Nonketotic diabetes mellitus: insulin deficiency or insulin resistance?

Therapeutic approaches to reducing insulin resistance in patients with noninsulin-dependent diabetes mellitus

Patients with noninsulin-dependent diabetes mellitus (NIDDM) are characterized by a loss of the normal ability of insulin to stimulate glucose uptake. The effects of diet, exercise, sulfonylurea compounds, and exogenous insulin on in vivo insulin-stimulated glucose uptake have been reviewed in this presentation. Although there is still a great deal to learn about the manner in which these various forms of treatment affect in vivo insulin action, the available information provides a rational framework for therapeutic attempts to enhance insulin sensitivity in patients with NIDDM.

Polymorphism in the 5' flanking region of the human insulin gene: a genetic marker for non-insulin-dependent diabetes

We sought to determine whether differences in the human insulin gene or its immediate flanking sequences could be found in diabetes. Peripheral leukocyte DNA from 217 unrelated persons, including blacks, whites, and Pima Indians, was analyzed by restriction-enzyme digestion, blotting to nitrocellulose filters, and hybridization to cloned [32P]insulin-gene probes. A region of length variation including deletions (0.1 to 0.2 kilobase pairs) or insertions (0.6 to 5.5 kb) of DNA was found only in the immediate 5' flanking region in 33 per cent of the genes examined. A 1.6-kb insertion accounted for 80 per cent of the polymorphism. This variant was found more often in subjects with non-insulin-dependent diabetes than in nondiabetics, regardless of race (P = 0.011). Length polymorphism in the 5' flanking region of the insulin gene may provide a genetic marker for non-insulin-dependent diabetes.

Basal insulin secretion increases with the onset of non-insulin dependent diabetes

Seven out of 206 subjects investigated at 6-mth intervals with a glucose tolerance test developed non-insulin dependent diabetes. The mean fasting serum C-peptide concentration in the diabetic subjects was greater at the time of diagnosis of diabetes than 6 mth prior to diagnosis (1.25 and 1.01 nmol/l respectively, p less than 0.05). There was no significant difference in mean ideal body weight and maximum post-glucose serum C-peptide reactivity (CPR) before and at diagnosis. There was no change in mean fasting CPR during a similar 6 mth period (0.84 and 0.84 nmol/l respectively) in 17 subjects with normal glucose tolerance matched with the diabetics for age and ideal body weight. It is postulated that at least in some subjects the transition to diabetes is accompanied by an increase in insulin resistance.

Insulin action and resistance in obesity and noninsulin-dependent type II diabetes mellitus

Resistance to the action of insulin can result from a variety of causes, including the formation of abnormal insulin or proinsulin molecules, the presence of circulating antagonists to insulin or the insulin receptor, or defects in insulin action at the target tissue level. Defects of the latter type are characteristic of obesity and of noninsulin-dependent diabetes mellitus. Analysis of the nature of the insulin resistance in those disorders has been investigated in intact subjects with the use of the euglycemic glucose clamp technique, and both insulin receptors and insulin-mediated glucose metabolism have been studied in adipocytes and monocytes from affected individuals. In both conditions, the cause of insulin resistance is heterogeneous. In some, insulin resistance appears to be due to a defect in the insulin receptor, whereas others have a defect both in the receptor and at the postreceptor level. In both groups, more severe insulin resistance is due to the postreceptor lesion and is correctable with appropriate therapy.

A new test of peripheral insulin sensitivity in vivo using artificial beta cell

A new in vivo test of insulin sensitivity is described. It utilizes closed-loop insulin delivery device (GCIIS, Biostator) capable of infusing glucose and insulin according to preselected algorithms. In euglycemic patients, insulin was infused by GCIIS to maintain euglycemia in the face of challenges with gradually increasing doses on intravenously administered glucose. Under the described experimental conditions, the endogenous insulin release was minimized as evidenced by serum C-peptide levels of less than 2 ng/ml, and thus the peripheral disposal of glucose should have depended entirely on the exogenous insulin. The amount of the insulin infused was considered to be a measure of peripheral insulin sensitivity. The test was applied to normal and non diabetic obese individuals, and to diabetics, both insulin dependent and independent. Significant insulin resistance was demonstrated in the obese and diabetic patients. In two obese females, the test was repeated after a prolonged period of starvation, and showed marked increase in insulin sensitivity. In two poorly controlled insulin dependent diabetics, marked increase in insulin sensitivity was also observed, here following a prolonged period of euglycemia (48 hours). It is concluded that the GCIIS controlled insulin sensitivity test is a simple, reliable test of peripheral insulin sensitivity, most convenient for clinical and experimental studies in vivo.

Effect of acute hyperglycaemia on plasma potassium and aldosterone levels in type 2 (non-insulin-dependent) diabetes

Potassium homeostasis during a 50-g oral glucose tolerance test was studied in 14 newly diagnosed, untreated Type 2 (non-insulin-dependent) diabetics. They showed a rise in plasma potassium from a mean +/- SEM basal of 3.9 +/- 0.1 to 4.4 +/- 0.1 mmol/l at 60 min and to 4.6 +/- 0.1 mmol/l at 90 min (p less than 0.01), whereas no change was seen in a group of 14 normal subjects. A possible role of mineralocorticoids was sought by measuring simultaneous serum aldosterone and deoxycorticosterone levels. Aldosterone was reduced after the glucose load in all subjects studied, falling to 73% of basal at 60 min in diabetics (p less than 0.01), and to 61% of basal at 90 min in normal subjects (p less than 0.001). Serum deoxycorticosterone showed a similar pattern. Thus it is unlikely that the rise in plasma potassium seen in the diabetic patients was due to abnormal levels of mineralocorticoids. Since the diabetic subjects were found to have an intact insulin response to the glucose load, it is suggested that resistance to insulin-stimulated potassium uptake into cells might be involved in the pathogenesis of the paradoxical hyperkalaemia induced by acute hyperglycaemia.

