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Bonet J, Fox D, Nelson R, Nelson MB, Nelson L, Fernandez C, Barbieri E, Dalla Man C, Santoro N. Modelling and assessment of glucose-lactate kinetics in youth with overweight, obesity and metabolic dysfunction-associated steatotic liver disease: A pilot study. Diabetes Obes Metab 2024. [PMID: 38742538 DOI: 10.1111/dom.15648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/16/2024]
Abstract
AIM In this study, we investigated glucose and lactate kinetics during a 75 g oral glucose tolerance test (OGTT) in 23 overweight and obese adolescents and assessed putative differences among participants with and without metabolic dysfunction-associated steatotic liver disease (MASLD). METHODS We enrolled 23 young people (six girls) with obesity [body mass index 33 (29-37)]. Glucose-lactate kinetics parameters (disposal glucose insulin sensitivity, SID; fraction of glucose converted into lactate, fr; fractional lactate clearance rate, kL) and lactate production rate (LPR) were estimated using the oral glucose-lactate minimal model. MASLD presence was assessed using the proton density fat fraction. We analysed glucose, lactate and LPR time to peak, peak values and area under the curve and evaluated differences using the Wilcoxon test. MASLD and no-MASLD participants were compared using the Mann-Whitney test. Correlations between parameters were assessed using the Spearman correlation coefficient (ρ). We also tested the performance of two (4 or 3 h OGTT) protocols in estimating oral glucose-lactate minimal model and LPR parameters. RESULTS Glucose peaks 30 min earlier than lactate (p = .0019). This pattern was present in the no-MASLD group (p < .001). LPR peaks 30 min later in the MASLD group (p = .02). LPR and kL were higher in MASLD, suggesting higher glycolysis and lactate utilization. SID and fr correlate significantly (ρ = -0.55, p = .008). SID and fr were also correlated with the body mass index, (ρ = -0.45, p = .04; and ρ = 0.45; p = .03). The protocol duration did not influence the estimates of the parameters. DISCUSSION Youth with MASLD showed a delayed glucose metabolism, possibly because of greater utilization of the underlying substrates. A 3-h OGTT may be used to assess lactate metabolism effectively.
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Affiliation(s)
- Jacopo Bonet
- Department of Information Engineering, Padua, Italy
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Delaney Fox
- Department of Pediatrics, Kansas University Medical Center, Kansas City, Kansas, USA
| | - Rafaela Nelson
- Department of Pediatrics, Kansas University Medical Center, Kansas City, Kansas, USA
| | - Michael B Nelson
- Department of Pediatrics, Kansas University Medical Center, Kansas City, Kansas, USA
| | - Loretta Nelson
- Department of Pediatrics, Kansas University Medical Center, Kansas City, Kansas, USA
| | - Cristina Fernandez
- Center for Children's Healthy Lifestyles & Nutrition, Kansas City, Kansas, USA
- University of Missouri-Kansas City School of Medicine, Kansas City, Kansas, USA
- Division of Weight Management, Children's Mercy, Kansas City, Missouri, USA
| | - Emiliano Barbieri
- Universita degli Studi di Napoli Federico II Scuola di Medicina e Chirurgia, Naples, Italy
| | | | - Nicola Santoro
- Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Medicine and Health Sciences, "V. Tiberio" University of Molise, Campobasso, Italy
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Visentin R, Brodersen K, Richelsen B, Møller N, Dalla Man C, Pedersen AK, Abrahamsen J, Holst JJ, Nielsen MF. Increased Insulin Secretion and Glucose Effectiveness in Obese Patients with Type 2 Diabetes following Bariatric Surgery. J Diabetes Res 2023; 2023:7127426. [PMID: 38020201 PMCID: PMC10663093 DOI: 10.1155/2023/7127426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 10/24/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
Background β-cell dysfunction and insulin resistance are the main mechanisms causing glucose intolerance in type 2 diabetes (T2D). Bariatric surgeries, i.e., sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB), are procedures both known to induce weight loss, increase insulin action, and enhance β-cell function, but hepatic insulin extraction and glucose effectiveness may also play a role. Methods To determine the contribution of these regulators on glucose tolerance after bariatric surgery, an oral glucose tolerance test (OGTT) was performed before and 2 months after surgery in 9 RYGB and 7 SG subjects. Eight healthy subjects served as metabolic controls. Plasma glucose, insulin, C-peptide, GLP-1, and GIP were measured during each OGTT. Insulin sensitivity and secretion, glucose effectiveness, and glucose rate of appearance were determined via oral minimal models. Results RYGB and SG resulted in similar weight reductions (13%, RYGB (p < 0.01); 14%, SG (p < 0.05)). Two months after surgery, insulin secretion (p < 0.05) and glucose effectiveness both improved equally in the two groups (11%, RYGB (p < 0.01); 8%, SG (p > 0.05)), whereas insulin sensitivity remained virtually unaltered. Bariatric surgery resulted in a comparable increase in the GLP-1 response during the OGTT, whereas GIP concentrations remained unaltered. Following surgery, oral glucose intake resulted in a comparable increase in hepatic insulin extraction, the response in both RYGB and SG patients significantly exceeding the response observed in the control subjects. Conclusions These results demonstrate that the early improvement in glucose tolerance in obese T2D after RYGB and SG surgeries is attributable mainly to increased insulin secretion and glucose effectiveness, while insulin sensitivity seems to play only a minor role. This trial is registered with NCT02713555.
