiences with the sensations of thirst and hunger, which have led physicians to question whether withdrawing or withholding nutritional support from a dying patient can be morally or ethically justified. When considered in light of the available evidence, the underlying premise of this question must be reevaluated. The evidence suggests an alternative formulation, namely, that unrequested nutritional support provided by either the enteral or parenteral route to a terminally ill patient may be both medically and ethically indefensible because it may increase suffering without improving outcome.

Hypoglycemia. Pathophysiology and treatment

Hypoglycemia is a common consequence of many diabetes treatments. As is true for many therapies for diseases with major pathologic consequences, the benefits and risks of treatment must be balanced. In intensified diabetes management, hypoglycemia is not an insurmountable problem but is unfortunately inevitable using the methods of glucose control currently available. Patients with type 1 diabetes seem to be at greater risk than patients with type 2 disease. The health care team must strive to help the patient maintain normoglycemia. The results of the DCCT and the United Kingdom Prospective Diabetes Study prove that near normoglycemia is clearly in the patient's best interest. Patient education has become focused on minimizing hyperglycemia; counseling on the dangers of hypoglycemia has not been given the same stature. Emphasis must be placed on minimizing even minor subclinical hypoglycemia because it will contribute to a vicious cycle of hypoglycemia begetting hypoglycemia.

Human brain beta-hydroxybutyrate and lactate increase in fasting-induced ketosis

Ketones are known to constitute an important fraction of fuel for consumption by the brain, with brain ketone content generally thought to be low. However, the recent observation of 1-mmol/L levels of brain beta-hydroxybutyrate (BHB) in children on the ketogenic diet suggests otherwise. The authors report the measurement of brain BHB and lactate in the occipital lobe of healthy adults using high field (4-T) magnetic resonance spectroscopy, measured in the nonfasted state and after 2- and 3-day fasting-induced ketosis. A 9-mL voxel located in the calcarine fissure was studied, detecting the BHB and lactate upfield resonances using a 1H homonuclear editing sequence. Plasma BHB levels also were measured. The mean brain BHB concentration increased from a nonfasted level of 0.05 +/- 0.05 to 0.60 +/- 0.26 mmol/L (after second day of fasting), increasing further to 0.98 +/- 0.16 mmol/L (after the third day of fasting). The mean nonfasted brain lactate was 0.69 +/- 0.17 mmol/L, increasing to 1.47 +/- 0.22 mmol/L after the third day. The plasma and brain BHB levels correlated well (r = 0.86) with a brain-plasma slope of 0.26. These data show that brain BHB rises significantly with 2- and 3-day fasting-induced ketosis. The lactate increase likely results from ketones displacing lactate oxidation without altering glucose phosphorylation and glycolysis.

Starvation increases the amount of pyruvate dehydrogenase kinase in several mammalian tissues

Covalent modification of the pyruvate dehydrogenase complex provides an important regulatory mechanism for controlling the disposal of glucose and other compounds metabolized to pyruvate. Regulation of the complex by this mechanism is achieved in part by tissue-specific expression of the genes encoding isoenzymes of pyruvate dehydrogenase kinase (PDK). Starvation is known from our previous work to increase PDK activity of heart and skeletal muscle by increasing the amount of PDK isoenzyme 4 (PDK4) present in these tissues. This study demonstrates that increased expression of both PDK4 and PDK2 occurs in rat liver, kidney, and lactating mammary gland in response to starvation. PDK4 and PDK2 message levels were also increased by starvation in the two tissues examined (liver and kidney), suggesting enhancement of gene transcription. Changes in PDK2 message and protein were of similar magnitude, but changes in PDK4 message were greater than those in PDK4 protein, suggesting regulation at the level of translation. In contrast to these tissues, starvation had little or no effect on PDK2 and PDK4 protein in brain, white adipose tissue, and brown adipose tissue. Nevertheless, PDK4 message levels were significantly increased in brain and white adipose tissue by starvation. The findings of this study indicate that increased expression of PDK isoenzymes is an important mechanism for bringing about inactivation of the pyruvate dehydrogenase complex during starvation in many but not all tissues of the body. The absence of this mechanism preserves the capacity of neuronal tissue to utilize glucose for energy during starvation.