Receptor and postreceptor defects contribute to the insulin resistance in noninsulin-dependent diabetes mellitus

We have assessed the mechanisms involved in the pathogenesis of the insulin resistance associated with impaired glucose tolerance and Type II diabetes mellitus by exploring, by means of the euglycemic glucose-clamp technique, the in vivo dose-response relationship between serum insulin and the overall rate of glucose disposal in 14 control subjects; 8 subjects with impaired glucose tolerance, and 23 subjects with Type II diabetes. Each subject had at least three studies performed on separate days at insulin infusion rates of 40, 120, 240, 1,200, or 1,800 mU/M2 per min. In the subjects with impaired glucose tolerance, the dose-response curve was shifted to the right (half-maximally effective insulin level 240 vs. 135 microunits/ml for controls), but the maximal rate of glucose disposal remained normal. In patients with Type II diabetes mellitus, the dose-response curve was also shifted to the right, but in addition, there was a posal. This pattern was seen both in the 13 nonobese and the 10 obese diabetic subjects. Among these patients, an inverse linear relationship exists (r = -0.72) so that the higher the fasting glucose level, the lower the maximal glucose disposal rate. Basal rates of hepatic glucose output were 74 +/- 4, 82 +/- 7, 139 +/- 24, and 125 +/- 16 mg/M2 per min for the control subjects, subjects with impaired glucose tolerance, nonobese Type II diabetic subjects, and obese Type II diabetic subjects, respectively. Higher serum insulin levels were required to suppress hepatic glucose output in the subjects with impaired glucose tolerance and Type II diabetics, compared with controls, but hepatic glucose output could be totally suppressed in each study group. We conclude that the mechanisms of insulin resistance in patients with impaired glucose tolerance and in patients with Type II noninsulin-dependent diabetes are complex, and result from heterogeneous causes. (a) In the patients with the mildest disorders of carbohydrate homeostasis (patients with impaired glucose tolerance) the insulin resistance can be accounted for solely on the basis of decreased insulin receptors. (b) In patients with fasting hyperglycemia, insulin resistance is due to both decreased insulin receptors and postreceptor defect in the glucose mechanisms. (c) As the hyperglycemia worsens, the postreceptor defect in peripheral glucose disposal emerges and progressively increases. And (d) no postreceptor defect was detected in any of the patient groups when insulin's ability to suppress hepatic glucose output was measured.

Dose-response characteristics for effects of insulin on production and utilization of glucose in man

To determine the dose-response characteristics for the effects of insulin on glucose production, glucose utilization, and overall glucose metabolism in normal man, 15 healthy subjects were infused with insulin for 8 h at sequential rates ranging from 0.2 to 5.0 mU.kg-1.min-1; each rate was used for 2 h. Glucose production and utilization were measured isotopically ([3-3H]glucose). Tissue insulin receptor occupancy was estimated from erythrocyte insulin binding. Glucose production was completely suppressed at plasma insulin concentrations of approximately 60 microunits/ml. Maximal glucose utilization (10-11 mg.kg-1.min-1) occurred at insulin concentrations of 200-700 microunits/ml. The concentration of insulin causing half-maximal glucose utilization (55 + 7 microunits/ml) was significantly greater than that required for half-maximal suppression of glucose production (29 +/- 2 microunits/ml, P less than 0.01). Maximal effects of insulin on glucose production and utilization occurred at plasma insulin concentrations causing 11 and 49% insulin receptor occupancy, respectively. The above dose-response relationships indicate that in man 1) glucose production is more sensitive to changes in plasma insulin concentration than is glucose utilization; 2) both hepatic and peripheral tissues may contain "spare" insulin receptors; and 3) relatively minor changes in plasma insulin concentration or insulin receptor function can cause appreciable alterations in glucose metabolism.

Selective potentiation of insulin-mediated glucose disposal in normal dogs by the sulfonylurea glipizide

Investigative data have suggested that the extrapancreatic actions of the sulfonylureas may be paramount in their chronic antidiabetic action. The present study examines the effects of chronic sulfonylurea treatment on in vivo insulin action. Peripheral insulin levels, hepatic glucose production (Ra), and overall glucose disposal (Rd) were studied in six awake, normal dogs given both 0.5 and 1.0 mU/kg per min pork insulin for 2.5 h. This produces stable hyperinsulinemia from 15 to 150 min. Fasting euglycemia was held constant by the glucose clamp technique and averaged 99% basal glucose in all studies. Ra and Rd were determined from infusion of [3-(3)H]glucose, begun 90 min prior to insulin infusion. 10 mg of the sulfonylurea glipizide, was given daily to the test animals for the 10 to 20 d following appropriate control studies, then was withheld for 24 h, and the dogs were restudied. Glipizide treatment did not significantly alter basal glucose turnover, Ra, mean glucose values, or mean insulin levels as determined by radioimmunoassay. Increase in Rd above basal glucose turnover in response to insulin (delta Rd) was significantly (P less than 0.05) increased by glipizide treatment at both insulin dosage levels (paired analysis). At 1.0 mU/kg per min insulin, delta Rd rose from 2.6 mg/kg per min before glipizide to 6.5 mg/kg per min after glipizide treatment. At 0.5 mU/kg per min insulin, delta Rd went from 1.1 mg/kg per min before glipizide to 2.2 mg/kg per min after glipizide treatment. Glipizide treatment doubled the effects of insulin on Rd, while showing no significant effect upon insulin suppression of Ra. We conclude that a significant extrapancreatic chronic action of glipizide lies in its ability to selectively potentiate Rd.

