Insulin and lipoprotein metabolism with special reference to the diabetic state

Cardiovascular risk in Gullah African Americans with high familial risk of type 2 diabetes mellitus: project SuGAR

OBJECTIVES

To determine the prevalence of cardiovascular disease, levels of cardiovascular risk factors, and extent of preventive care in Gullah African Americans with a high familial risk of type 2 diabetes mellitus.

METHODS

Between 1995 and 2003, 1321 Gullah African Americans with a high prevalence of diabetes mellitus from the South Carolina Sea Islands consented to and enrolled in the Sea Islands Genetic African American Registry (Project SuGAR). A cross-sectional analysis of cardiometabolic risk, preventive care, and self-reported cardiovascular disease was conducted.

RESULTS

Cardiometabolic risk factor levels were high and vascular disease was prevalent. Among the subjects with diabetes mellitus, the mean disease duration was 10.5 years; approximately one-third reported reduced vision or blindness; and >80% reported numbness, pain, or burning in their feet. Preventive diabetes care was limited, with <60%, <25%, and <40% seeing an ophthalmologist, podiatrist, and dentist, respectively, within the past year. Only 54.4% of women and 39.3% of men reported daily glucose monitoring.

CONCLUSIONS

As the largest existing study of Gullah individuals, our study offers insight into not only the level of cardiovascular risk in this population but also the pathophysiological mechanisms central to ancestral differences in cardiometabolic risk in the broader African American population.

Vitamin C may have similar beneficial effects to Gemfibrozil on serum high-density lipoprotein-cholesterol in type 2 diabetic patients

Objective:

Type 2 diabetes mellitus (DM-T2) is commonly associated with increased triglycerides (TG), low-density lipoprotein cholesterol (LDL-C) and low high-density lipoprotein cholesterol (HDL-C) levels. Fibrates like gemfibrozil are frequently used in diabetic patients to decrease TG and increase HDL-C levels. We compared the efficacy of Vitamin C, an antioxidant vitamin, with gemfibrozil on serum HDL-C in diabetic patients.

Methods:

Type 2 diabetic patients, referred to our out-patient clinic were randomly divided into three groups. After 1 month of lifestyle and diet modifications, groups A, B, and C were prescribed 1000 mg Vitamin C, 600 mg gemfibrozil and combination of both, respectively. Before the study initiation and after 6^th week of drug prescription, the blood samples were taken and analyzed for total cholesterol (Total-C), HDL-C, TG, fasting blood sugar (FBS), and hemoglobin A1c (HbA1c) levels.

Findings:

Sixty-seven patients entered, and 50 patients (18 male, 32 female) finished the study. Overall, serum HDL-C increased significantly from 39.8 to 45.2 mg/dL in the participants (P = 0.001). HDL-C increased 6.3, 4.4 and 5.0 mg/dL in groups A, B and C, respectively (related significances were 0.017, 0.022 and 0.033, respectively). Significant decrease of serum TG and Total-C occurred in gemfibrozil and combination groups, but not in Vitamin C group. Changes in serum HDL-C between three groups were not significant (P = 0.963). We found a significant decrease in TG and Total-C in the groups B and C (P < 0.05), but no significant changes of TG, Total-C, LDL-C, FBS and HbA1c in group A (P > 0.05).

Conclusion:

The results demonstrated that Vitamin C may have beneficial effects on HDL-C in diabetic patients without significant effects on plasma glucose or other lipid parameters; however, its role for the treatment of low HDL-C patients should be evaluated in larger studies.

Low serum apolipoprotein A1/B ratio is associated with proliferative diabetic retinopathy in type 2 diabetes

BACKGROUND

The association between lipids and diabetic retinopathy (DR) remains unclear. Only a few studies have reported the association between proliferative diabetic retinopathy (PDR) and the serum concentrations of apolipoprotein A1 (apoA1), apolipoprotein B (apoB) and apolipoprotein E (apoE). So we investigated the lipid profile in type 2 diabetic patients of long duration with very mild nonproliferative diabetic retinopathy (NPDR) or PDR.