Zinc-induced cortical neuronal death: contribution of energy failure attributable to loss of NAD(+) and inhibition of glycolysis

Excessive zinc influx may contribute to neuronal death after certain insults, including transient global ischemia. In light of evidence that levels of intracellular free Zn(2+) associated with neurotoxicity may be sufficient to inhibit glyceraldehyde-3-phosphate dehydrogenase (GAPDH), experiments were performed looking for reduced glycolysis and energy failure in cultured mouse cortical neurons subjected to lethal Zn(2+) exposure. As predicted, cultures exposed for 3-22 hr to 40 mixroM Zn(2+) developed an early increase in levels of dihydroxy-acetone phosphate (DHAP) and fructose 1,6-bisphosphate (FBP) and a progressive loss of ATP levels, followed by neuronal cell death; furthermore, addition of the downstream glycolytic substrate pyruvate to the bathing medium attenuated the fall in ATP and neuronal death. However, an alternative to direct Zn(2+) inhibition of GAPDH was raised by the observation that Zn(2+) exposure also induced an early decrease in nicotinamide-adenine dinucleotide (NAD(+)) levels, an event itself capable of inhibiting GAPDH. Favoring this indirect mechanism of GAPDH inhibition, the neuroprotective effects of pyruvate addition were associated with normalization of cellular levels of NAD(+), DHAP, and FBP. Zn(2+)-induced neuronal death was also attenuated by addition of the energy substrate oxaloacetate, the activator of pyruvate dehydrogenase, dichloroacetate, or the inhibitors of NAD(+) catabolism, niacinamide or benzamide. Acetyl carnitine, alpha-keto butyrate, lactate, and beta-hydroxy-butyrate did not attenuate Zn(2+)-induced neurotoxicity, perhaps because they could not regenerate NAD(+) or be used for energy production in the presence of glucose.

Hormones and metabolites of arctic foxes (Alopex lagopus) in response to season, starvation and re-feeding

Svalbard's arctic foxes experience large seasonal variations in light, temperature and food supply throughout the year, which may result in periods of starvation. The aim of this work is to investigate if there are seasonal variations in post-absorptive plasma thyroid hormones (free thyroxin (fT(4)), free triiodothyronine (fT(3)) and reverse triiodothyronine (rT(3))) and metabolites (free fatty-acids (FFA) and beta-hydroxybutyrate (beta-OHB)) with season and their response to starvation and re-feeding. The concentrations of post-absorptive free triiodothyronine were significantly higher in November than May, while those of thyroxin, reverse triiodothyronine, free fatty-acids and beta-hydroxybutyrate remained unchanged. Possible explanations for the seasonal variations in free triiodothyronine are discussed. There were no significant changes from post-absorptive concentrations of thyroxin and reverse triiodothyronine in starved and re-fed foxes. However, free triiodothyronine concentrations decreased during starvation and increased again with re-feeding both in May and November. Starvation induced high levels of free fatty acids in both May and November, indicating increased lipolysis. There was a significant increase in beta-hydroxybutyrate in November only, indicating that arctic foxes are capable of protein conservation during starvation.

Zinc-induced cortical neuronal death: contribution of energy failure attributable to loss of NAD(+) and inhibition of glycolysis

Excessive zinc influx may contribute to neuronal death after certain insults, including transient global ischemia. In light of evidence that levels of intracellular free Zn(2+) associated with neurotoxicity may be sufficient to inhibit glyceraldehyde-3-phosphate dehydrogenase (GAPDH), experiments were performed looking for reduced glycolysis and energy failure in cultured mouse cortical neurons subjected to lethal Zn(2+) exposure. As predicted, cultures exposed for 3-22 hr to 40 mixroM Zn(2+) developed an early increase in levels of dihydroxy-acetone phosphate (DHAP) and fructose 1,6-bisphosphate (FBP) and a progressive loss of ATP levels, followed by neuronal cell death; furthermore, addition of the downstream glycolytic substrate pyruvate to the bathing medium attenuated the fall in ATP and neuronal death. However, an alternative to direct Zn(2+) inhibition of GAPDH was raised by the observation that Zn(2+) exposure also induced an early decrease in nicotinamide-adenine dinucleotide (NAD(+)) levels, an event itself capable of inhibiting GAPDH. Favoring this indirect mechanism of GAPDH inhibition, the neuroprotective effects of pyruvate addition were associated with normalization of cellular levels of NAD(+), DHAP, and FBP. Zn(2+)-induced neuronal death was also attenuated by addition of the energy substrate oxaloacetate, the activator of pyruvate dehydrogenase, dichloroacetate, or the inhibitors of NAD(+) catabolism, niacinamide or benzamide. Acetyl carnitine, alpha-keto butyrate, lactate, and beta-hydroxy-butyrate did not attenuate Zn(2+)-induced neurotoxicity, perhaps because they could not regenerate NAD(+) or be used for energy production in the presence of glucose.

Controversies regarding definition of neonatal hypoglycemia: suggested operational thresholds

The definition of clinically significant hypoglycemia remains one of the most confused and contentious issues in contemporary neonatology. In this article, some of the reasons for these contentions are discussed. Pragmatic recommendations for operational thresholds, ie, blood glucose levels at which clinical interventions should be considered, are offered in light of current knowledge to aid health care providers in neonatal medicine. Future areas of research to resolve some of these issues are also presented.