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Affiliation(s)
- Roberto Visentin
- Department of Information Engineering, University of Padova, Padova, Italy
| | | | - Bjørn Richelsen
- Steno Diabetes Center Aarhus, Aarhus University Hospital & Clinical Medicine, Aarhus University, Denmark
| | - Niels Møller
- Steno Diabetes Center Aarhus, Aarhus University Hospital & Clinical Medicine, Aarhus University, Denmark
| | - Chiara Dalla Man
- Department of Information Engineering, University of Padova, Padova, Italy
| | | | - Jan Abrahamsen
- Department of Radiology, Viborg General Hospital, Denmark
| | - Jens Juul Holst
- Novo Nordisk Foundation, Center of Basic Metabolic Research and Department of Biomedical Sciences, The Panum Institute, University of Copenhagen, Denmark
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Cobelli C, Kovatchev B. Developing the UVA/Padova Type 1 Diabetes Simulator: Modeling, Validation, Refinements, and Utility. J Diabetes Sci Technol 2023; 17:1493-1505. [PMID: 37743740 PMCID: PMC10658679 DOI: 10.1177/19322968231195081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Arguably, diabetes mellitus is one of the best quantified human conditions. In the past 50 years, the metabolic monitoring technologies progressed from occasional assessment of average glycemia via HbA1c, through episodic blood glucose readings, to continuous glucose monitoring (CGM) producing data points every few minutes. The high-temporal resolution of CGM data enabled increasingly intensive treatments, from decision support assisting insulin injection or oral medication, to automated closed-loop control, known as the "artificial pancreas." Throughout this progress, mathematical models and computer simulation of the human metabolic system became indispensable for the technological progress of diabetes treatment, enabling every step, from assessment of insulin sensitivity via the now classic Minimal Model of Glucose Kinetics, to in silico trials replacing animal experiments, to automated insulin delivery algorithms. In this review, we follow these developments, beginning with the Minimal Model, which evolved through the years to become large and comprehensive and trigger a paradigm change in the design of diabetes optimization strategies: in 2007, we introduced a sophisticated model of glucose-insulin dynamics and a computer simulator equipped with a "population" of N = 300 in silico "subjects" with type 1 diabetes. In January 2008, in an unprecedented decision, the Food and Drug Administration (FDA) accepted this simulator as a substitute to animal trials for the pre-clinical testing of insulin treatment strategies. This opened the field for rapid and cost-effective development and pre-clinical testing of new treatment approaches, which continues today. Meanwhile, animal experiments for the purpose of designing new insulin treatment algorithms have been abandoned.
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Affiliation(s)
| | - Boris Kovatchev
- Center for Diabetes Technology,
University of Virginia, Charlottesville, VA, USA
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A modelling approach to hepatic glucose production estimation. PLoS One 2022; 17:e0278837. [PMID: 36542610 PMCID: PMC9770442 DOI: 10.1371/journal.pone.0278837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
Stable isotopes are currently used to measure glucose fluxes responsible for observed glucose concentrations, providing information on hepatic and peripheral insulin sensitivity. The determination of glucose turnover, along with fasting and postprandial glucose concentrations, is relevant for inferring insulin sensitivity levels. At equilibrium (e.g. during the fasting state) the rate of glucose entering the circulation equals its rate of disappearance from the circulation. If under these conditions tracer is infused at a constant rate and Specific Activity (SA) or Tracer to Tracee (TTR) ratio is computed, the Rate of Appearance (RA) equals the Rate of Disappearance (RD) and equals the ratio between infusion rate and TTR or SA. In the post-prandial situation or during perturbation studies, however, estimation of RA and RD becomes more complex because they are not necessarily equal and, furthermore, may vary over time due to gastric emptying, glucose absorption, appearance of ingested or infused glucose, variations of EGP and glucose disappearance. Up to now, the most commonly used approach to compute RA, RD and EGP has been the single-pool model by Steele. Several authors, however, report pitfalls in the use of this method, such as "paradoxical" increase in EGP immediately after meal ingestion and "negative" rates of EGP. Different attempts have been made to reduce the impact of these errors, but the same problems are still encountered. In the present work a completely different approach is proposed, where cold and labeled [6, 6-2H2] glucose observations are simultaneously fitted and where both RD and EGP are represented by simple but reasonable functions. As an example, this approach is applied to an intra-venous experiment, where cold glucose is infused at variable rates to reproduce a desired glycaemic time-course. The goal of the present work is to show that appropriate, if simple, modelling of the whole infusion procedure together with the underlying physiological system allows robust estimation of EGP with single-tracer administration, without the artefacts produced by the Steele method.
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Cobelli C, Dalla Man C. Minimal and Maximal Models to Quantitate Glucose Metabolism: Tools to Measure, to Simulate and to Run in Silico Clinical Trials. J Diabetes Sci Technol 2022; 16:1270-1298. [PMID: 34032128 PMCID: PMC9445339 DOI: 10.1177/19322968211015268] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Several models have been proposed to describe the glucose system at whole-body, organ/tissue and cellular level, designed to measure non-accessible parameters (minimal models), to simulate system behavior and run in silico clinical trials (maximal models). Here, we will review the authors' work, by putting it into a concise historical background. We will discuss first the parametric portrait provided by the oral minimal models-building on the classical intravenous glucose tolerance test minimal models-to measure otherwise non-accessible key parameters like insulin sensitivity and beta-cell responsivity from a physiological oral test, the mixed meal or the oral glucose tolerance tests, and what can be gained by adding a tracer to the oral glucose dose. These models were used in various pathophysiological studies, which we will briefly review. A deeper understanding of insulin sensitivity can be gained by measuring insulin action in the skeletal muscle. This requires the use of isotopic tracers: both the classical multiple-tracer dilution and the positron emission tomography techniques are discussed, which quantitate the effect of insulin on the individual steps of glucose metabolism, that is, bidirectional transport plasma-interstitium, and phosphorylation. Finally, we will present a cellular model of insulin secretion that, using a multiscale modeling approach, highlights the relations between minimal model indices and subcellular secretory events. In terms of maximal models, we will move from a parametric to a flux portrait of the system by discussing the triple tracer meal protocol implemented with the tracer-to-tracee clamp technique. This allows to arrive at quasi-model independent measurement of glucose rate of appearance (Ra), endogenous glucose production (EGP), and glucose rate of disappearance (Rd). Both the fast absorbing simple carbs and the slow absorbing complex carbs are discussed. This rich data base has allowed us to build the UVA/Padova Type 1 diabetes and the Padova Type 2 diabetes large scale simulators. In particular, the UVA/Padova Type 1 simulator proved to be a very useful tool to safely and effectively test in silico closed-loop control algorithms for an artificial pancreas (AP). This was the first and unique simulator of the glucose system accepted by the U.S. Food and Drug Administration as a substitute to animal trials for in silico testing AP algorithms. Recent uses of the simulator have looked at glucose sensors for non-adjunctive use and new insulin molecules.