METHODS

Serum samples were obtained from 25 type 2 diabetic patients with very mild NPDR and 25 type 2 diabetic patients with PDR, and the two groups were matched by diabetes duration and glycosylated hemoglobin (HbA(1c)) levels. The levels of total cholesterol, triglycerides, LDL cholesterol, HDL cholesterol, apoA1, apoB, and apoE were measured by enzymatic colorimetric, surfactant, and immunotubidimetric method.

RESULTS

Compared with PDR subjects, very mild NPDR subjects were characterized by increased HDL cholesterol (P = 0.0433) and apoA1 (P = 0.0290) levels, higher HDL cholesterol/LDL cholesterol (P = 0.0377) and apoA1/apoB (P = 0.0061) ratio in serum. There were significant associations between the decreased apoA1 and low apoA1/apoB ratio in serum and PDR. Even after adjustment for age, decreased apoA1 level (P = 0.0304) and low apoA1/apoB ratio (P = 0.0218) in serum were significantly associated with PDR in type 2 diabetic patients of over 15 years' duration.

CONCLUSIONS

Low apolipoprotein A1/apolipoprotein B ratio in serum was associated with PDR in type 2 diabetic patients of long duration.

Acute pancreatitis due to diabetes: the role of hyperglycaemia and insulin resistance

BACKGROUND

The co-existence of diabetes mellitus (DM) in patients with acute pancreatitis (AP) is linked to poor outcomes. Four large epidemiological studies have suggested an aetiological role for DM in AP. The exact nature of this role is poorly understood.

OBJECTIVE

To analyse the available clinical and experimental literature to determine if DM may play a causative role in AP.

METHODS

A systematic search of the scientific literature was carried out using EMBASE, PubMed/MEDLINE, and the Cochrane Central Register of Controlled Trials for the years 1965-2011 to obtain access to all publications, especially randomized controlled trials, systematic reviews, and meta-analyses exploring the mechanisms of pathogenesis of AP in patients with DM.

RESULTS

No clinical studies could be identified directly providing pathogenetic mechanisms of DM in the causation of AP. The available data on DM and its associated metabolic changes and therapy indicate that hyperglycaemia coupled with the factors influencing insulin resistance (tumour necrosis-α, NFκB, amylin) cause an increase in reactive oxygen species generation in acinar cells.

CONCLUSIONS

Complex pathogenetic connections exist between AP and factors involved in the development and therapy of DM. Insulin resistance and hyperglycaemia, hallmarks of DM, are important factors linked to the susceptibility of diabetics to AP. Given the high morbidity associated with an attack of AP in a diabetic patient, targeting these two aspects by therapy may help not only to reduce the risk of development of AP, but may also help reduce the severity of an established attack in a diabetic patient.

Abnormal HDL subclasses distribution in overweight children with insulin resistance or type 2 diabetes mellitus

BACKGROUND

Small HDL particles have emerged as significant predictors of incident type 2 diabetes mellitus (T2DM) in adults with impaired glucose tolerance (IGT). However, no previous study has investigated HDL size in pediatric subjects with these clinical conditions.

METHODS

We studied the HDL size distribution by native polyacrilamide gradient gel electrophoresis in 106 overweight children, 47 with T2DM, 43 with normal glucose tolerance (NGT), 16 with IGT, and 39 healthy weight controls.

RESULTS

Diabetic children had significantly lower proportions of HDL2b and HDL2a, and higher proportions of HDL3b and HDL3c than the other 3 groups. Overweight subjects showed HDL size distributions similar to those of controls. However, insulin-resistant children had lower proportions of HDL2b, and HDL2a, and higher proportions of HDL3b when compared with the insulin-sensitive overweight subjects. Multiple linear regression analyses showed that homeostasis model assessment correlated inversely with HDL2b and HDL2a, and directly with HDL3b, while BMI was independently associated only with HDL3a.

