Determinants of mild fasting hypertriglyceridaemia in non-insulin-dependent diabetes

Fasting, non-fasting and postprandial triglycerides for screening cardiometabolic risk

Fasting triacylglycerols have long been associated with cardiovascular disease (CVD) and other cardiometabolic conditions. Evidence suggests that non-fasting triglycerides (i.e. measured within 8 h of eating) better predict CVD than fasting triglycerides, which has led several organisations to recommend non-fasting lipid panels as the new clinical standard. However, unstandardised assessment protocols associated with non-fasting triglyceride measurement may lead to misclassification, with at-risk individuals being overlooked. A third type of triglyceride assessment, postprandial testing, is more controlled, yet historically has been difficult to implement due to the time and effort required to execute it. Here, we review differences in assessment, the underlying physiology and the pathophysiological relevance of elevated fasting, non-fasting and postprandial triglycerides. We also present data suggesting that there may be a distinct advantage of postprandial triglycerides, even over non-fasting triglycerides, for early detection of CVD risk and offer suggestions to make postprandial protocols more clinically feasible.

Insulin-mediated FFA suppression is associated with triglyceridemia and insulin sensitivity independent of adiposity

CONTEXT

A central/visceral fat distribution and excess free fatty acid (FFA) availability are associated with dyslipidemia and insulin resistance. However, these two characteristics often coexist, making it difficult to detect the independent contributions of each. Whether FFA suppression is more closely linked to metabolic abnormalities is not clear.

OBJECTIVE

The aim of the study was to examine the relationship between FFA suppression, body fat distribution, and fitness as contributors toward insulin resistance and hypertriglyceridemia.

DESIGN

We measured systemic palmitate turnover using an iv infusion of [9,10-(3)H]palmitate; upper body sc adipose tissue (UBSQ) and visceral adipose tissue (VAT) with dual-energy x-ray absorptiometry and a single-slice abdominal computed tomography scan; fitness with a graded exercise treadmill test; and insulin sensitivity with both the iv glucose tolerance test (IVGTT) (SI(IVGTT)) and mixed meal tolerance test (SI(Meal)).

SETTING

The study was conducted at a General Clinical Research Center.

PARTICIPANTS

Baseline data were obtained from 140 elderly adults (age, 60-88 yr; 83 males) and 60 young adults (age, 18-31 yr; 31 males) who participated in a previously published trial assessing the effects of 2-yr supplementation of dehydroepiandrosterone or testosterone on body composition, glucose metabolism, and bone density.

INTERVENTIONS

There were no interventions.

MAIN OUTCOME MEASURES

We measured fasting plasma triglyceride (TG) concentrations, SI(IVGTT), and SI(Meal).

RESULTS

Using multivariate regression analysis, the strongest combined predictors of TG concentrations were VAT, postmeal nadir FFA concentrations, sex, and age. The best predictors of SI(IVGTT) were IVGTT nadir palmitate concentration, VAT, UBSQ fat, fitness, and age, whereas the best predictors of SI(Meal) were meal nadir palmitate concentration, UBSQ fat, fitness, and sex.

CONCLUSIONS

FFA suppression is associated with both fasting TG concentrations and insulin sensitivity, independent of measures of adiposity.

Animal and human tissue Na,K-ATPase in normal and insulin-resistant states: regulation, behaviour and interpretative hypothesis on NEFA effects