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Affiliation(s)
- Claudio Cobelli
- Department of Woman and Child’s Health University of Padova, Padova, Italy
- Claudio Cobelli, PhD, Department of Woman and Child’s Health, University of Padova, Via N. Giustiniani, 3, Padova 35128, Italy.
| | - Chiara Dalla Man
- Department of Information Engineering, University of Padova, Padova, Italy
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Visentin R, Cobelli C, Dalla Man C. A software interface for in silico testing of type 2 diabetes treatments. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2022; 223:106973. [PMID: 35792365 DOI: 10.1016/j.cmpb.2022.106973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 06/09/2022] [Accepted: 06/21/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND AND OBJECTIVE The increasing incidence of diabetes continuously stimulates the research on new antidiabetic drugs. Computer simulation can save time and costs, alleviating the need of animal trials and providing useful information for optimal experiment design and drug dosing. We recently presented a type 2 diabetes (T2D) simulator as tool for in silico testing of new molecules and guiding treatment optimization. Here we present a user-friendly interface aimed to increase the usability of the simulator. METHOD The simulator, based on a large-scale glucose, insulin, and C-peptide model and equipped with 100 virtual subjects well describing system dynamics in a real T2D population, is extended to incorporate pharmacokinetics/pharmacodynamics (PK/PD) of a drug of interest. A graphical interface is developed on top of the simulator, allowing an easy design of in silico experiments: specifically, it is possible to select the population size to test, design the experiment (crossover or parallel), its duration and the sampling grid, choose glucose and insulin doses, and define treatment PK/PD and dose administered. The simulator also provides the outcome metrics requested by the user, and performs statistical comparisons among treatments and/or placebo. RESULTS To illustrate the potential of the simulator, we provided a case study using metformin and liraglutide. Literature-based PK/PD models of metformin and liraglutide have been incorporated in the simulator, by modulating key drug-sensitive model parameters. An in silico placebo-controlled trial has been done by simulating a three-arm meal tolerance test with subjects receiving placebo, metformin 850 mg, liraglutide 1.80 mg, respectively. The obtained results are in agreement with the clinical evidences, in terms of main glucose, insulin, and C-peptide outcome metrics. CONCLUSIONS We developed a user-friendly software interface for the T2D simulator to support the design and test of new antidiabetic drugs and treatments. This increases the simulator usability, making it suitable also for users who have low experience with computer programming.
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Affiliation(s)
- Roberto Visentin
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Claudio Cobelli
- Department of Woman and Child's Health, University of Padova, Padova, Italy
| | - Chiara Dalla Man
- Department of Information Engineering, University of Padova, Padova, Italy.
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Bonet J, Galuppo B, Santoro N, DallaMan C. A New Oral Model to Assess Postprandial Lactate Production Rate. IEEE Trans Biomed Eng 2021; 69:1533-1540. [PMID: 34727021 DOI: 10.1109/tbme.2021.3124143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Pediatric obesity predisposes children and adolescents to early onset insulin resistance and dysglycemia. In the last 20 years this has led to a rise in the prevalence of prediabetes, diabetes and fatty liver in youngsters, due to the high degree of insulin resistance experienced by these patients and the consequent high availability of glucose. As glucose accesses the liver, it is partly metabolized through glycolysis, whose main product is pyruvate that is then converted into Acetyl CoA and lactate. Therefore, lactate production rate (LPR) represents the best proxy for the assessment of glycolysis. Since to date there are not methods to estimate postprandial LPR, here we proposed a novel oral glucose-lactate model to estimate LPR during an oral glucose tolerance test and tested it in 24 youth with and without obesity. METHODS The model is based on the oral glucose minimal model and assumes that LPR is a fraction (fr) of glucose disposal rate, proportional to glucose concentration and controlled by insulin action. RESULTS The model well fitted the glucose and lactate data, and provided both precise parameter estimates (e.g. fr=22.5 [12.6-54.1]%, median [IQR]), CV=18 [13-25]%) and LPR time course. CONCLUSIONS The proposed model is a valid tool to assess LPR, and thus glycolysis, during OGTT in nondiabetic subjects. SIGNIFICANCE The proposed methodology will allow to assess postprandial LPR in simple and cost-effective way.