Glucose metabolism in the developing brain

As in adults, glucose is the predominant cerebral energy fuel for the fetus and newborn. Studies in experimental animals and humans indicate that cerebral glucose utilization initially is low and increases with maturation with increasing regional heterogeneity. The increases in cerebral glucose utilization with advancing age occurs as a consequence of increasing functional activity and cerebral energy demands. The levels of expression of the 2 primary facilitative glucose transporter proteins in brain, GLUT1 (blood-brain barrier and glia) and GLUT3 (neuronal), display a similar maturational pattern. Alternate cerebral energy fuels, specifically the ketone bodies and lactate, can substitute for glucose, especially during hypoglycemia, thereby protecting the immature brain from potential untoward effects of hypoglycemia. Unlike adults, glucose supplementation during hypoxia-ischemia is protective in the immature brain, whereas hypoglycemia is deleterious. Accordingly, glucose plays a critical role in the developing brain, not only as the primary substrate for energy production but also to allow for normal biosynthetic processes to proceed.

Compartmentation of brain glutamate metabolism in neurons and glia

Intrasynaptic [glutamate] must be kept low in order to maximize the signal-to-noise ratio after the release of transmitter glutamate. This is accomplished by rapid uptake of glutamate into astrocytes, which convert glutamate into glutamine. The latter then is released to neurons, which, via mitochondrial glutaminase, form the glutamate that is used for neurotransmission. This pattern of metabolic compartmentation is the "glutamate-glutamine cycle." This model is subject to the following two important qualifications: 1) brain avidly oxidizes glutamate via aspartate aminotransferase; and 2) because almost no glutamate crosses from blood to brain, it must be synthesized in the central nervous system (CNS). The primary source of glutamate carbon is glucose, and a major source of glutamate nitrogen is the branched-chain amino acids, which are transported rapidly into the CNS. This arrangement accomplishes the following: 1) maintenance of low external [glutamate], thereby maximizing signal-to-noise ratio upon depolarization; 2) the replenishing of the neuronal glutamate pool; 3) the "trafficking" of glutamate through the extracellular fluid in a nonneuroactive form (glutamine); 4) the importation of amino groups from blood, thus maintaining brain nitrogen homeostasis; and 5) the oxidation of glutamate/glutamine, a process that confers an additional level of control in terms of the regulation of brain glutamate, aspartate and gamma-aminobutyric acid.

Effect of cerebroventricular infusion of insulin and (or) glucose on hypothalamic expression of leptin receptor and pituitary secretion of LH in diet-restricted ewes

The objective was to determine the effect of central infusion of insulin and (or) glucose on hypothalamic expression of leptin receptor and pituitary secretion of LH in the ewe. Twenty-two ovariectomized ewes (32 wk of age) were fitted with two lateral cerebroventricular (LCV) cannulae and fed 33% of NRC requirements for 8 wk. Ewes (n> or =5/group) were then infused, via LCV cannulae, with artificial cerebrospinal fluid (aCSF) or aCSF containing physiological concentrations of insulin (INS), glucose (GLU), or INS + GLU; the mass of each increasing linearly from Day 0 (mass = 0 units/h) to Day 8 (mass of INS = 80 mIU/hr and GLU = 10 mg/hr). Jugular serum was collected every 12 min for 4 hr on Days 0, 2, and 4. Ewes treated with INS or INS + GLU had greater (P<0.06) mean concentrations of LH than aCSF treated ewes on Day 2 (13.8+/-1.8 and 12.5+/-1.3 > 8.0+/-3.3 ng/ml). Furthermore, on Day 4, concentrations of LH in INS treated ewes exceeded that (P<0.07) of aCSF treated ewes (14.8+/-2.0 > 7.4+/-3.0 ng/ml). Expression of NPY mRNA did not differ between treatments (P = 0.87). Leptin receptor mRNA expression was dramatically reduced (P<0.0002) in INS+GLU versus aCSF treated ewes. These data provide evidence to suggest that insulin may be an important component of hypothalamic mechanisms regulating secretion of LH and expression of leptin receptors in undernourished ruminants.

Higher ketogenic diet ratios confer protection from seizures without neurotoxicity

The present study was designed to establish a dose-response relationship for the efficacy of the ketogenic diet (KD). Sprague-Dawley rats were fed ketogenic diets containing varying ratios of fats; (carbohydrates + proteins) whereas control animals were fed rodent chow. Unless otherwise indicated, all animals were fed calorie-restricted, isocaloric diets beginning at P37 and ketonemia, seizure threshold and neurotoxic effects were determined. Despite being provided isocaloric quantities, animals fed lower ketogenic ratios gained weight relative to those fed diets having greater proportions of fats. A significantly increased metabolic rate was noted for animals fed a high-fat diet, suggesting a basis for the weight differences. Results also showed that the animals fed calorie-restricted high-fat diets exhibited significant ketonemia and protection from pentylenetetrazole (PTZ)-induced seizures. There were no detectable neurotoxic effects for any diet group. For animals of the same age, there was no correlation between beta-hydroxybutyrate (beta-OHB) and seizure threshold. These findings suggest that beta-OHB is not directly involved in the anticonvulsant mechanism of the diet. Also, data presented here show that the conventional 4:1 ketogenic diet does not confer the greatest level of seizure protection. We conclude that a 6:1 ketogenic diet, which shows no evidence of neurotoxicity, may be maximally efficacious in rats.