CONCLUSIONS

This study showed that HDL size distribution was shifted toward smaller particles in T2DM pediatric patients and in overweight children with insulin resistance, independent of their glucose tolerance status. Insulin resistance was the main factor associated with these HDL size abnormalities. This parameter could be useful as an early risk marker of incident diabetes and, probably, of coronary heart disease.

New insight into the pathophysiology of lipid abnormalities in type 2 diabetes

Lipid abnormalities in patients with type 2 diabetes are likely to play an important role in the development of atherogenesis. These lipid disorders include not only quantitative but also qualitative abnormalities of lipoproteins which are potentially atherogenic. The main quantitative abnormalities are increased triglyceride levels, related to an augmented hepatic production of VLDL and a reduction of both VLDL and IDL catabolism, and decreased HDL-Cholesterol levels due to an accelerated HDL catabolism. The main qualitative abnormalities include large VLDL particles (VLDL1), relatively rich in triglycerides, small dense LDL particles, increase in triglyceride content of LDL and HDL, glycation of apolipoproteins and increased susceptibility of LDL to oxidation. Moreover, although plasma LDL-cholesterol level is usually normal in type 2 diabetic patients, LDL particles show significant kinetic abnormalities, such as reduced turn-over, which is potentially harmful. The pathophysiology of lipid abnormalities in type 2 diabetes is not yet totally explained. However, insulin resistance and the "relative" insulin deficiency, observed in patients with type 2 diabetes, are likely to play a crucial role since insulin has an important function in the regulation of lipid metabolism. In addition, it is not excluded that adipocytokines, such as adiponectin, could play a role in the pathophysiology of lipid abnormalities in type 2 diabetes.

Serum lipoproteins in the diabetes control and complications trial/epidemiology of diabetes intervention and complications cohort: associations with gender and glycemia

OBJECTIVE

To relate the nuclear magnetic resonance (NMR)-determined lipoprotein profile, conventional lipid and apolipoprotein measures, and in vitro oxidizibility of LDL with gender and glycemia in type 1 diabetes.

RESEARCH DESIGN AND METHODS

In the 1997-1999 Diabetes Control and Complications Trial/Epidemiology of Diabetes Intervention and Complications (DCCT/EDIC) cohort, serum from 428 women and 540 men were characterized by conventional lipids, NMR, apolipoprotein levels, and LDL susceptibility to in vitro oxidation. Simple and partial correlation coefficients were calculated for each lipoprotein-related parameter versus gender, with and without covariates (age, diabetes duration, concurrent HbA(1c), DCCT randomization, hypertension, BMI, waist-to-hip ratio, and albuminuria). For concurrent HbA(1c), data were analyzed as above, exchanging gender for HbA(1c). Associations were significant if P < 0.05.

RESULTS

Although men and women had similar total and LDL cholesterol and triglycerides, men exhibited the following significant percent differences in NMR profiles versus women: small VLDL 41; IDL -30; medium LDL 39; small LDL 21; large HDL -32; small HDL 35; LDL particle concentration 4; VLDL and HDL diameters -8 and -4, respectively. Small VLDL, small HDL, medium LDL (women only), small LDL (men only), and LDL particle concentration were positively correlated, and HDL size was inversely correlated, with concurrent HbA(1c). NMR profile was unrelated to prior DCCT randomization. Susceptibility of LDL to oxidation was unrelated to gender and glycemia.

CONCLUSIONS

Male gender and poor glycemia are associated with a potentially more atherogenic NMR lipoprotein profile. Neither gender nor glycemia influence LDL oxidation in vitro.