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Bruce CR, Hamley S, Ang T, Howlett KF, Shaw CS, Kowalski GM. Translating glucose tolerance data from mice to humans: Insights from stable isotope labelled glucose tolerance tests. Mol Metab 2021; 53:101281. [PMID: 34175474 PMCID: PMC8313600 DOI: 10.1016/j.molmet.2021.101281] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/18/2021] [Accepted: 06/19/2021] [Indexed: 11/29/2022] Open
Abstract
Objective The glucose tolerance test (GTT) is widely used in human and animal biomedical and pharmaceutical research. Despite its prevalent use, particularly in mouse metabolic phenotyping, to the best of our knowledge we are not aware of any studies that have attempted to qualitatively compare the metabolic events during a GTT in mice with those performed in humans. Methods Stable isotope labelled oral glucose tolerance tests (siOGTTs; [6,6-2H2]glucose) were performed in both human and mouse cohorts to provide greater resolution into postprandial glucose kinetics. The siOGTT allows for the partitioning of circulating glucose into that derived from exogenous and endogenous sources. Young adults spanning the spectrum of normal glucose tolerance (n = 221), impaired fasting (n = 14), and impaired glucose tolerance (n = 19) underwent a 75g siOGTT, whereas a 50 mg siOGTT was performed on chow (n = 43) and high-fat high-sucrose fed C57Bl6 male mice (n = 46). Results During the siOGTT in humans, there is a long period (>3hr) of glucose absorption and, accordingly, a large, sustained insulin response and robust suppression of lipolysis and endogenous glucose production (EGP), even in the presence of glucose intolerance. In contrast, mice appear to be highly reliant on glucose effectiveness to clear exogenous glucose and experience only modest, transient insulin responses with little, if any, suppression of EGP. In addition to the impaired stimulation of glucose uptake, mice with the worst glucose tolerance appear to have a paradoxical and persistent rise in EGP during the OGTT, likely related to handling stress. Conclusions The metabolic response to the OGTT in mice and humans is highly divergent. The potential reasons for these differences and their impact on the interpretation of mouse glucose tolerance data and their translation to humans are discussed. We compared the mechanisms governing glucose handling in humans and mice. Humans and mice underwent stable isotope labelled oral glucose tolerance tests. Metabolic responses between humans and mice were highly divergent. Unlike humans, most mice exhibit little EGP suppression or insulin response.
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Affiliation(s)
- Clinton R Bruce
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Science, Deakin University, Geelong, Waurn Ponds, Victoria, 3216, Australia
| | - Steven Hamley
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Science, Deakin University, Geelong, Waurn Ponds, Victoria, 3216, Australia
| | - Teddy Ang
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Science, Deakin University, Geelong, Waurn Ponds, Victoria, 3216, Australia
| | - Kirsten F Howlett
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Science, Deakin University, Geelong, Waurn Ponds, Victoria, 3216, Australia
| | - Christopher S Shaw
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Science, Deakin University, Geelong, Waurn Ponds, Victoria, 3216, Australia
| | - Greg M Kowalski
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Science, Deakin University, Geelong, Waurn Ponds, Victoria, 3216, Australia; Metabolic Research Unit, School of Medicine, Deakin University, Geelong, Waurn Ponds, Victoria, 3216, Australia.
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Carreau AM, Xie D, Garcia-Reyes Y, Rahat H, Bartlette K, Diniz Behn C, Pyle L, Nadeau KJ, Cree-Green M. Good agreement between hyperinsulinemic-euglycemic clamp and 2 hours oral minimal model assessed insulin sensitivity in adolescents. Pediatr Diabetes 2020; 21:1159-1168. [PMID: 32592269 PMCID: PMC7762730 DOI: 10.1111/pedi.13072] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Revised: 06/09/2020] [Accepted: 06/23/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND/OBJECTIVE Rates of dysglycemia are increasing in youth, secondary to obesity and decreased insulin sensitivity (IS) in puberty. The oral minimal model (OMM) has been developed in order to measure IS using an easy oral glucose load, such as an oral glucose tolerance test (OGTT), instead of an hyperinsulinemic-euglycemic clamp (HE-clamp), a more invasive and time-consuming procedure. However, this model, following a standard 2 hour- OGTT has never been validated in youth, a population known for a different physiologic response to OGTT than adults. Thus, we compared IS measurements obtained from OMM following a 2-hour OGTT to HE-clamp and isotope tracer-assessed tissue IS in adolescents. We also compared the liver/muscle-specific IS from HE-clamp with other liver/muscle-specific IS surrogates following an OGTT previously validated in adults. METHODS Secondary analysis of a cross-sectional study. Adolescent girls with (n = 26) and without (n = 7) polycystic ovary syndrome (PCOS) (14.6 ± 1.7 years; BMI percentile 23.3%-98.2%) underwent a 2-hour 75 g OGTT and a 4-phase HE-clamp. OMM IS (Si), dynamic Si (Sid ) and other OGTT-derived muscle and liver IS indices were correlated with HE-clamp tissue-specific IS. RESULTS OMM Si and Sid correlated with HE-clamp-measured peripheral IS (r = 0.64, P <.0001 and r = 0.73; P <.0001, respectively) and the correlation coefficient trended higher than the Matsuda index (r = 0.59; P =.003). The other tissue-specific indices were poorly correlated with their HE-clamp measurements. CONCLUSION In adolescent girls, the 2-hour OMM provided the best estimate of peripheral IS. Additional surrogates for hepatic IS are needed for youth.
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Affiliation(s)
- Anne-Marie Carreau
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Danielle Xie
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Yesenia Garcia-Reyes
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Haseeb Rahat
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Kai Bartlette
- Department of Applied Mathematics and Statistics, Colorado School of Mines, Golden, Colorado
| | - Cecilia Diniz Behn
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Colorado Anschutz Medical Campus, Aurora, Colorado,Department of Applied Mathematics and Statistics, Colorado School of Mines, Golden, Colorado
| | - Laura Pyle
- Department of Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado,Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado
| | - Kristen J. Nadeau
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Colorado Anschutz Medical Campus, Aurora, Colorado,Center for Women’s Health Research, Aurora, Colorado
| | - Melanie Cree-Green
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Colorado Anschutz Medical Campus, Aurora, Colorado,Center for Women’s Health Research, Aurora, Colorado
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Report of a member-led meeting: how stable isotope techniques can enhance human nutrition research. Proc Nutr Soc 2020; 79:373-379. [PMID: 32495731 DOI: 10.1017/s0029665120007016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
A Nutrition Society member-led meeting was held on 9 January 2020 at The University of Surrey, UK. Sixty people registered for the event, and all were invited to participate, either through chairing a session, presenting a '3 min lightning talk' or by presenting a poster. The meeting consisted of an introduction to the topic by Dr Barbara Fielding, with presentations from eight invited speakers. There were also eight lightning talks and a poster session. The meeting aimed to highlight recent research that has used stable isotope tracer techniques to understand human metabolism. Such studies have irrefutably shaped our current understanding of metabolism and yet remain a mystery to many. The meeting aimed to de-mystify their use in nutrition research.