Animal models of the ketogenic diet: what have we learned, what can we learn?

Despite its clinical use as a therapy for refractory epilepsy for more than 75 years, the ketogenic diet (KD) remains a therapy in search of an explanation. The mechanism of action of the KD is unclear and the optimal indications for its clinical use are incompletely defined. Animal models could help to elucidate these questions. Surprisingly, there have been very few animal studies of the KD, and those that have been performed are difficult to compare because of wide discrepancies in experimental methods. Earlier models concentrated on the effect of the KD on acute seizure threshold in normal (i.e. nonepileptic) animals. Recent studies are beginning to examine the longer term effects of the KD and its role in epileptogenesis. Some features of clinical experience have been replicated in animal models, including the role of ketosis, elevation of seizure threshold by both classic ketogenic and medium chain triglyceride diets, better effectiveness at younger ages, and rapid reversal of the seizure protective effect when the diet is discontinued. These parallels raise hope that pertinent clinical questions can be addressed in the more controlled setting of the research laboratory. As in the clinical arena, there has been a recent resurgence of interest in pursuing basic questions related to the ketogenic diet, using techniques of modern neuroscience. Experimental approaches such as brain slice neurophysiology, genetic models, dissection of metabolic pathways, and neurohistological techniques hold much promise in the effort to understand this intriguing alternative to standard anticonvulsants.

Controlling the sugar bowl. Regulation of glucose homeostasis in children

In this article, the authors have attempted to provide a reasonable, working, and dynamic model incorporating a number of factors that are known to be involved in the regulation of glucose homeostasis in infants, children, and adults. Through the understanding of this model and its application, it is hoped that some of the authors' speculations regarding the pathophysiology of hyperglycemia and hypoglycemia might be challenged and either supported or rejected. In the meantime, the model can provide a framework for several of the facts and observations about the regulation of glucose homeostasis.

Insulin resistance: a chicken that has come to roost

Insulin-mediated glucose disposal varies approximately 10-fold in apparently healthy human beings. Insulin (I)-resistant individuals can remain glucose tolerant if the pancreas compensates for this defect by secreting large amounts of I. Type 2 diabetes develops when I-resistant persons cannot sustain this state of compensatory hyperinsulinemia (increases I). However, the ability of increases I to prevent decompensation of glucose tolerance is a mixed blessing, and the combination of I resistance and increases I predisposes such individuals to develop a series of abnormalities that increase risk of coronary heart disease (CHD). Given the health-related consequences of I resistance and increases I, it has been suggested that a "thrifty" genotype exists that favored evolutionary survival by enhancing I secretion and thereby promoting energy accumulation. An alternative view is that conservation of muscle mass was necessary for survival, and that muscle I resistance was the "thrifty" genotype. This latter hypothesis is more consistent with current data, and there is evidence of a genetic basis for I resistance. In either case, there is little question as to the importance of I resistance and related abnormalities in diseases of Western civilization. However, the strength of the association between I resistance and its consequences varies in magnitude, and it is necessary to emphasize that development of a clinical end-point will vary as a function of (1) degree of I resistance; (2) "closeness" of I resistance to the end-point; and (3) the ability to compensate for the effects of I resistance. I resistance is a physiological characteristic, genetically determined, that helped primitive humans to survive. It is greatly aggravated by obesity and physical inactivity, and represents a modern scourge.

The control of partitioning between protein and fat during human starvation: its internal determinants and biological significance

Human subjects vary in the extent to which their body's protein and fat compartments are mobilized for fuel during starvation. Although an inverse association between the initial adiposity and the contribution of protein as fuel during starvation has been known for nearly a century, interest in the quantitative importance and functional significance of the initial percentage fat as a determinant of biological variation in energy-partitioning between protein and fat (and hence in determining the partitioning characteristic of the individual) is relatively recent. The present paper addresses these issues by revisiting the classic Minnesota experiment of semi-starvation and refeeding from a standpoint of system physiology. In a quantitative analysis of the relationship between the initial body composition (ration FAT0: fat-free mass (FFM)0) and the composition of weight loss (ratio delta FAT: delta FFM) in the thirty-two men in the Minnesota study, the arguments are put forward that the fraction of FFM lost when the fat stores reach total depletion is independent of the initial percentage fat, and that this fraction represents the 'dispensable' component of the protein compartment that is compatible with life (i.e. the protein energy-reserve, rp). The concepts are developed that (1) the initial percentage body fat (which reflects the initial ratio FAT0:FFM0) provides a 'memory of partitioning' which dictates the control of partitioning between protein and fat in such a way that both the protein energy-reserve (rp) and the fat energy-reserve (rf) each complete depletion simultaneously, a strategy that would ensure maximum length of survival during long-term food scarcity, and that (2) variability in the relative sizes of these two energy reserves (i.e. in rf:rp) could, in addition to the initial percentage fat, also contribute to human variability in energy-partitioning. The basic assumptions underlying this re-analysis of the Minnesota data, and the concepts that are derived from it, have been integrated in the simple mathematical model for predicting the partitioning characteristic of the individual. This model is used to explain how variability in the fraction of the protein compartment that could function as an energy reserve (rp) can be as important as the initial percentage fat in determining inter-individual variability in protein-sparing during the early phase of starvation, in fuel partitioning during prolonged starvation, or in the maximum percentage weight loss during starvation. The elucidation of factors underlying variability in the size of the protein energy-reserve may have important implications for our understanding of the pathophysiology of starvation and age-associated susceptibility to muscle wasting, and in the clinical management of cachexia and obesity.