Relationship between insulin resistance, insulin secretion, very low density lipoprotein kinetics, and plasma triglyceride levels in normotriglyceridemic man

We have previously postulated that resistance to insulin-mediated glucose uptake was the basic metabolic abnormality in patients with endogenous hypertriglyceridemia. In this situation, glucose tolerance would tend to deteriorate, and could only be maintained by the increased secretion of insulin. Although the ensuing hyperinsulinemia might prevent the development of glucose intolerance, we suggested that it would also lead to increased hepatic very low density (VLDL) triglyceride (TG) synthesis and secretion. In the current study we have quantified these four metabolic variables in 16 nonobese human subjects with plasma TG concentrations less than 175 mg/dl. The results demonstrate the following degree of correlation: insulin resistance (Formula: see text) insulin response to food (Formula: see text) VLDL-TG secretion rate (Formula: see text) plasma TG concentration. These data indicate that nonobese subjects with normal TG levels have the same relationship between degree of insulin sensitivity, insulin response to food, VLDL-TG secretion, and TG concentration previously described in patients with endogenous hypertriglyceridemia.

Mechanisms of insulin resistance in man. Assessment using the insulin dose-response curve in conjunction with insulin-receptor binding

During the past few years it has become increasingly apparent that insulin resistance may be a more frequent cause of carbohydrate intolerance or contributing factor in carbohydrate intolerance than was hitherto appreciated. Abnormal insulin action may result from prereceptor, receptor or postreceptor defects. These may be manifested by an increase in the concentration of insulin necessary for a half-maximal effect (decreased sensitivity) or a decrease in the maximal response to insulin (decreased responsiveness), or both. Alterations in sensitivity and responsiveness to insulin can be distinguished only by evaluating insulin dose-response curves. When used in conjunction with measurements of insulin binding to its receptor, the characteristics of these curves can provide insight into the mechanism or mechanisms responsible for insulin resistance.

Mechanisms of insulin resistance in obesity and noninsulin-dependent (type II) diabetes

Insulin resistance is a characteristic feature of both obesity and noninsulin-dependent diabetes mellitus. In general, the causes of insulin resistance can be placed into three categories: (1) abnormal beta cell secretory products, (2) circulating insulin antagonists, and (3) target tissue defects in insulin action. In obesity and in noninsulin-dependent diabetes mellitus, the cause of the insulin resistance resides at the level of the target tissue. However, the specific mechanisms underlying these insulin-resistant states are heterogeneous. Mechanisms of insulin resistance can be evaluated by constructing in vivo dose-response curves using the euglycemic glucose clamp technique. If dose-response curves are shifted to the right with no impairment in maximal insulin action, then this is termed a decrease in "insulin sensitivity" and is consistent with a pure defect in insulin receptors. If a decrease in maximal insulin action exists, then this is termed a decrease in "insulin responsiveness" and is consistent with a postreceptor defect in insulin action. In obese patients, cellular insulin receptors are decreased and the magnitude of this decrease is inversely related to the degree of hyperinsulinemia. In those patients with only moderate hyperinsulinemia, the insulin resistance is not severe. In these patients, the in vivo dose-response curve between plasma insulin levels and glucose disposal demonstrates a rightward shift with no change in maximal insulin responsiveness. Thus, in this situation, insulin resistance is due to decreased insulin receptors only. In obese patients with more severe insulin resistance, decreased maximal insulin responsiveness is also seen indicating a combined receptor and postreceptor defect. In patients with non-insulin-dependent diabetes mellitus, the same phenomenon is observed; i.e., those patients with mild insulin resistance have decreased insulin sensitivity due to decreased insulin receptors whereas those with severe insulin resistance have decreased insulin sensitivity and decreased insulin responsiveness due to a combined receptor and postreceptor defect. When the spectrum of patients is examined, a continuum of defects exists. In patients with mild insulin resistance, decreased insulin receptors are the only abnormality; in patients with severe insulin resistance, decreased numbers of insulin receptors and the postreceptor defect in insulin action coexist, but the postreceptor defect is the predominant abnormality. Between these extremes the relative roles of receptor defects and postreceptor defects vary, but the general trend is that as insulin resistance worsens, the postreceptor defect becomes more prominant.

Insulin release, insulin sensitivity, and glucose intolerance

Groups of subjects with different degrees of glucose intolerance were examined in order to determine, first, the capacity of the beta cells to release insulin upon glucose stimulation and, second, sensitivity to insulin. The groups were selected on the basis of fasting blood glucose value and tolerances to oral and intravenous glucose administration. The body weights, ages, and sexes of the subjects were well matched with those of control subjects with normal tolerances to oral and intravenous glucose administration. Computer analysis of the glucose and insulin curves during a standardized glucose infusion test made possible the measurement of the initiatory (parameters KI and IP) and potentiatory (parameter KP) effects of glucose on insulin release and of the sensitivity to endogenous insulin (parameter KG). In subjects with impaired oral but normal intravenous glucose tolerance tests, KG was decreased, KP was increased, and KI and IP were normal. However, in these subjects, KI and IP were considerably lower than in a matched group of control subjects with the same decrease in KG but with normal oral and intravenous glucose tolerance tets. In subjects in which both oral and intravenous glucose tolerance tests were impaired and in subjects with mild manifest diabetes, KI, IP, and KG were decreased whereas KP was normal. These data suggest that all stages of glucose intolerance are accompanied by a decreased ability of glucose to initiate insulin release and by decreased sensitivity to insulin. These derangements seem to be partially compensated for by enhancement of the capacity of glucose to potentiate insulin release in subjects with decreased oral but normal intravenous glucose tolerance tests.