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Hamley S, Kloosterman D, Duthie T, Dalla Man C, Visentin R, Mason SA, Ang T, Selathurai A, Kaur G, Morales-Scholz MG, Howlett KF, Kowalski GM, Shaw CS, Bruce CR. Mechanisms of hyperinsulinaemia in apparently healthy non-obese young adults: role of insulin secretion, clearance and action and associations with plasma amino acids. Diabetologia 2019; 62:2310-2324. [PMID: 31489455 PMCID: PMC6861536 DOI: 10.1007/s00125-019-04990-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 07/29/2019] [Indexed: 01/07/2023]
Abstract
AIMS/HYPOTHESIS This study aimed to examine the metabolic health of young apparently healthy non-obese adults to better understand mechanisms of hyperinsulinaemia. METHODS Non-obese (BMI < 30 kg/m2) adults aged 18-35 years (N = 254) underwent a stable isotope-labelled OGTT. Insulin sensitivity, glucose effectiveness and beta cell function were determined using oral minimal models. Individuals were stratified into quartiles based on their insulin response during the OGTT, with quartile 1 having the lowest and quartile 4 the highest responses. RESULTS Thirteen per cent of individuals had impaired fasting glucose (IFG; n = 14) or impaired glucose tolerance (IGT; n = 19), allowing comparisons across the continuum of insulin responses within the spectrum of normoglycaemia and prediabetes. BMI (~24 kg/m2) was similar across insulin quartiles and in those with IFG and IGT. Despite similar glycaemic excursions, fasting insulin, triacylglycerols and cholesterol were elevated in quartile 4. Insulin sensitivity was lowest in quartile 4, and accompanied by increased insulin secretion and reduced insulin clearance. Individuals with IFG had similar insulin sensitivity and beta cell function to those in quartiles 2 and 3, but were more insulin sensitive than individuals in quartile 4. While individuals with IGT had a similar degree of insulin resistance to quartile 4, they exhibited a more severe defect in beta cell function. Plasma branched-chain amino acids were not elevated in quartile 4, IFG or IGT. CONCLUSIONS/INTERPRETATION Hyperinsulinaemia within normoglycaemic young, non-obese adults manifests due to increased insulin secretion and reduced insulin clearance. Individual phenotypic characterisation revealed that the most hyperinsulinaemic were more similar to individuals with IGT than IFG, suggesting that hyperinsulinaemic individuals may be on the continuum toward IGT. Furthermore, plasma branched-chain amino acids may not be an effective biomarker in identifying hyperinsulinaemia and insulin resistance in young non-obese adults.
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Affiliation(s)
- Steven Hamley
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia
| | - Danielle Kloosterman
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia
| | - Tamara Duthie
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia
| | - Chiara Dalla Man
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Roberto Visentin
- Department of Information Engineering, University of Padova, Padova, Italy
| | - Shaun A Mason
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia
| | - Teddy Ang
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia
| | - Ahrathy Selathurai
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia
| | - Gunveen Kaur
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia
| | - Maria G Morales-Scholz
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia
| | - Kirsten F Howlett
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia
| | - Greg M Kowalski
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia
| | - Christopher S Shaw
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia
| | - Clinton R Bruce
- Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC, 3125, Australia.
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12
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Carreau AM, Jin ES, Garcia-Reyes Y, Rahat H, Nadeau KJ, Malloy CR, Cree-Green M. A simple method to monitor hepatic gluconeogenesis and triglyceride synthesis following oral sugar tolerance test in obese adolescents. Am J Physiol Regul Integr Comp Physiol 2019; 317:R134-R142. [PMID: 31042400 DOI: 10.1152/ajpregu.00047.2019] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Hepatic energy metabolism is a key element in many metabolic diseases. Hepatic anaplerosis provides carbons for gluconeogenesis (GNG) and triglyceride (TG) synthesis. We aimed to optimize a protocol that measures hepatic anaplerotic contribution for GNG, TG synthesis, and hepatic pentose phosphate pathway (PPP) activity using a single dose of oral [U-13C3]glycerol paired with an oral sugar tolerance test (OSTT) in a population with significant insulin resistance. The OSTT (75 g glucose + 25 g fructose) was administered to eight obese adolescents with polycystic ovarian syndrome (PCOS) followed by ingestion of [U-13C3]glycerol at t = 180 or t = 210 min. 13C-labeling patterns of serum glucose and TG-glycerol were determined by nuclear magnetic resonance. 13C enrichment in plasma TG-glycerol was detectable and stable from 240 to 390 min with the [U-13C3]glycerol drink at t = 180 min(3.65 ± 2.3 to 4.47 ± 1.4%; P > 0.4), but the enrichment was undetectable at 240 min with the glycerol drink at t = 210 min. The relative contribution from anaplerosis was determined at the end of the OSTT [18.5 ±3.4% (t = 180 min) vs. 16.0 ± 3.5% (t = 210 min); P = 0.27]. [U-13C3]glycerol was incorporated into GNG 390 min after the OSTT with an enrichment of 7.5-12.5%. Glucose derived from TCA cycle activity was 0.3-1%, and the PPP activity was 2.8-4.7%. In conclusion, it is possible to obtain relative measurements of hepatic anaplerotic contribution to both GNG and TG esterification following an OSTT in a highly insulin-resistant population using a minimally invasive technique. Tracer administration should be timed to allow enough de novo TG esterification and endogenous glucose release after the sugar drink.