Effects of insulin resistance and type 2 diabetes on lipoprotein subclass particle size and concentration determined by nuclear magnetic resonance

The insulin resistance syndrome (IRS) is associated with dyslipidemia and increased cardiovascular disease risk. A novel method for detailed analyses of lipoprotein subclass sizes and particle concentrations that uses nuclear magnetic resonance (NMR) of whole sera has become available. To define the effects of insulin resistance, we measured dyslipidemia using both NMR lipoprotein subclass analysis and conventional lipid panel, and insulin sensitivity as the maximal glucose disposal rate (GDR) during hyperinsulinemic clamps in 56 insulin sensitive (IS; mean +/- SD: GDR 15.8 +/- 2.0 mg. kg(-1). min(-1), fasting blood glucose [FBG] 4.7 +/- 0.3 mmol/l, BMI 26 +/- 5), 46 insulin resistant (IR; GDR 10.2 +/- 1.9, FBG 4.9 +/- 0.5, BMI 29 +/- 5), and 46 untreated subjects with type 2 diabetes (GDR 7.4 +/- 2.8, FBG 10.8 +/- 3.7, BMI 30 +/- 5). In the group as a whole, regression analyses with GDR showed that progressive insulin resistance was associated with an increase in VLDL size (r = -0.40) and an increase in large VLDL particle concentrations (r = -0.42), a decrease in LDL size (r = 0.42) as a result of a marked increase in small LDL particles (r = -0.34) and reduced large LDL (r = 0.34), an overall increase in the number of LDL particles (r = -0.44), and a decrease in HDL size (r = 0.41) as a result of depletion of large HDL particles (r = 0.38) and a modest increase in small HDL (r = -0.21; all P < 0.01). These correlations were also evident when only normoglycemic individuals were included in the analyses (i.e., IS + IR but no diabetes), and persisted in multiple regression analyses adjusting for age, BMI, sex, and race. Discontinuous analyses were also performed. When compared with IS, the IR and diabetes subgroups exhibited a two- to threefold increase in large VLDL particle concentrations (no change in medium or small VLDL), which produced an increase in serum triglycerides; a decrease in LDL size as a result of an increase in small and a reduction in large LDL subclasses, plus an increase in overall LDL particle concentration, which together led to no difference (IS versus IR) or a minimal difference (IS versus diabetes) in LDL cholesterol; and a decrease in large cardioprotective HDL combined with an increase in the small HDL subclass such that there was no net significant difference in HDL cholesterol. We conclude that 1) insulin resistance had profound effects on lipoprotein size and subclass particle concentrations for VLDL, LDL, and HDL when measured by NMR; 2) in type 2 diabetes, the lipoprotein subclass alterations are moderately exacerbated but can be attributed primarily to the underlying insulin resistance; and 3) these insulin resistance-induced changes in the NMR lipoprotein subclass profile predictably increase risk of cardiovascular disease but were not fully apparent in the conventional lipid panel. It will be important to study whether NMR lipoprotein subclass parameters can be used to manage risk more effectively and prevent cardiovascular disease in patients with the IRS.

Diabetic hypertriglyceridemia-induced acute pancreatitis masquerading as biliary pancreatitis

Diabetes mellitus has a profound effect on plasma lipid metabolism especially triglycerides. One complication of hypertriglyceridemia is acute pancreatitis. Here, we report a case of diabetic hypertriglyceridemia-induced recurrent acute pancreatitis that masquerades as biliary pancreatitis. Institution of insulin therapy caused a resolution of the hypertriglyceridemia and a cessation of the episodes of acute pancreatitis.

Energy intake-independent modulation of triglyceride metabolism by glucocorticoids in the rat