Physiological correlates of musth: lipid metabolites and chemical composition of exudates

Physiological changes related to lipid metabolism, behavior, and chemicals released in body exudates were studied during musth in the Asian elephant, Elephas maximus, as a case study. During musth, changes in serum testosterone and triglyceride concentrations followed similar patterns, with the former increasing sooner than the latter. Deviant behavior increased during changing androgen levels. The observed high concentrations of testosterone were positively and significantly correlated with increased triglycerides. Lipase activity elevated significantly immediately before and after musth. Blood pH increased significantly in alkalinity. Urine and temporal gland secretions released variable amounts of compounds, some of which may be chemical signals. During musth, temporal gland and urinary exudates demonstrated increased acetone and other ketones indicative of lipid metabolic alterations. Large quantities of nonmethane hydrocarbons, especially 2-butanone, were released from the seemingly dry orifice of the temporal gland before the start of overt musth and before maximum blood elevations were observed; isoprene release was similar. However, maximal acetone levels occurred simultaneously in blood, temporal gland secretions, and urine. Metabolically, musth is a series of interwoven, changing stages of increasing and decreasing hormones and lipid-related constituents. Released chemicals can be quantitatively related to these internal physiological events; some observed behaviors appear to result from altered chemical signals.

Possible physiological roles of acetone metabolism in humans

Recently, the metabolic routes for acetone metabolism have been described. Therefore, acetone cannot further be regarded as a waste product of metabolism. However, its physiological role in biochemical machinery is not clear. Here, an integrative model for the role of acetone metabolism is presented that orders the events occurring in acetonemia in sequence: (i) acetone participates in pH regulation; and (ii) acetone degradation in the liver both contributes to glucostatic function of the liver and provides C3 fragments to peripheral tissues as additional fuel. The model raises a novel approach to the study of the physiological role of acetone metabolism.

Physiology of glucose counterregulation to hypoglycemia

Prevention of hypoglycemia is essential for the preservation of brain metabolism and survival of the whole body. Normally, glucose is the only substrate used by the brain to meet its metabolic requirements. Therefore, a continuous supply of circulatory glucose is a necessary prerequisite for normal cerebral metabolism. When plasma glucose concentration decreases (e.g., during prolonged fasting or after administration of glucose-lowering drugs) several physiologic responses are activated to prevent further decreases in blood glucose. The first response is known as counterregulation, a system that prevents and corrects hypoglycemia through the release of counterregulatory hormones.

Seizure resistance is dependent upon age and calorie restriction in rats fed a ketogenic diet

The present study was designed to evaluate the effects of age on the efficacy of the ketogenic diet in suppressing seizures evoked by tail-vein infusion of pentylenetetrazole (PTZ). Male rats of various ages were divided into three groups and fed one of three diets: (1) a calorie-restricted ketogenic diet, (2) a calorie-restricted normal (rodent chow) diet, or (3) a normal diet, ad libitum. After animals had been on experimental or control diets for more than 20 days, seizure threshold and blood levels of beta-hydroxybutyrate (beta-OHB) were determined. Animals fed a ketogenic diet exhibited significant elevations in levels of beta-OHB and seizure resistance compared to animals fed either a calorie-restricted normal diet or a normal diet, ad libitum. The levels of beta-OHB and seizure resistance were greatest for young pups. A surprising finding was that young animals fed a calorie-restricted rodent chow diet exhibited a significantly increased resistance to seizures compared to those fed the same diet, ad libitum. Results presented here demonstrate that the ketogenic diet produces the highest levels of ketonemia and seizure threshold in young animals. Collectively, these data suggest that age and caloric restriction are important considerations for implementing the ketogenic diet.