In vitro metabolic effects of gliclazide and glibenclamide in the rat

The actions of gliclazide and glibenclamide on glucose uptake and glycogen deposition by rat hemidiaphragm and glucose utilization by rat epididymal adipose tissue have been examined in vitro. Neither drug exerted an insulin-like action on muscle or adipose tissue with respect to glucose uptake, glycogen deposition or glucose utilization. Neither gliclazide nor glibenclamide augmented the stimulating action of insulin on glucose uptake or glycogen deposition in the rat hemidiaphragm. In a high concentration (1 microgram ml-1), but not in lower concentrations, glibenclamide enhanced the action of insulin in stimulating glucose utilization by rat epididymal adipose tissue. Gliclazide was without any significant effect. Twenty eight day oral treatment with gliclazide did not increase basal or insulin-stimulated glucose uptake or glycogen deposition in rat hemidiaphragm muscle or glucose utilization by epididymal adipose tissue. It is concluded that in normal rats sulphonylureas do not exert important insulin-like actions or insulin potentiating effects.

Reversible mild diabetes in children after treatment with chlorpropamide

In 9 patients with juvenile-onset chemical diabetes treated with oral chlorpropamide, oral or intravenous assessments of carbohydrate tolerance were made regularly three weeks after withdrawal of therapy. 6 patients with sequential intravenous tests achieved statistically significant reversal of their carbohydrate intolerance and have remained normal for an average of 5.6 years (range 1-11 years). 2 patients who subsequently required insulin therapy were maintained in remission for 3.5 years and 5 years, respectively. There appears to be a group of young patients with chemical diabetes who achieve significant remission with sulphonylurea therapy.

Therapy of insulin-independent diabetes mellitus: general considerations

Rational approaches to the therapy of patients with insulin-independent diabetes should be based on correcting the underlying defects. The major metabolic abnormalities present in patients with insulin-independent diabetes are: (1) impaired insulin action, (2) defective glucose-mediated insulin secretion, and (3) hyperglucagonemia. All of these defects could be due to a generalized plasma membrane abnormality that affects insulin and glucose receptors or to a generalized disturbance in postreceptor insulin action. Insulin action may be increased by sulfonylureas, possibly by alterations in intracellular cyclic AMP content, or by weight-reducing diets. Insulin secretion may be increased by gastrointestinal hormones, sulfonylureas, serotonin antagonists, or weight-reducing diets. Individual patients with insulin-independent diabetes have varying degrees of insulin resistance or impaired glucose-mediated insulin secretion. The use of therapeutic agents to correct the predominant defect should provide the most effective means of controlling the hyperglycemia and glucose intolerance of the individual patient.

Insulin secretion improves following dietary control of plasma glucose in severely hyperglycemic obese patients

Severely hyperglycemic obese patients show deficient insulin secretion as well as insulin resistance. To determine whether the secretory defect is reversible, we placed 7 hospitalized patients on severe caloric restriction for 4--12 wk. Insulin secretory responses to oral glucose and intravenous tolbutamide were assessed before and after the diet. On entry, mean fasting plasma glucose (FPG) was 326 +/- 23 mg/dl. The insulin response to oral glucose was completely flat, although modest secretion was evoked by tolbutamide. After initiating caloric restriction, FPG rapidly fell, reaching 150 +/- 21 mg/dl by 2 wk, and remained low throughout the duration of the diet period. At restudy, improved oral glucose tolerance was accompanied by significant increases in the insulin secretory responses to both glucose and tolbutamide. These results support the concept that control of plasma glucose concentration allows recovery of insulin secretion. The degree of weight loss necessary to achieve this effect was modest. Since blood glucose was effectively controlled by caloric restriction alone, exogenous insulin is probably not required in the initial management of most obese patients with severe hyperglycemia.

Diabetes due to secretion of an abnormal insulin

A 51-year-old, nonobese man with diabetes mellitus had marked hyperinsulinemia (70 to 120 muU per milliliter; 502 to 860 pmol per liter) and fasting hyperglycemia (140 to 170 mg per 100 ml; 7.8 to 9.4 mmol per liter). Plasma proinsulin, glucagon, growth hormone, and cortisol levels were normal; insulin antibodies and insulin-receptor antibodies were not detected. The patient showed relatively normal insulin sensitivity, and insulin receptors on circulating monocytes were within the normal range. Insulin from the patient's serum bound to IM-9 lymphocytes and rat adipocytes approximately 40 per cent as well as insulin standards. Its biologic activity on rat adipocytes averaged 15 per cent of that expected from its immunologic concentration. The impaired biologic activity of this patient's circulating insulin was probably due to a structural abnormality. Subsequent studies of the patient's insulin (fortuitously obtained from his pancreas during a laparotomy for a pancreatic cyst) have confirmed this conclusion. (N Engl J Med 302:129-135, 1980).