This study aimed to dissociate the peripheral effects of adrenalectomy (ADX) on triglyceride (TG) metabolism from those it exerts centrally on energy intake and to determine the impact of diet composition therein. Rats were fed either rodent chow or a diet high in sucrose and fat (HSF) and were adrenalectomized or left intact and pair fed to the ADX animals. Liver TG content, an index of hepatic TG production, was not affected by ADX, but was increased twofold by the HSF diet. ADX decreased the rate of hepatic TG secretion by 41% in chow-fed but not in HSF-fed animals. Triglyceridemia and postheparin plasma lipase activities remained largely unchanged by treatments. ADX decreased insulinemia fivefold in chow-fed rats, but less so in HSF-fed animals. Likewise, subcutaneous and visceral adipose depots were 40-60% smaller in ADX than in intact pair-fed rats given chow, but the effect of ADX was dampened by consumption of the HSF diet. Although smaller, adipose tissues of ADX rats maintained a higher activity of lipoprotein lipase (LPL) than those of intact pair-fed rats, whereas muscle LPL was decreased. The study confirms that in the presence of reduced energy intake, corticosterone contributes to the maintenance of adipose stores and that the consequences of its absence tend to be attenuated when a high-energy diet is fed. The study further shows that, contrary to ad libitum feeding conditions, most determinants of TG metabolism, such as hepatic TG stores, triglyceridemia, postheparin plasma LPL, and adipose tissue LPL, are minimally affected by glucocorticoids when consumption of a high-energy diet is restricted, suggesting that glucocorticoids affect TG metabolism mostly indirectly through their central action on ingestive behavior.

Important contribution of lipoprotein particle number to plasma triglyceride concentration in type 2 diabetes

The aim of the present study was to determine the contributions of particle size versus number to differences in plasma triglyceride-rich lipoprotein concentrations in patients with type 2 diabetes. Fasting plasma was obtained from 174 consecutive eligible men and women with type 2 diabetes (with or without insulin treatment, mean age 57.0 + 6.3 years) who were undergoing coronary angiography. The triglyceride-rich (Sf 12-400) lipoproteins (TRL) were subfractionated into the Sf 12-60 and Sf 60-400 subfractions. Particle numbers, estimated by measuring apolipoprotein B by electroimmunoassay, in each of these lipoprotein fractions were related to enzymatically determined triglyceride levels in the triglyceride-rich lipoproteins. Approximately 87% of the triglyceride-rich lipoprotein particles were in the Sf 12-60 fraction and 13% in the Sf 60-400 fraction. Multiple linear regression indicated that 69% (i.e. r2=0.69) of the variance in the triglyceride levels could by explained by differences in TRL particle number and 17% (i. e. r2=0.17) by the differences in particle triglyceride content. These observations are similar in each gender and in those with or without insulin treatment. In conclusion, in type 2 diabetes, the vast majority of triglyceride-rich lipoproteins are smaller particles which are in the Sf 12-60 fraction. Differences in particle number, rather than triglyceride content, account for approximately 70% of the differences in triglyceride levels observed between individuals. Previous demonstrations, in those without diabetes, of an association between small triglyceride-rich lipoproteins with coronary artery disease suggest the importance of these findings to the increased atherosclerosis in diabetes.

Low density lipoprotein binding and uptake by human and rat islet beta cells

Abnormalities in lipoprotein metabolism are common in diabetes. It is unknown whether variations in form or concentration of lipoproteins influence the function of pancreatic beta cells. This study investigates whether low density lipoproteins (LDL) exhibit specific interactions with islet beta cells. Radioactively labeled LDL (125I-LDL) and fluorescently labeled LDL (DiI-LDL) were used as tracers. Rat islet cells express high affinity LDL binding sites (K(d) = 9 nM), which are also recognized by very low density lipoproteins and which are down-regulated by LDL. Binding of LDL appears restricted to the beta cells, as it was not detected on islet endocrine non-beta cells. At 37 C, LDL is taken up and lysosomally degraded by islet beta cells but not by islet non-beta cells. Human islet cells were also found to present LDL binding, uptake, and degradation. Compared with rat islet cells, human islet cells exhibit 10-fold less binding sites (2.10(7) vs. 2.10(8) per 10(3) cells) with a 2-fold lower K(d) value (5 nM) and an equal sensitivity to LDL-induced down-regulation. In conclusion, human and rat islet beta cells express LDL receptors that can internalize the lipoprotein. This pathway should be examined for its potential role in (dys)regulating pancreatic beta cell functions.