Effect of primary congenital hypothyroidism upon expression of genes mediating murine brain glucose uptake

Using hyt/hyt mice that exhibit naturally occurring primary hypothyroidism (n = 72) and Balb/c controls (n = 66), we examined the mRNA, protein, and activity of brain glucose transporters (Glut 1 and Glut 3) and hexokinase I enzyme at various postnatal ages (d 1, 7, 14, 21, 35, and 60). The hyt/hyt mice showed an age-dependent decline in body weight (p < 0.04) and an increase in serum TSH levels (p < 0.001) at all ages. An age-dependent translational/posttranslational 40% decline in Glut 1 (p = 0.02) with no change in Glut 3 levels was observed. These changes were predominant during the immediate neonatal period (d 1). A posttranslational 70% increase in hexokinase enzyme activity was noted at d 1 alone (p < 0.05) with no concomitant change in brain 2-deoxy-glucose uptake. This was despite a decline in the hyt/hyt glucose production rate. We conclude that primary hypothyroidism causes a decline in brain Glut 1 associated with no change in Glut 3 levels and a compensatory increase in hexokinase enzyme activity. These changes are pronounced only during the immediate neonatal period and disappear in the postweaned stages of development. These hypothyroid-induced compensatory changes in gene products mediating glucose transport and phosphorylation ensure an adequate supply of glucose to the developing brain during transition from fetal to neonatal life.

Cerebral oxygen/glucose ratio is low during sensory stimulation and rises above normal during recovery: excess glucose consumption during stimulation is not accounted for by lactate efflux from or accumulation in brain tissue

Functional activation stimulates CMRglc more than CMRO2 and raises lactate levels in brain. This has been interpreted as evidence that brain work is supported mainly by energy derived from anaerobic glycolysis. To determine if lactate production accounts for the "excess" glucose consumption, cerebral arteriovenous differences were measured in conscious rats before, during, and 15 minutes after sensory stimulation; the brains were rapidly frozen in situ immediately after completion of blood sampling and assayed for metabolite levels. The molar O2/glucose uptake ratio fell from 6.1+/-1.1 (mean+/-SD) before stimulation to 5.0+/-1.1 during activation (P<0.01); lactate efflux from brain to blood was detectable at rest but not during stimulation. By 15 minutes after activation, O2 and lactate arteriovenous differences normalized, whereas that for glucose fell, causing the O2/glucose ratio to rise above preactivation levels to 7.7+/-2.6 (P<0.01). Brain glucose levels remained stable through all stages of activity. Brain lactate levels nearly doubled during stimulation but normalized within 15 minutes of recovery. Brain glycogen content fell during activation and declined further during recovery. These results indicate that brain glucose metabolism is not in a steady state during and shortly after activation. Furthermore, efflux from and increased content of lactate in the brain tissue accounted for less than 54% of the "excess" glucose used during stimulation, indicating that a shift to anaerobic glycolysis does not fully explain the disproportionately greater increases in CMRglc above that of CMRO2 in functionally activated brain. These results also suggest that the apparent dissociation between glucose utilization and O2 consumption during functional activation reflects only a temporal displacement; during activation, glycolysis increases more than oxidative metabolism, leading to accumulation of products in intermediary metabolic pools that are subsequently consumed and oxidized during recovery.

Plasma glucose alone does not predict neurologic dysfunction in hypoglycemic nondiabetic subjects

STUDY OBJECTIVE

To assess the value of plasma glucose concentration alone as a predictor of neurologic dysfunction in nondiabetic subjects with normal baseline neurologic examination and electroencephalographic (EEG) findings.

METHODS

Neurologic function and EEG results were evaluated in 17 subjects before and during insulin-induced hypoglycemia using relevant and reliable clinical tools for bedside use.

RESULTS

Hypoglycemia (mean nadir concentration, 30 mg/dL) was without effect on level of consciousness or cranial nerve, motor, sensory, vestibulocerebellar, language, or simple visuospatial functions. Attention was minimally impaired in all subjects, but memory in only 3. EEG results remained normal in 5 subjects; minimal to moderate nonspecific changes occurred in the rest. All patients manifested signs of sympathetic stimulation from hypoglycemia, including tremor, tachycardia, and diaphoresis. The manifestations of neuroglycopenia did not correlate significantly with nadir plasma glucose or duration of hypoglycemia.

CONCLUSION

Moderately severe hypoglycemia of short duration can be neurologically occult, or subtle inattention can be its first and only clinical manifestation. Our findings are at variance with reports in the emergency medicine literature in which marked deficits are universally present at glucose concentrations equal to those attained in this study. This discrepancy suggests that the expression of neuroglycopenia is multifactorially determined and that plasma glucose concentration alone does not predict neurologic dysfunction in nondiabetic subjects with normal baseline neurologic examinations.