Extrapancreatic action of sulphonylureas: effect of gliquidone on insulin and glucagon binding to rat liver plasma membranes

Gliquidone (a second generation sulphonylurea) was administered orally to normal rats 1 h before killing. Gliquidone treatment led to a decrease in plasma glucose, an increase in insulin and a diminution in glucagon concentration. Insulin binding to liver plasma membranes was enhanced by 40% in comparison with controls, whereas glucagon binding was slightly diminished. These findings indicate a greater sensitivity of liver cells to insulin during sulphonylurea treatment and support the view that sulphonylureas potentiate insulin action on the liver.

Insulin deficiency and insulin resistance interaction in diabetes: estimation of their relative contribution by feedback analysis from basal plasma insulin and glucose concentrations

The liver and beta cells function in a negative feedback loop, which appears to have a predominant role in regulating both the basal plasma glucose and insulin concentrations. The degree of basal hyperglycemia in diabetes probably provides a bioassay of both the effect of a reduction in insulin secretory capacity and the degree of insulin resistance. A mathematic model of the interaction of insulin deficiency and insulin resistance has been constructed, based on the known response characteristics of the beta cells to glucose, and of plasma glucose and insulin control of hepatic and peripherpal glucose flux. The degree to which beta cell deficiency increases basal plasma glucose reflects the hyperbolic shape of the normal insulin secretory response to different glucose concentrations. The height of basal plasma insulin is a function of the degree of insulin resistance. From the basal plasma insulin and glucose concentrations, the model provides an estimate of the degree to which both beta cell deficiency and insulin resistance contribute to diabetes. The predictions arising from the model are in accord with experimental data in man and in animals. In normal-weight diabetics who do not have increased insulin resistance, the model predicts that more than 85% of beta cell function has to be lost for the basal plasma glucose to rise to 6 mmol/liter, but a further 5%--10% loss increases the basal plasma glucose to over 10 mmol/liter. In a third of a consecutive series of 65 newly presenting, uncomplicated diabetics, both normal weight and obese, the analysis from the model suggested that insulin resistance, rather than beta cell deficit, was the predominant feature.

Glucose clamp technique: a method for quantifying insulin secretion and resistance

Methods for the quantification of beta-cell sensitivity to glucose (hyperglycemic clamp technique) and of tissue sensitivity to insulin (euglycemic insulin clamp technique) are described. Hyperglycemic clamp technique. The plasma glucose concentration is acutely raised to 125 mg/dl above basal levels by a priming infusion of glucose. The desired hyperglycemic plateau is subsequently maintained by adjustment of a variable glucose infusion, based on the negative feedback principle. Because the plasma glucose concentration is held constant, the glucose infusion rate is an index of glucose metabolism. Under these conditions of constant hyperglycemia, the plasma insulin response is biphasic with an early burst of insulin release during the first 6 min followed by a gradually progressive increase in plasma insulin concentration. Euglycemic insulin clamp technique. The plasma insulin concentration is acutely raised and maintained at approximately 100 muU/ml by a prime-continuous infusion of insulin. The plasma glucose concentration is held constant at basal levels by a variable glucose infusion using the negative feedback principle. Under these steady-state conditions of euglycemia, the glucose infusion rate equals glucose uptake by all the tissues in the body and is therefore a measure of tissue sensitivity to exogenous insulin.

Insulin responsiveness of adipose tissue from normal weight subjects with early diabetes

In normal weight subjects, classified by a 2-h glucose infusion test as having normal (11), borderline (3) or pathological (9) carbohydrate tolerance (CHT), subcutaneous adipose tissue was removed under intracutaneous anesthesia by surgical biopsy. The biological responsiveness of isolated adipocytes as well as adipose tissue fragments measured as incorportion of (1-14C) glucose into CO2 or triglycerides was studied in the absence or presence of different insulin concentrations. In persons with normal CHT the insulin-stimulated (62.5 microU/ml) glucose conversion to CO2 by adipocytes as well as fat pads increased significantly up to 156 +/- 14% and 285 +/- 30%, respectively. Insulin enhanced the glucose incorporation into triglycerides up to 154 +/- 20% (fat cells) and 258 +/- 30% (fat pads) in adipose tissue from subjects displaying a normal CHT. Rates of glucose oxidation and triglyceride synthesis was markedly reduced in adipose tissue obtained from patients with borderline or pathological CHT. A significant positive relationship was found between glucose oxiation to CO2 and triglyceride production of fat cells and fat pads (r = 0.964 and 0.783, respectively). There was no correlation with responsiveness of adipose tissue to insulin and insulin secretion during glucose infusion test. The results indicate that sensitivity to insulin of target cells might be important for the development of carbohydrate intolerance also in normal weight subjects.

The effect of aging on carbohydrate metabolism: a review of the English literature and a practical approach to the diagnosis of diabetes mellitus in the elderly

There seems little doubt that the disposal of a glucose load is progressively impaired during aging. The mechanism(s) for this alteration remains unclear. Five possibilities have been raised: (1) poor diet, (2) physical inactivity, (3) decreased lean body mass in which to store the carbohydrate load, (4) decreased insulin secretion, and (5) insulin antagonism. Although poor diet and physical inactivity may contribute to some of the abnormal glucose tolerance tests of the older population, these two factors do not provide a full explanation. Diminished lean body mass may play some role but there is almost certainly an additional effect due to aging. A few papers have suggested that glucose-induced insulin secretion may be impaired as the population ages, but the bulk of studies in this area conclude that normal or increased amounts of insulin are released by the pancreatic beta-cell during aging. If abnormalities of insulin secretion exist, either in degree or timing, they are subtle and would not seem sufficient to account for the great number of older subjects who manifest impaired glucose tolerance. The evidence for insulin antagonism seems the strongest but the data are certainly not conclusive. In actuality, the aging effect on carbohydrate metabolism may be heterogeneous in nature. Either some or all of these five factors may contribute to the aging effect to varying degrees in individual subjects. Alternatively, the glucose intolerance of aging may represent a heterogeneous group of disorders. In any event, until better methods to identify possible subgroups of these subjects and/or a marker for diabetes mellitus independent of glucose concentration become available, this problem will remain difficult to resolve. Based on the currently available data, it seems prudent to diagnose diabetes mellitus only if fasting hyperglycemia is present.