The sodium(Na)- and potassium(K)-activated adenosine-triphosphatase (Na,K-ATPase) is a membrane enzyme that energizes the Na-pump by hydrolysing adenosine triphosphate and wasting energy as heat, so playing a role in thermogenesis and energy balance. Na,K-ATPase regulation by insulin is controversial; in tissue of hyperglycemic-hyperinsulinemic ob/ob mice, we reported a reduction, whereas in streptozotocin-treated hypoinsulinemic-diabetic Swiss and ob/ob mice we found an increased activity, which is against a genetic defect and suggests a regulation by hyperinsulinemia. In human adipose tissue from obese patients, Na,K-ATPase activity was reduced and negatively correlated with body mass index, oral glucose tolerance test-insulinemic area and blood pressure. We hypothesized that obesity is associated with tissue Na,K-ATPase reduction, apparently linked to hyperinsulinemia, which may repress or inactivate the enzyme, thus opposing thyroid hormones and influencing thermogenesis and obesity development. Insulin action on Na,K-ATPase, in vivo, might be mediated by the high level of non-esterified fatty acids, which are circulating enzyme inhibitors and increase in obesity, diabetes and hypertension. In this paper, we analyse animal and human tissue Na,K-ATPase, its level, and its regulation and behaviour in some hyperinsulinemic and insulin-resistant states; moreover, we discuss the link of the enzyme with non-esterified fatty acids and attempt to interpret and organize in a coherent view the whole body of the exhaustive literature on this complicated topic.

Coordinated regulation of fat-specific and liver-specific glycerol channels, aquaporin adipose and aquaporin 9

Plasma glycerol is a major substrate for hepatic gluconeogenesis. Aquaporin adipose (AQPap/7), an adipose-specific glycerol channel, provides fat-derived glycerol into plasma. In the present study, we cloned the coding and promoter regions of mouse aquaporin 9 (AQP9), a liver-specific glycerol channel. Fasting and refeeding of mice increased and decreased hepatic AQP9 mRNA levels, respectively. Insulin deficiency induced by streptozotocin resulted in increased hepatic AQP9 mRNA. These changes in hepatic AQP9 mRNA were accompanied by those of hepatic gluconeogenic mRNAs and plasma glycerol levels. In cultured hepatocytes, insulin downregulated AQP9 mRNA. The AQP9 promoter contained the negative insulin response element TGTTTTC at -496/-502, similar to the promoter of the AQPap/7 gene. In contrast, in insulin-resistant db+/db+ mice, AQPap/7 mRNA in fat and AQP9 mRNA in liver were increased, despite hyperinsulinemia, with high plasma glycerol and glucose levels. Glycerol infusion in the db+/db+ mice augmented hepatic glucose output. Our results indicate that coordinated regulations of fat-specific AQPap/7 and liver-specific AQP9 should be crucial to determine glucose metabolism in physiology and insulin resistance.

Insulin improves fasting and postprandial lipemia in type 2 diabetes

BACKGROUND: The purpose of the investigation presented here was to study the effects of insulin therapy in type 2 diabetes mellitus (type 2 DM) not only on glycemic control but also on other components of the metabolic syndrome, including lipid metabolism, blood pressure, and body weight. METHODS: Twelve patients with type 2 DM were studied before and after replacement of sulphonylurea treatment with insulin for 4 months. RESULTS: Insulin therapy resulted in a significant decrease in fasting glucose levels by 26%; glycated hemoglobin decreased by 17% and fructosamine values by 19%. With insulin treatment, fasting plasma triglyceride levels decreased by 28% and total HDL cholesterol and HDL(3) cholesterol increased by 17 and 11%, respectively. Low-density lipoprotein (LDL) cholesterol showed no significant change. The magnitude of postprandial lipemia after ingestion of a standard fatty meal decreased by 38%. Insulin treatment was also accompanied by a 21% increase in lipoprotein lipase (LPL) activity in postheparin plasma and by a 20% increase in cholesteryl ester transfer protein (CETP) activity. Hepatic lipase activity was not changed significantly with insulin. Mean BMI decreased from 28.5+/-4.2 to 28.0+/-3.1 kg/m(2) (P=0.02), which is in keeping with the finding that peripheral insulin levels did not increase and which can be explained by the fact that the insulin regimen was combined with dietary counseling. Accordingly, blood pressure showed no significant change. CONCLUSION: Our study demonstrates that judicious replacement of sulfonylurea treatment with insulin therapy, together with dietary counseling, can result in a simultaneous improvement in the major stigmata of the metabolic syndrome, i.e. a significant improvement in glycemic control and lipid metabolism without unfavorable effects on body weight and blood pressure.