Feeding enhances extracellular lactate of local origin in the rostromedial hypothalamus but not in the cerebellum

The use of brain microdialysis together with chronic vascular catheterization allowed us to assay extracellular fluid lactate (ECFL) in both the ventromedial-paraventricular (VMH-PVN) area of the hypothalamus and the cerebellum, in parallel with measures of plasma levels, and in relation to food intake. A 45 min scheduled meal increased VMH-PVN ECFL by 28%. This increase was not observed in the cerebellum. The prandial increase in plasma glucose (43%, from 4.74 to 6.77 mM) and lactate (84%, from 0.83 to 1.53 mM) showed a different temporal pattern and lasted longer than that of the ECFL. Glucose delivery by reverse dialysis for 45 min into the VMH-PVN area increased ECFL by 49%. When local glucose utilization was prevented by reverse dialysis-delivered 2-deoxy-d-glucose (2-DG), not only did VMH-PVN ECFL drop, but the feed-related increase in ECFL was blocked without affecting the normal rise in plasma glucose and in lactate. These results indicate that meal-related ECFL production and variations are independent of circulating lactate, but may depend on substrate availability in these hypothalamic structures.

Adipose tissue in human infancy and childhood: an evolutionary perspective

Humans diverge from most mammals, including nonhuman primates, by depositing significant quantities of body fat in utero and are consequently one of the fattest species on record at birth. While explanations for the fat layer of human neonates have commonly assumed that it serves as insulation to compensate for hairlessness, empirical support for this hypothesis is presently weak. Whether the tissue's abundance at birth and growth changes in adiposity during infancy and childhood might be explained in light of its role as energy buffer has not been assessed, and this possibility is explored through development of a model of fat function and growth centered on two related hypotheses. The first is that the greater adiposity of human neonates is at least partially explainable as an accompaniment of the enlarged human brain, which demands a larger energy reserve to ensure that its obligatory needs are met when the flow of resources from mother or other caretakers is disrupted. The second is that age-related changes in the likelihood of experiencing such disruption have influenced the pattern of investment in the tissue, reflected today in peak adiposity during infancy and a decline to a leaner childhood period. Nutritional disruption is common at birth and until lactation is established, during which time human newborns survive from fats deposited prenatally, suggesting one possible explanation for the early onset of fat deposition. At weaning, the transition from breast milk to supplemental foods and the parallel transition from maternal to endogenous immune protection interact to increase the frequency and impact of nutritional disruption, and this may help explain why newborns devote roughly 70% of growth expenditure to fat deposition during the early postnatal months. Evidence is presented that fat stores are mobilized during infections, hinting at one possible mechanism underlying the association between nutritional status and infectious morbidity and mortality among infants in nutritionally stressed human populations. Consistent with the proposed hypothesis, well-fed infants acquire peak fat reserves by an age of peak prevalence of malnutrition, infectious disease, and fat reserve depletion in less-buffered contexts, and childhood--characterized by minimal investment in the tissue--is a stage of reduced risk of energy stress. The model presented here foregrounds energy storage in adipose tissue as an important life-history strategy and a means to modify mortality risk during the nutritionally turbulent period of infancy.

From malnutrition to refeeding during anorexia nervosa

Anorexia nervosa is one of the most common forms of malnutrition observed in Western society in individuals without physical diseases, with an average risk of mortality of 20% in a younger population aged between 15 and 25 years. It is characterised by an initial dramatic decrease in food intake that leads to profound depletion in muscle and fat mass. During the course of the disease, the resting energy expenditure decreases proportionally to the loss of lean body mass with a decrease in thyroid hormone secretion. The metabolic adaptation during anorexia nervosa is similar to that observed during starvation with a relative sparing of protein stores. After an initial weight loss, the total energy expenditure is similar to that in normal individuals, with a decrease in resting energy expenditure and an increased energy-related physical activity. At the end stage of wasting, however, physical activity dramatically decreases as well as energy intake. This metabolic adaptation of semi-starvation is impaired during refeeding with an increase in the thermic effect of food and a high risk of refeeding syndrome with severe hypophosphatemia.

Monocarboxylate transporter expression in mouse brain

Although glucose is the major metabolic fuel needed for normal brain function, monocarboxylic acids, i.e., lactate, pyruvate, and ketone bodies, can also be utilized by the brain as alternative energy substrates. In most mammalian cells, these substrates are transported either into or out of the cell by a family of monocarboxylate transporters (MCTs), first cloned and sequenced in the hamster. We have recently cloned two MCT isoforms (MCT1 and MCT2) from a mouse kidney cDNA library. Northern blot analysis revealed that MCT1 mRNA is ubiquitous and can be detected in most tissues at a relatively constant level. MCT2 expression is more limited, with high levels of expression confined to testes, kidney, stomach, and liver and lower levels in lung, brain, and epididymal fat. Both MCT1 mRNA and MCT2 mRNA are detected in mouse brain using antisense riboprobes and in situ hybridization. MCT1 mRNA is found throughout the cortex, with higher levels of hybridization in hippocampus and cerebellum. MCT2 mRNA was detected in the same areas, but the pattern of expression was more specific. In addition, MCT1 mRNA, but not MCT2, is localized to the choroid plexus, ependyma, microvessels, and white matter structures such as the corpus callosum. These results suggest a differential expression of the two MCTs at the cellular level.