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Affiliation(s)
- Anne-Marie Carreau
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Colorado Anschutz Medical Campus , Aurora, Colorado
| | - Eunsook S Jin
- Advanced Imaging Research Center, University of Texas Southwestern Medical Center , Dallas, Texas
| | - Yesenia Garcia-Reyes
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Colorado Anschutz Medical Campus , Aurora, Colorado
| | - Haseeb Rahat
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Colorado Anschutz Medical Campus , Aurora, Colorado
| | - Kristen J Nadeau
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Colorado Anschutz Medical Campus , Aurora, Colorado.,Center for Women's Health Research , Aurora, Colorado
| | - Craig R Malloy
- Advanced Imaging Research Center, University of Texas Southwestern Medical Center , Dallas, Texas
| | - Melanie Cree-Green
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Colorado Anschutz Medical Campus , Aurora, Colorado.,Center for Women's Health Research , Aurora, Colorado
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13
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Errazuriz I, Dube S, Slama M, Visentin R, Nayar S, O’Connor H, Cobelli C, Das SK, Basu A, Kremers WK, Port J, Basu R. Randomized Controlled Trial of a MUFA or Fiber-Rich Diet on Hepatic Fat in Prediabetes. J Clin Endocrinol Metab 2017; 102:1765-1774. [PMID: 28323952 PMCID: PMC5443322 DOI: 10.1210/jc.2016-3722] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 02/27/2017] [Indexed: 12/22/2022]
Abstract
CONTEXT Increased prevalence of type 2 diabetes mellitus and prediabetes worldwide is attributed in part to an unhealthy diet. OBJECTIVE To evaluate whether 12 weeks of high monounsaturated fatty acid (MUFA) or fiber-rich weight-maintenance diet lowers hepatic fat and improves glucose tolerance in people with prediabetes. DESIGN Subjects underwent a [6, 6-2H2]-labeled 75-g oral glucose tolerance test to estimate hepatic insulin sensitivity and liver fat fraction (LFF) using magnetic resonance spectroscopy before and after intervention. SETTING Mayo Clinic Clinical Research Trials Unit. PARTICIPANTS 43 subjects with prediabetes. INTERVENTION Subjects were randomized into three isocaloric weight-maintaining diets containing MUFA (olive oil), extra fiber, and standard US food (control-habitual diet). OUTCOME MEASURES LFF, glucose tolerance, and indices of insulin action and secretion. RESULTS Body weight was maintained constant in all groups during the intervention. Glucose and hormonal concentrations were similar in all groups before, and unchanged after, 12 weeks of intervention. LFF was significantly lower after intervention in the MUFA group (P < 0.0003) but remained unchanged in the fiber (P = 0.25) and control groups (P = 0.45). After 12 weeks, LFF was significantly lower in the MUFA than in the control group (P = 0.01), but fiber and control groups did not differ (P = 0.41). Indices of insulin action and secretion were not significantly different between the MUFA and control groups after intervention (P ≥ 0.11), but within-group comparison showed higher hepatic (P = 0.01) and total insulin sensitivity (P < 0.04) with MUFA. CONCLUSIONS Twelve weeks of a MUFA diet decreases hepatic fat and improves both hepatic and total insulin sensitivity.
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Affiliation(s)
- Isabel Errazuriz
- Endocrine Research Unit, Mayo Clinic, Rochester, Minnesota 55905
| | - Simmi Dube
- Endocrine Research Unit, Mayo Clinic, Rochester, Minnesota 55905
| | - Michael Slama
- Endocrine Research Unit, Mayo Clinic, Rochester, Minnesota 55905
| | - Roberto Visentin
- Department of Information Engineering, University of Padova, Padova 35131, Italy
| | - Sunita Nayar
- Clinical Research and Trials Unit, Mayo Clinic, Rochester, Minnesota 55905
| | - Helen O’Connor
- Clinical Research and Trials Unit, Mayo Clinic, Rochester, Minnesota 55905
| | - Claudio Cobelli
- Department of Information Engineering, University of Padova, Padova 35131, Italy
| | - Swapan Kumar Das
- Endocrinology and Metabolism, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina 27109
| | - Ananda Basu
- Endocrine Research Unit, Mayo Clinic, Rochester, Minnesota 55905
| | - Walter Karl Kremers
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota 55905
| | - John Port
- Department of Radiology, Mayo Clinic, Rochester, Minnesota 55905
| | - Rita Basu
- Endocrine Research Unit, Mayo Clinic, Rochester, Minnesota 55905
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14
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Marchetti L, Reali F, Dauriz M, Brangani C, Boselli L, Ceradini G, Bonora E, Bonadonna RC, Priami C. A Novel Insulin/Glucose Model after a Mixed-Meal Test in Patients with Type 1 Diabetes on Insulin Pump Therapy. Sci Rep 2016; 6:36029. [PMID: 27824066 PMCID: PMC5099899 DOI: 10.1038/srep36029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 10/10/2016] [Indexed: 11/30/2022] Open
Abstract
Current closed-loop insulin delivery methods stem from sophisticated models of the glucose-insulin (G/I) system, mostly based on complex studies employing glucose tracer technology. We tested the performance of a new minimal model (GLUKINSLOOP 2.0) of the G/I system to characterize the glucose and insulin dynamics during multiple mixed meal tests (MMT) of different sizes in patients with type 1 diabetes (T1D) on insulin pump therapy (continuous subcutaneous insulin infusion, CSII). The GLUKINSLOOP 2.0 identified the G/I system, provided a close fit of the G/I time-courses and showed acceptable reproducibility of the G/I system parameters in repeated studies of identical and double-sized MMTs. This model can provide a fairly good and reproducible description of the G/I system in T1D patients on CSII, and it may be applied to create a bank of “virtual” patients. Our results might be relevant at improving the architecture of upcoming closed-loop CSII systems.