Cachexia of malignancy: potential role of insulin in nutritional management

Patients manifesting the syndrome of cachexia of malignancy exhibit an abnormal diabetic glucose tolerance. In our patients this has been correlated with a marked resistance to administered insulin, while insulin receptors on monocytes are normal. Lipolysis remains responsive to the effects of insulin. The oxidation of FFA, as a substrate for metabolism, has been reported to be increased, and the utilization of glucose as a metabolic fuel is reduced. Increased Cori cycle activity has been demonstrated, which produces an enhanced gluconeogenesis from lactate and amino acids; there is an expenditure of 6 ATP for the synthesis of each mole of glucose. An attempt to interrupt the Cori cycle in man, using hydrazine sulfate to inhibit the enzyme phosphoenolpyruvate carboxykinase, has not resulted in reproducible clinical benefit. However, successful treatment of the underlying tumor may produce a total reversal of the cachexia syndrome, suggesting that neoplasms have the potential to elaborate an, as yet, unidentified metabolic toxin. The use of insulin to counteract the reported abnormalities should be examined as a possible supportive measure in the total nutritional management of the cancer patient.

Insulin resistance in patients with insulin independent diabetes mellitus: partial amelioration by the sulfonylurea glipizide

Studies in patients with insulin independent diabetes indicate that treatment with the second generation sulfonylurea glipizide results in partial amelioration of their insulin resistance and that this effect is significant in glipizide's antidiabetic action.

Reduced chromium retention in patients with hemochromatosis, a possible basis of hemochromatotic diabetes

Chromium (III) has recently been shown to be an essential trace mineral in rats, being required for normal function of insulin in controlling glucose metabolism. Chromium is transported in the body bound to transferrin, where it binds competitively with iron. Hemochromatosis is an iron storage disease in humans characterized by highly saturated transferrin levels and sometimes by diabetes. We postulated that the diabetes may be due to exclusion of chromium by iron at metabolic binding sites. 51Cr(III) was administered i.v. to 5 normal males, 6 patients with hemochromatosis prior to therapeutic removal of iron, and 5 patients with varying levels of iron loading. The retention of 51Cr was measured with a whole-body counter for 8 mo and blood levels were measured for 40--80 days. Analysis of the whole-body retention curves revealed 3 exponential components with T1/2s of .56 days, 12.7 days, and 192 days; the blood curves had 4 components with T1/2s of 13 min; 6.3 hr, 1.9 days, and 8.3 days. The T1/2s were not significantly different between the normals and patients. The coefficients of these components however, were significantly lower for the long T1/2 components in the iron-loaded patients, demonstrating reduced retention of 51Cr as postulated. Whether this reduced retention of chromium is causally related to diabetes in hemochromatosis and whether abnormal chromium metabolism is involved in endogenous diabetes, thus, becomes an important question for future study.

Pathogenesis of glucose intolerance in uremia

The pathogenesis of glucose intolerance in uremia was examined with the glucose clamp technique. Hyperglycemic clamp (n = 8): The plasma glucose concentration is acutely raised and maintained at 125 mg/dl above basal levels. Under these steady state conditions the glucose infusion rate, M, equals the amount of glucose metabolized: Predialysis M averaged 4.23 +/- 0.36 mg/kg/min and increased to 7.71 +/- 0.43 postdialysis (p less than 0.001). The plasma insulin response predialysis was 90 +/- 20 microU/ml and decreased to 80 +/- 23 microU/ml following dialysis. Consequently the M/l ratio, a measure of tissue sensitivity to insulin, increased by 80% +/- 25% (p less than 0.001) but still remained less than controls (p less than 0.01). Euglycemic insulin clamp (n = 10): The plasma insulin concentration is acutely raised by 100 microU/ml and the plasma glucose concentration is held constant at the basal level. Predialysis both M (3.37 +/- 0.36 mg/kg/min) and M/l (3.56 +/- 0.33 mg/kg/min per microU/ml X 100) were significantly less than controls (p less than 0.01). Postdialysis both M and M/l increased significantly (p less than 0.01) to a mean that was not significantly different from controls. Basal hepatic glucose production (n = 6), 2.15 +/- 0.09 mg/kg/min, was similar to controls and fell (87% +/- 4%) normally during the insulin clamp. In five uremic subjects in wom insulin binding to monocytes was measured, there was no correlation with tissue sensitivity to insulin (M/l). Significant abnormalities in both growth hormone and glucagon physiology were present in uremic individuals, but no correlation with either the presence or degree of glucose intolerance was demonstrable. In conclusion, glucose intolerance is universally present in uremic subjects and results primarily from peripheral tissue insensitivity to insulin. Insulin secretion is usually enhanced in an attempt to compensate for this insulin resistance but in occasional subjects uremia also inhibits beta cell sensitivity to glucose. Hepatic glucose production is unaffected by uremia. The lack of correlation between insulin binding and tissue sensitivity to insulin suggests that the cellular mechanism accounting for the insulin resistance is probably the result of a defect in intracellular metabolism or in the glucose transport system.