Fasting in healthy individuals and adaption to undernutrition during chronic disease

During long-term fasting, gluconeogenesis from amino acids was thought to lessen, when ketone bodies from lipolysis became a major fuel source. Thus, muscle mass is conserved. However, recent studies show that this adaptation does not occur in chronic undernourishment. In cancer, chronic undernutrition without disease, and HIV infection, carbohydrate utilization is high. Enhanced hepatic glucose production occurs in active inflammatory bowel disease and in underweight cancer patients. Repletion of tissue after undernutrition is energetically inefficient because of enhanced diet induced thermogenesis (following anorexia nervosa) and decreased fat, and increased protein, oxidation (in tuberculosis).

Enzymes of ketone body utilization in human tissues: protein and messenger RNA levels of succinyl-coenzyme A (CoA):3-ketoacid CoA transferase and mitochondrial and cytosolic acetoacetyl-CoA thiolases

We describe the distribution in human tissues of three enzymes of ketone body utilization: succinyl-CoA:3-ketoacid CoA transferase (SCOT), mitochondrial acetoacetyl-CoA thiolase (T2), and cytosolic acetoacetyl-CoA thiolase (CT). Hereditary deficiency of each of these enzymes has been associated with ketoacidosis. Physiologically the two mitochondrial enzymes have different roles: SCOT mediates energy production from ketone bodies (ketolysis), whereas T2 functions both in ketogenesis and ketolysis. In contrast, CT is implicated in cytosolic cholesterol synthesis. We investigated the tissue distribution of these enzymes in humans by quantitative immunoblots and by Northern blots. In most tissues, polypeptide and mRNA levels were proportional. CT and T2 proteins were detected in all tissues examined. CT levels were highest in liver, were 4-fold lower in adrenal glands, kidney, brain, and lung, and were lowest in skeletal and heart muscles. T2 was most abundant in liver but substantial amounts were present in kidney, heart, adrenal glands, and skeletal muscle. SCOT was detected in all tissues except liver: myocardium > brain, kidney and adrenal glands. The relative amounts of T2 and SCOT were similar in all tissues except for liver (T2 > > SCOT) and brain (SCOT > T2). The observed distribution of SCOT, T2, and CT is consistent with current views of their physiologic roles.

Substrate signaling by insulin: a ketone bodies ratio mimics insulin action in heart

The administration of saturating doses of insulin to the glucose perfused, working rat heart acutely increased activity of the glucose transporter 4, GLUT 4, in the plasma membrane (equilibrating extracellular glucose and intracellular [glucose]), activated glycogen synthase (stimulating the rate of glycogen synthesis), and increased mitochondrial acetyl CoA production by the pyruvate dehydrogenase multienzyme complex. Unexpectedly, insulin increased cardiac hydraulic work but decreased net glycolytic flux and O2 consumption, improving net cardiac efficiency by 28%. These improvements in physiologic performance and metabolic efficiency resulted from reduction of the mitochondrial free [NAD+]/[NADH] and oxidation of mitochondrial [coenzyme Q]/[coenzyme QH2], increasing the energy of the proton gradient between cytosolic and mitochondrial phases and leading to a doubling of the cytosolic free [sigmaATP]/[sigmaADP][sigmaPi]. The acute metabolic effects of insulin were qualitatively duplicated by addition of a ratio of 4 mM D-beta-hydroxybutyrate and 1 mM acetoacetate, and the increase in the efficiency was the same as with addition of insulin. Addition of both insulin and ketones to the glucose perfusate increased the efficiency of cardiac hydraulic work by 35%. The ability of a physiologic ratio of ketone bodies to correct most of the metabolic defects of acute insulin deficiency suggests therapeutic roles for these natural substrates during periods of impaired cardiac performance and in insulin-resistant states.

Expression of monocarboxylate transporter MCT1 by brain endothelium and glia in adult and suckling rats

A polyclonal affinity-purified antibody to the carboxyl-terminal end of the rat monocarboxylate transporter 1 (MCT1) was generated in chickens and used in immunocytochemical studies of brain tissue sections from adult and suckling rats. The antibody identified a 48-kDa band on immunoblots and stained tissue sections of heart, cecum, kidney, and skeletal muscle, consistent with the reported molecular mass and cellular expression for this transporter. In tissue sections from adult brains, the antibody labeled brain microvessel endothelial cells, ependymocytes, glial-limiting membranes, and neuropil. In brain sections from 3- to 14-day-old rats, microvessels were much more strongly labeled and neuropil was weakly labeled compared with sections from adults. Immunoelectron microscopy indicated that labeling was present on both luminal and abluminal endothelial cell plasma membranes. These results suggest that MCT1 may play an important role in the passage of lactate and other monocarboxylates across the blood-brain barrier and that suckling rats may be especially dependent on this transporter to supply energy substrates to the brain.