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Affiliation(s)
- Luca Marchetti
- The Microsoft Research - University of Trento Centre for Computational and Systems Biology (COSBI), Rovereto (TN), Italy
| | - Federico Reali
- The Microsoft Research - University of Trento Centre for Computational and Systems Biology (COSBI), Rovereto (TN), Italy.,Department of Mathematics, University of Trento, Trento, Italy
| | - Marco Dauriz
- Department of Medicine, Section of Endocrinology, University of Verona School of Medicine, Verona, Italy
| | - Corinna Brangani
- Department of Medicine, Section of Endocrinology, University of Verona School of Medicine, Verona, Italy
| | - Linda Boselli
- Department of Medicine, Section of Endocrinology, University of Verona School of Medicine, Verona, Italy
| | - Giulia Ceradini
- Department of Medicine, Section of Endocrinology, University of Verona School of Medicine, Verona, Italy
| | - Enzo Bonora
- Department of Medicine, Section of Endocrinology, University of Verona School of Medicine, Verona, Italy.,Division of Endocrinology and Metabolic Diseases, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Riccardo C Bonadonna
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy.,Division of Endocrinology, Azienda Ospedaliera Universitaria of Parma, Italy
| | - Corrado Priami
- The Microsoft Research - University of Trento Centre for Computational and Systems Biology (COSBI), Rovereto (TN), Italy.,Department of Mathematics, University of Trento, Trento, Italy
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15
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Abstract
Biological systems can maintain constant steady-state output despite variation in biochemical parameters, a property known as exact adaptation. Exact adaptation is achieved using integral feedback, an engineering strategy that ensures that the output of a system robustly tracks its desired value. However, it is unclear how physiological circuits also keep their output dynamics precise-including the amplitude and response time to a changing input. Such robustness is crucial for endocrine and neuronal homeostatic circuits because they need to provide a precise dynamic response in the face of wide variation in the physiological parameters of their target tissues; how such circuits compensate their dynamics for unavoidable natural fluctuations in parameters is unknown. Here, we present a design principle that provides the desired robustness, which we call dynamical compensation (DC). We present a class of circuits that show DC by means of a nonlinear feedback loop in which the regulated variable controls the functional mass of the controlling endocrine or neuronal tissue. This mechanism applies to the control of blood glucose by insulin and explains several experimental observations on insulin resistance. We provide evidence that this mechanism may also explain compensation and organ size control in other physiological circuits.
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Affiliation(s)
- Omer Karin
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
| | - Avital Swisa
- Department of Developmental Biology and Cancer Research and Molecular Biology, The Institute for Medical Research Israel-Canada, The Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Benjamin Glaser
- Endocrinology and Metabolism Service, Department of Internal Medicine, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Yuval Dor
- Department of Developmental Biology and Cancer Research and Molecular Biology, The Institute for Medical Research Israel-Canada, The Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Uri Alon
- Department of Molecular Cell Biology, Weizmann Institute of Science, Rehovot, Israel
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16
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Hinshaw L, Schiavon M, Dadlani V, Mallad A, Dalla Man C, Bharucha A, Basu R, Geske JR, Carter RE, Cobelli C, Basu A, Kudva YC. Effect of Pramlintide on Postprandial Glucose Fluxes in Type 1 Diabetes. J Clin Endocrinol Metab 2016; 101:1954-62. [PMID: 26930181 PMCID: PMC4870844 DOI: 10.1210/jc.2015-3952] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
CONTEXT Early postprandial hyperglycemia and delayed hypoglycemia remain major problems in current management of type 1 diabetes (T1D). OBJECTIVE Our objective was to investigate the effects of pramlintide, known to suppress glucagon and delay gastric emptying, on postprandial glucose fluxes in T1D. DESIGN This was a single-center, inpatient, randomized, crossover study. PATIENTS Twelve patients with T1D who completed the study were analyzed. INTERVENTIONS Subjects were studied on two occasions with or without pramlintide. Triple tracer mixed-meal method and oral minimal model were used to estimate postprandial glucose turnover and insulin sensitivity (SI). Integrated liver insulin sensitivity was calculated based on glucose turnover. Plasma glucagon and insulin were measured. MAIN OUTCOME MEASURE Glucose turnover and SI were the main outcome measures. RESULTS With pramlintide, 2-hour postprandial glucose, insulin, glucagon, glucose turnover, and SI indices showed: plasma glucose excursions were reduced (difference in incremental area under the curve [iAUC], 444.0 mMmin, P = .0003); plasma insulin concentrations were lower (difference in iAUC, 7642.0 pMmin; P = .0099); plasma glucagon excursions were lower (difference in iAUC, 1730.6 pg/mlmin; P = .0147); meal rate of glucose appearance was lower (difference in iAUC: 1196.2 μM/kg fat free mass [FFM]; P = .0316), endogenous glucose production was not different (difference in iAUC: -105.5 μM/kg FFM; P = .5842), rate of glucose disappearance was lower (difference in iAUC: 1494.2 μM/kg FFM; P = .0083). SI and liver insulin sensitivity were not different between study visits (P > .05). CONCLUSIONS Inhibition of glucagon and gastric emptying delaying reduced 2-hour prandial glucose excursions in T1D by delaying meal rate of glucose appearance.
