Basu, Ananda

Abstract Carbohydrate metabolism in humans is regulated by insulin secretion from pancreatic β‐cells and glucose disposal by insulin‐sensitive tissues. Insulin facilitates glucose utilization in peripheral tissues and suppresses hepatic glucose production. Any defects in insulin action predispose an individual to glucose intolerance and Type 2 diabetes mellitus. Early detection of defects in insulin action could provide opportunities to prevent or delay progression of the disease state. There are different approaches to assess insulin action. Initial methods, such as peripheral insulin concentration and simple indices, have several limitations. Subsequently, researchers developed methodologies using intravenous glucose infusion to determine glucose fluxes. However, these methodologies are limited by being non‐physiological. Newer, innovative techniques that have been developed are more sophisticated and physiological. By modelling glucose kinetics using isotope dilution techniques, several robust parameters can be obtained that are physiologically relevant and sound. This brief review summarizes most of the non‐physiological and physiological methodologies used to measure the variables of insulin action.

We recently demonstrated a diurnal pattern to insulin action (i.e., insulin sensitivity [SI]) in healthy individuals with higher SI at breakfast than at dinner. To determine whether such a pattern exists in type 1 diabetes, we studied 19 subjects with C-peptide–negative diabetes (HbA1c 7.1 ± 0.6%) on insulin pump therapy with normal gastric emptying. Identical mixed meals were ingested during breakfast, lunch, and dinner at 0700, 1300, and 1900 h in randomized Latin square of order on 3 consecutive days when measured daily physical activity was equal. The triple tracer technique enabled measurement of glucose fluxes. Insulin was administered according to the customary insulin:carbohydrate ratio for each participant. Although postprandial glucose excursions did not differ among meals, insulin concentration was higher (P < 0.01) and endogenous glucose production less suppressed (P < 0.049) at breakfast than at lunch. There were no differences in meal glucose appearance or in glucose disappearance between meals. Although there was no statistical difference (P = 0.34) in SI between meals in type 1 diabetic subjects, the diurnal pattern of SI taken across the three meals in its entirety differed (P = 0.016) from that of healthy subjects. Although the pattern in healthy subjects showed decreasing SI between breakfast and lunch, the reverse SI pattern was observed in type 1 diabetic subjects. The results suggest that in contrast to healthy subjects, SI diurnal pattern in type 1 diabetes is specific to the individual and cannot be extrapolated to the type 1 diabetic population as a whole, implying that artificial pancreas algorithms may need to be personalized.

Recently, we proposed a model describing the suppression of endogenous glucose production (EGP) during a meal. It assumes that EGP suppression depends on glucose concentration and its rate of change and on delayed insulin action. Hepatic insulin sensitivity (SILmeal) can be derived from EGP model parameters. This model was shown to adequately describe EGP profiles measured with multiple tracer techniques; however, SILmealhas never been compared directly with its euglycemic hyperinsulinemic clamp counterpart (SILclamp). To do so, 62 subjects with different degrees of glucose tolerance underwent a triple-tracer mixed meal. Fifty-seven subjects also underwent a labeled ([3-3H]glucose) euglycemic hyperinsulinemic clamp. From the triple-tracer meal data, virtually model-independent estimates of EGP were obtained using the tracer-to-tracee clamp technique, and the EGP model was identified in each subject. Model fit was satisfactory, and SILmealwas estimated with good precision. Correlation between SILclampand SILmealwas good ( r = 0.72, P < 0.001); however, SILmealwas lower than SILclamp(4.60 ± 0.64 vs. 8.73 ± 1.07 10−4dl·kg−1·min−1per μU/ml, P < 0.01). This difference may be due to different ranges of insulin explored during the two tests (ΔIclamp= 15.60 ± 1.61 vs. ΔImeal= 83.37 ± 10.71 μU/ml) as well as steady- vs. non-steady-state glucose and insulin profiles. In conclusion, the new EGP model provides an estimate of hepatic insulin sensitivity during a meal that is in good agreement with that derived in the same individuals with a hyperinsulinemic clamp. When used in conjunction with the minimal model, the approach potentially enables estimation of hepatic insulin sensitivity from a single-tracer labeled meal or oral glucose tolerance test.