Response of insulin, glucagon, lactate, and nonesterified fatty acids to glucose in visceral obesity with and without NIDDM: relationship to hypertension

Insulin, glucagon, glucose, nonesterified fatty acids (NEFA), and lactate response to oral glucose tolerance test (OGTT, 75 g glucose) and their correlation with mean blood pressure (BP), were studied in 10 normal subjects (N), 25 subjects with abdominal obesity (O), and 9 subjects with abdominal obesity and IGT or non-insulin-dependent diabetes (OD). O and OD patients, as compared to N subjects, showed increased fasting NEFA, lactate, insulin, and glucagon. NEFA area and insulin total and incremental areas were increased in O and OD (P < 0.001 in all instances). Glucagon total areas were increased only in OD (P < 0.01). Lactate total areas were increased in O (P < 0.001) and in OD (P < 0.01), while lactate incremental area was diminished in O and, even more, in OD subjects (P < 0.001 in both instances) and was inversely correlated with the basal level (P < 0.001). In all subjects as a whole, increase in NEFA area was weakly correlated with total and incremental insulinemic areas (P < 0.05) and more strongly correlated with glucagon and lactate areas (P < 0.01). Conversely, the incremental areas of lactate were negatively correlated with total insulin (P < 0.05), NEFA (P < 0.05), and glucagon (P < 0.001) areas. BP was increased in O (103.62 +/- 2.37) and, even more, in OD (109.41 +/- 5.22) compared to that seen in N (92.55 +/- 0.94 mm Hg), with P < 0.01, and was correlated with fasting insulin (P < 0.01) and glucose (P < 0.05) and, even more, with total (P < 0.001) and incremental (P < 0.01) insulin areas and NEFA areas (P < 0.001). Conversely, BP also was negatively correlated with incremental lactate area (P < 0.01) (similarly to insulin and NEFA area). Our data would suggest that in O and OD patients, insulin resistance is associated with elevated NEFA, insulin and glucagon as well as with high BP. since NEFA are inhibitors of Na,K-ATPase, they could contribute to elevate BP through the repression of this enzyme (which we have shown previously to be reduced in adipose tissue of obese subjects and correlated negatively with BP.

In search of the ideal treatment for migraine headache

Migraine headache is a common syndrome, afflicting millions, that has so far defied a definitive cure. Experimental research studies of the syndrome tend to describe the triggering factors separately. We propose a common denominator--namely, high levels of blood lipids and free fatty acids--as underlying factor in the development of migraine headaches. Biological states that may cause increases in free fatty acids and blood lipids include: high dietary fat intake, obesity, insulin resistance, vigorous exercise, hunger, consumption of alcohol, coffee, and other caffeinated beverages, oral contraceptives, smoking, and stress. Elevated blood lipids and free fatty acids are associated with increased platelet aggregability, decreased serotonin, and heightened prostaglandin levels. These changes lead to the vasodilatation that precedes migraine headache. We suggest that migraine headache should not be seen as an isolated symptom, but as a first signal of potential biochemical imbalances in the body, which can lead to development of chronic disease.

Studies in hypertriglyceridaemia, III: Glucose tolerance, insulin sensitivity and indices of adipose tissue lipolysis in randomly selected non-diabetic hypertriglyceridaemic Swedish men