Modeling of plasma disappearance of unlabeled insulin in man

Fifty-two portal and 68 peripheral, brief infusions of unlabeled insulin were given to ambulant, nondiabetic patients. After intraportal insulin infusion (5--50 mU/kg), plasma clearance rate (PCR, dose/area of the incremental plasma insulin concentrations) decreased with increasing dose, varying from 32 to 14 ml-min-1-kg-1 at normoglycemia. After peripheral insulin infusion (5--30 mU/kg), PCR (mean value 15 ml-min-1-kg-1) showed no certain dose-dependence, but transfer rate constants and distribution volumes did. Despite a detectable reentry of insulin from one or more extravascular pools to the plasma pool, transfer rate constants or distribution volumes could not be accurately determined. The shortcomings of conventional noncompartmental and compartmental models did not appear to be due to the dose-dependence demonstrated. Instead, the limitations of these models were caused mainly by the difficulty of defining a proper base-line concentration and, in particular, by the imprecision of the experimental data, indicating that it will be difficult to find more appropriate models from data obtained with unlabeled insulin.

The effect of ten days of fasting on various aspects of carbohydrate metabolism in obese diabetic subjects with significant fasting hyperglycemia

Patients with nonketotic diabetes mellitus, who were both obese and had significant fasting hyperglycemia (mean plasma glucose = 310 mg/100 ml), were fasted for 10 days. There was a prompt drop of plasma glucose levels as the result of the caloric deprivation with a mean fall of approximately 200 mg/dl at the end of the fast. The drop in plasma glucose level that occurred during the fast was associated with a drop in plasma insulin level. Fasting plasma glucose concentration rose immediately after food intake was resumed and stabilized within 3--4 days at levels halfway between the initial and the lowest value. At this time, the patients also seemed capable of disposing of an oral glucose load more efficiently. The apparent improvement in carbohydrate homeostasis observed after the fast could not be attributed to an increase in insulin response, but was associated with some amelioration of the insulin resistance that characterizes these patients. Unfortunately, the beneficial effects of the 10-day period of caloric deprivation were transitory and fasting plasma glucose values had returned to prefast levels in most patients within a few months.

Ability of circulating insulin to chronically regulate the cellular glucose transport system

We have tested the idea that the circulating plasma insulin level plays an important role in the long-term regulation, or maintenance, of the cellular glucose transport system, distinct from insulin's ability to acutely accelerate glucose transport. To study this hypothesis, groups of rats were made either hyperinsulinemic or hypoinsulinemic by daily insulin injections or Streptozotocin treatment, respectively. Different levels of hypoinsulinemia were produced by using different doses of Streptozotocin (40 and 55 mg/kg). Isolated adipocytes were prepared from each animal and glucose transport was assessed by measuring the initial rates of uptake of the nonmetabolyzable hexose 2-deoxy glucose. In cells from control animals, the Vmax of in vitro adipocyte glucose transport was 7.1 +/- 0.7 nmole/min/10(6) cells in the basal state and 22.9 +/- 0.9 nmole/min/10(6) cells in the presence of a maximally effective insulin concentration (25 ng/ml) in the buffer. In cells from the experimentally hyperinsulinemic animals, these Vmax values were increased to 11.7 +/- 0.8 and 44.2 +/- 1.1 nmole/min/10(6) cells. Using adipocytes from both groups of Streptozotocin treated (high dose, 55 mg/kg, low dose, 40 mg/kg) insulin deficient diabetic animals, Vmax values were found to be progressively decreased. Thus, in the low dose group, basal and insulin stimulated Vmax values were 1.6 +/- 0.5 and 5.7 +/- 0.7 nmole/min/10(6) cells, as compared to values of 0.9 +/- 0.2 and 1.7 +/- 0.6 in the high dose group. Furthermore, when hyperinsulinemia was induced by feeding rats high carbohydrate diets for 10 days, adipocyte glucose transport Vmax increased 50%. In contrast, when hypoinsulinemia was achieved by fasting rats for 72 hr, transport Vmax decreased by 50%. The apparent Km for 2-deoxy glucose uptake was the same under all conditions. In conclusion, assuming that the Vmax of transport is some function of the number of glucose transport carriers per cell, then these results support the hypothesis that in addition to acute acceleration of glucose transport, insulin is also an important long-term regulator of the number of available adipocyte glucose transport carriers.

Lack of a gastrointestinal mediator of insulin action in maturity-onset diabetes

It is suggested that hepatic uptake of orally ingested glucose depends not only on insulin secretion but also on the release of a gastrointestinal factor which mediates insulin action on the liver. In maturity-onset diabetes characterised by hyperinsulinaemia and insulin resistance, deficiency of this gastrointestinal factor may be the primary pathogenetic event leading to postprandial hyperglycaemia. Postprandial hyperglycaemia brings about an increase in insulin secretion; and hyperinsulinaemia, in turn, results in decreased binding of insulin to its receptor and in peripheral (extrahepatic) resistance to insulin.

Pathophysiology of diabetes mellitus

Techniques have been developed for examining the binding of insulin to its target cells and for evaluating the in vivo action of insulin, rekindling interest in the possible role of insulin resistance in adult-onset diabetes. A host of new data have accumulated regarding the contribution of glucagon to the syndrome.