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Affiliation(s)
- Ling Hinshaw
- Division of Endocrinology and Metabolism (L.H., V.D., A.M., R.B., A.B., Y.C.K.), Mayo Clinic, Rochester, Minnesota; Department of Information Engineering (M.S., C.D.M., C.C.), University of Padova, Padova, Italy; Division of Gastroenterology (A.B.), Mayo Clinic, Rochester, Minnesota; Department of Health Sciences Research (J.R.G., R.E.C.), Mayo Clinic, Rochester, Minnesota 55905
| | - Michele Schiavon
- Division of Endocrinology and Metabolism (L.H., V.D., A.M., R.B., A.B., Y.C.K.), Mayo Clinic, Rochester, Minnesota; Department of Information Engineering (M.S., C.D.M., C.C.), University of Padova, Padova, Italy; Division of Gastroenterology (A.B.), Mayo Clinic, Rochester, Minnesota; Department of Health Sciences Research (J.R.G., R.E.C.), Mayo Clinic, Rochester, Minnesota 55905
| | - Vikash Dadlani
- Division of Endocrinology and Metabolism (L.H., V.D., A.M., R.B., A.B., Y.C.K.), Mayo Clinic, Rochester, Minnesota; Department of Information Engineering (M.S., C.D.M., C.C.), University of Padova, Padova, Italy; Division of Gastroenterology (A.B.), Mayo Clinic, Rochester, Minnesota; Department of Health Sciences Research (J.R.G., R.E.C.), Mayo Clinic, Rochester, Minnesota 55905
| | - Ashwini Mallad
- Division of Endocrinology and Metabolism (L.H., V.D., A.M., R.B., A.B., Y.C.K.), Mayo Clinic, Rochester, Minnesota; Department of Information Engineering (M.S., C.D.M., C.C.), University of Padova, Padova, Italy; Division of Gastroenterology (A.B.), Mayo Clinic, Rochester, Minnesota; Department of Health Sciences Research (J.R.G., R.E.C.), Mayo Clinic, Rochester, Minnesota 55905
| | - Chiara Dalla Man
- Division of Endocrinology and Metabolism (L.H., V.D., A.M., R.B., A.B., Y.C.K.), Mayo Clinic, Rochester, Minnesota; Department of Information Engineering (M.S., C.D.M., C.C.), University of Padova, Padova, Italy; Division of Gastroenterology (A.B.), Mayo Clinic, Rochester, Minnesota; Department of Health Sciences Research (J.R.G., R.E.C.), Mayo Clinic, Rochester, Minnesota 55905
| | - Adil Bharucha
- Division of Endocrinology and Metabolism (L.H., V.D., A.M., R.B., A.B., Y.C.K.), Mayo Clinic, Rochester, Minnesota; Department of Information Engineering (M.S., C.D.M., C.C.), University of Padova, Padova, Italy; Division of Gastroenterology (A.B.), Mayo Clinic, Rochester, Minnesota; Department of Health Sciences Research (J.R.G., R.E.C.), Mayo Clinic, Rochester, Minnesota 55905
| | - Rita Basu
- Division of Endocrinology and Metabolism (L.H., V.D., A.M., R.B., A.B., Y.C.K.), Mayo Clinic, Rochester, Minnesota; Department of Information Engineering (M.S., C.D.M., C.C.), University of Padova, Padova, Italy; Division of Gastroenterology (A.B.), Mayo Clinic, Rochester, Minnesota; Department of Health Sciences Research (J.R.G., R.E.C.), Mayo Clinic, Rochester, Minnesota 55905
| | - Jennifer R Geske
- Division of Endocrinology and Metabolism (L.H., V.D., A.M., R.B., A.B., Y.C.K.), Mayo Clinic, Rochester, Minnesota; Department of Information Engineering (M.S., C.D.M., C.C.), University of Padova, Padova, Italy; Division of Gastroenterology (A.B.), Mayo Clinic, Rochester, Minnesota; Department of Health Sciences Research (J.R.G., R.E.C.), Mayo Clinic, Rochester, Minnesota 55905
| | - Rickey E Carter
- Division of Endocrinology and Metabolism (L.H., V.D., A.M., R.B., A.B., Y.C.K.), Mayo Clinic, Rochester, Minnesota; Department of Information Engineering (M.S., C.D.M., C.C.), University of Padova, Padova, Italy; Division of Gastroenterology (A.B.), Mayo Clinic, Rochester, Minnesota; Department of Health Sciences Research (J.R.G., R.E.C.), Mayo Clinic, Rochester, Minnesota 55905
| | - Claudio Cobelli
- Division of Endocrinology and Metabolism (L.H., V.D., A.M., R.B., A.B., Y.C.K.), Mayo Clinic, Rochester, Minnesota; Department of Information Engineering (M.S., C.D.M., C.C.), University of Padova, Padova, Italy; Division of Gastroenterology (A.B.), Mayo Clinic, Rochester, Minnesota; Department of Health Sciences Research (J.R.G., R.E.C.), Mayo Clinic, Rochester, Minnesota 55905
| | - Ananda Basu
- Division of Endocrinology and Metabolism (L.H., V.D., A.M., R.B., A.B., Y.C.K.), Mayo Clinic, Rochester, Minnesota; Department of Information Engineering (M.S., C.D.M., C.C.), University of Padova, Padova, Italy; Division of Gastroenterology (A.B.), Mayo Clinic, Rochester, Minnesota; Department of Health Sciences Research (J.R.G., R.E.C.), Mayo Clinic, Rochester, Minnesota 55905
| | - Yogish C Kudva
- Division of Endocrinology and Metabolism (L.H., V.D., A.M., R.B., A.B., Y.C.K.), Mayo Clinic, Rochester, Minnesota; Department of Information Engineering (M.S., C.D.M., C.C.), University of Padova, Padova, Italy; Division of Gastroenterology (A.B.), Mayo Clinic, Rochester, Minnesota; Department of Health Sciences Research (J.R.G., R.E.C.), Mayo Clinic, Rochester, Minnesota 55905
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