Hypertriglyceridaemia, insulin resistance and glucose intolerance are conditions associated with an increased risk of coronary heart disease. In this study we have examined randomly selected nondiabetic hypertriglyceridaemic (HTG) males, 40-50 years (n = 65) and age-matched normotriglyceridaemic (NTG) controls (n = 61). The (mean +/- SD) insulin sensitivity index, as assessed by the Minimal Model method, was significantly lower in the HTG compared with the NTG group (3.69 +/- 2.96 vs. 6.29 +/- 3.38 x 10(-4) min-1 per mUL-1; P < 0.001). Thirty-eight per cent of the HTG group was glucose intolerant, compared with 8% in the NTG group (X2 = 13.16; P < 0.001). The glucose intolerant HTG sub-group had, when compared with the glucose tolerant one, significantly higher serum concentrations of apoB (1318 +/- 284 vs. 1094 +/- 312 mg L-1; P < 0.01) and glycerol (84 +/- 26 vs. 65 +/- 22 nmol L-1; P < 0.01). Serum FFA concentrations were, irrespective of glucose tolerance/intolerance, higher in the HTG than in the NTG group. By logistic regression analysis with the HTG/NTG state as the dichotomous variable, it was found that neither a low insulin sensitivity, nor glucose intolerance were independently linked with the HTG state. Instead, the lower insulin sensitivity of the HTG group was related to their higher body mass index. The higher frequency of glucose intolerance in the HTG group was explained by their higher mean serum apoB concentration, when compared with the NTG group. In conclusion, this study of a randomly selected of HTG group has confirmed the frequent coexistance of HTG, insulin resistance and glucose intolerance. The new important finding was that neither of these two latter conditions appear to be of direct pathogenetic importance for HTG.

Lipoprotein disorders in diabetes mellitus

In IDDM or NIDDM, the total plasma cholesterol and triglycerides are usually within normal limits when the blood glucose is controlled. Marked hypertriglyceridemia can develop with loss of glycemic control and is often due to superimposed genetic abnormalities in lipoprotein metabolism. Tight control in IDDM usually reduces LDL and VLDL to normal levels and may raise HDL above the normal range. Low HDL cholesterol and mild to moderate elevations of VLDL triglyceride are common in NIDDM if obesity or proteinuria is also present. Both HDL and LDL may be smaller and more dense and may be enriched with triglyceride as compared with cholesterol. These abnormalities may require weight loss for control. The increased incidence of cardiovascular disease in diabetes is unexplained but is amplified by the well-defined cardiovascular risk factors. The new American Diabetes Association guidelines call for treatment of high triglycerides and LDL cholesterol to be aggressively reduced. Triglycerides should be under 200 mg/dL, are considered borderline high between 200 and 400 mg/dL, and high when above 400 mg/dL. Low HDL is defined as less than 35 mg/dL. Control of obesity with diet and exercise and reduced intake of saturated fat and cholesterol are important first steps. If needed, drug therapy is appropriate to reduce LDL to levels below 130 mg/dL in all adult diabetics and below 100 mg/dL in those with cardiovascular disease.

The response of hepatic lipase and serum lipoproteins to acute hyperinsulinaemia in type 2 diabetes

Hepatic lipase has a putative role in the catabolism of HDL particles and, while its activity is dependent upon insulin in the rat, no such insulin responsiveness has been demonstrated in man. We studied 21 patients with type 2 diabetes to examine whether hepatic lipase activity was influenced by hyperinsulinaemia during a 2-4 h isoglycaemic clamp study. Acute changes in lipids, lipoproteins and apolipoproteins were also documented in pre- and post-clamp serum. Hepatic lipase activity during hyperinsulinaemia was compared with activity measured after an equivalent period without insulin. For comparison, nine non-diabetic subjects (matched for age and body mass index) underwent similar clamp studies. In the control experiment without insulin, hepatic lipase activity did not change significantly (mean 9.7 (range 2.3-22.3) in the morning and 9.9 (3.0-22.5) mmol h-1 l-1 in the afternoon, NS). In contrast, after the hyperinsulinaemic clamp, hepatic lipase activity fell significantly in diabetic subjects from 12.8 (4.4-30.6) to 10.4 (3.3-31.3) mmol h-1 l-1, P less than 0.0002 along with serum triglycerides and total and LDL cholesterol. The change in hepatic lipase activity was positively related to the fasting apoprotein B concentration (Spearman r = 0.54, P = 0.016). In the normal subjects, a similar decline in hepatic lipase activity was observed during hyperinsulinaemia (from 15.1 (9.8-32.7) to 12.6 (6.3-28.3) mmol h-1 l-1, P less than 0.01) along with decreases in total, HDL and LDL cholesterol, triglycerides and apoproteins A1 and B.(ABSTRACT TRUNCATED AT 250 WORDS)