Long-term regulation of adipocyte glucose transport capacity by circulating insulin in rats

We have tested the idea that the circulating plasma insulin level plays an important role in the long-term regulation, or maintenance, of the cellular glucose transport system, distinct from insulin's ability to acutely accelerate glucose transport. To study this hypothesis, groups of rats were made either hyperinsulinemic or hypoinsulinemic by daily insulin injections, or streptozotocin treatment, respectively. Different levels of hypoinsulinemia were produced by using different doses of streptozotocin (40 and 55 mg/kg). The mean (+/-SE) 9 a.m. plasma insulin level for each experimental group was: hyperinsulinemic animals, 65+/-5 muU/ml; controls, 32+/-3 muU/ml; low dose streptozotocin group, 18+/-3 muU/ml; and high dose streptozotocin group 5+/-2 muU/ml. Isolated adipocytes were prepared from each animal and glucose transport was assessed by measuring the initial rates of uptake of the nonmetabolyzable hexose 2-deoxy glucose. The V(max) and K(m) values for adipocyte glucose transport were calculated from the 2-deoxy glucose uptake data. The results demonstrated that in cells from control animals the V(max) of in vitro adipocyte glucose transport was 7.1+/-0.7 nmol/min per 10(6) cells in the basal state and 22.9+/-0.9 nmol/min per 10(6) cells in the presence of a maximally effective insulin concentration (25 ng/ml) in the buffer. In cells from the experimentally hyperinsulinemic animals these V(max) values were increased to 11.7+/-0.8 and 44.2+/-1.1 nmol/min per 10(6) cells. Using adipocytes from both groups of streptozotocin-treated (high dose, 55 mg/kg; low dose, 40 mg/kg) insulin-deficient diabetic animals, V(max) values were found to be progressively decreased. Thus, in the low dose group, basal-and insulin-stimulated V(max) values were 1.6+/-0.5 and 5.7+/-0.7 nmol/min per 10(6) cells, as compared to values of 0.9+/-0.2 and 1.7+/-0.6 in the high dose group. Thus, when considered as group data a positive relationship was found between circulating plasma insulin levels and adipocyte glucose transport V(max), with increased V(max) values in hyperinsulinemic rats and decreased V(max) values in hypoinsulinemic rats. Furthermore, when the individual data were analyzed, highly significant correlation coefficients were found between the height of the plasma insulin level and both the basal (r = 0.82, P < 0.001) and insulin-stimulated (r = 0.93, P < 0.001) V(max) values. The apparent K(m) for 2-deoxy glucose uptake was the same under all conditions. In conclusion, assuming that the V(max) of transport is some function of the number of glucose transport carriers per cell, then these results support the hypothesis that in addition to acute acceleration of glucose transport, insulin is also an important long-term regulator of the number of available adipocyte glucose transport carriers.

Development of insulin resistance in normal dogs following alloxan-induced insulin deficiency

Insulin resistance was measured in 16 normal dogs by a method involving the continuous intravenous infusion of epinephrine, propranolol, glucose and insulin. With this approach, endogenous insulin secretin is inhibited, similar steady state levels of exogenous insulin are achieved in all doags, and the resultant steady state plasma glucose level provides a direct estimate of the ability of insulin to dispose of the infused glucose load. Thus, the higher the steady state plasma glucose level, the more the insulin resistance. Different amounts of alloxan were then administered to these dogs in order to produce insulin deficiency of varying degrees. Insulin resistance was then measured again in each dog. The results indicated that insulin resistance did not develop in dogs with only a moderate degree of insulin deficiency (fasting plasma glucose levels less than 150 mg/100 ml). On the other hand, a significant degree of insulin resistance developed in dogs with severe insulin deficiency (fasting plasma glucose greater than 150 mg/100 ml). Furthermore, the insulin resistance that developed in dogs with severe insulin deficiency could be returned to normal with insulin replacement for one week. These results indicate that insulin resistance can occur as a secondary manifestation of insulin deficiency.

Glucagon and diabetes. II. Complete suppression of glucagon by insulin in human diabetes

In order to determine whether glucagon levels of diabetic subjects are suppressible, alpha cell responsiveness to acute insulin administration (0.1 units/kg intravenously) was determined in fourteen juvenile onset, healthy diabetic and eight control subjects. In the diabetics, insulin produced a significant but slow fall in blood glucose over 60 min (P less than 0.01). On the other hand, glucagon levels fell dramatically in all diabetics to undetectable levels (P less than 0.001). Only one diabetic became hypoglycaemic and he alone showed a rebound rise of glucagon at 60 min. The rate of fall of blood glucose in the diabetic subjects was not influenced by the basal glucagon level (r=0.13) or the rate of fall of plasma glucagon (r=0.04). The glucose and glucagon responses of control subjects to insulin administration were in sharp contrast to the diabetics: blood glucose levels fell rapidly to hypoglycaemic levels and were associated with a major rise in glucagon levels (mean rise 116 pmol/1, P less than 0.001). We conclude that alpha cell hyperfunction in human diabetes can be completely suppressed by insulin administration and is therefore not autonomous, and that the slow rate of fall of blood glucose following insulin administration in diabetics is not secondary to glucagon excess.

Glucagon levels in normal and diabetic subjects: use of a specific immunoabsorbent for glucagon radioimmunoassay

Non-specific plasma effects may produce major errors in the estimation of true plasma pancreatic glucagon concentrations by radioimmunoassay. This has been circumvented by the production of glucagon-free plasma for each individual investigated, by means of glucagon antibody, coupled to sepharose beads. True fasting pancreatic glucagon levels (mean+/-SEM) in 18 healthy subjects (24+/-3 pg/ml) were significantly lower (p less than .005) than in 10 non-ketotic non-obese diabetics (38+/-3 pg/ml). It is suggested that, in the presence of decreased insulin-effect in the diabetic, this 55% glucagon elevation in diabetics may be of biological importance and contribute to the fasting hyperglycaemia.