The present analysis tests the hypothesis that quantifiable disruption of the glucose-stimulated insulin-secretion dose-response pathway mediates impaired fasting glycemia (IFG) and type 2 diabetes mellitus (DM). To this end, adults with normal and impaired fasting glycemia (NFG, n = 30), IFG ( n = 32), and DM ( n = 14) were given a mixed meal containing 75 g glucose. C-peptide and glucose were measured over 4 h, 13 times in NFG and IFG and 16 times in DM (age range 50–57 yr, body mass index 28–32 kg/m2). Wavelet-based deconvolution analysis was used to estimate time-varying C-peptide secretion rates. Logistic dose-response functions were constructed analytically of the sensitivity, potency, and efficacy (in the pharmacological sense of slope, one-half maximal stimulation, and maximal effect) of glucose's stimulation of prehepatic insulin (C-peptide) secretion. A hysteresis changepoint time, demarcating unequal glucose potencies for onset and recovery pathways, was estimated simultaneously. According to this methodology, NFG subjects exhibited distinct onset and recovery potencies of glucose in stimulating C-peptide secretion (6.5 and 8.5 mM), thereby defining in vivo hysteresis (potency shift −2.0 mM). IFG patients manifested reduced glucose onset potency (8.6 mM), and diminished C-peptide hysteretic shift (−0.80 mM). DM patients had markedly decreased glucose potency (18.8 mM), reversal of C-peptide's hysteretic shift (+4.5 mM), and 30% lower C-peptide sensitivity to glucose stimulation. From these data, we conclude that a dynamic dose-response model of glucose-dependent control of C-peptide secretion can identify disruption of in vivo hysteresis in patients with IFG and DM. Pathway-defined analytic models of this kind may aid in the search for prediabetes biomarkers.

Purrpose: To evaluate myocardial microvascular disease in patients with type 2 diabetes mellitus (DM) using myocardial contrast echocardiography (MCE) and to report on its diagnostic accuracy using single photon emission tomography (SPECT) as reference test. Methods: We prospectively enrolled 79 patients (25 DM; 66±11 years) who underwent simultaneous SPECT and MCE with contrast agent during adenosine stress. MCE and SPECT were visually analyzed using 17 segments. Quantitative MCE parameters were derived from replenishment curves. Microbubble velocity (β min −1 ), absolute myocardial blood flow (MBF ml/min/g), and reserve values were calculated. Diagnostic accuracy and area under curve (AUC) was reported. Results: Patients with DM had higher BMI vs non DM (33±7 vs 28±5kg/m 2 P=0 .007), with more prior myocardial infarction (40 vs 15% P=.01). Visual MCE was abnormal in 40 (51%) patients (60% in DM vs 46% in non DM P=0.04). SPECT was abnormal in 38 (48%) patients [60% in DM vs 42% non DM, P=0.01]. Reserve parameters were lower in DM vs. non DM patients: (β 1.77±1.12 vs 2.20±1.4, P<0.001 and MBF 2.86± 2.62 vs. 3.67±2.84, P<0.001). DM patients without CAD on SPECT had significantly lower β, and MBF reserve compared to non DM patients without CAD. Compared to SPECT, β reserve cutoff 1.6 had AUC 0.817, sensitivity 81%, and specificity 66% while MBF reserve cutoff 1.9 had AUC 0.760, sensitivity 79%, and specificity 63% in DM patients. Conclusion: Diabetes is associated with myocardial microvascular abnormalities as evidenced by abnormal myocardial perfusion on visual and quantitative MCE.

The deuterated water method is used extensively to measure gluconeogenesis in humans. This method assumes negligible exchange of the lower three carbons of fructose 6-phsophate via transaldolase exchange since this exchange will result in enrichment of carbon 5 of glucose in the absence of net gluconeogenesis. The present studies tested this assumption.2H2O and acetaminophen were ingested and [1-13C]acetate infused in 11 nondiabetic subjects after a 16-h fast. Plasma and urinary glucuronide enrichments were measured using nuclear magnetic resonance spectroscopy before and during a 0.35 mU·kg FFM−1·min−1insulin infusion. Rates of endogenous glucose production measured with [3-3H]- and [6,6-2H2]glucose did not differ either before (14.0 ± 0.7 vs. 13.8 ± 0.7 μmol·kg−1·min−1) or during the clamp (10.4 ± 0.9 vs. 10.9 ± 0.7 μmol·kg−1·min−1), consistent with equilibration and quantitative removal of tritium during triose isomerase exchange. Plasma [3-13C] glucose-to-[4-13C]glucose and urinary [3-13C] glucuronide-to-[4-13C]glucuronide ratios were <1.0 ( P < 0.001) in all subjects both before (0.66 ± 0.04 and 0.60 ± 0.04) and during (059 ± 0.05 and 0.56 ± 0.06) the insulin infusion, respectively, indicating that ∼35–45% of the labeling of the 5th carbon of glucose by deuterium was due to transaldolase exchange rather than gluconeogenesis. When corrected for transaldolase exchange, rates of gluconeogenesis were lower ( P < 0.001) and glycogenolysis higher ( P < 0.001) than uncorrected rates both before and during the insulin infusion. In conclusion, assuming negligible dilution by glycerol and near-complete triose isomerase equilibration, these data provide strong experimental evidence that transaldolase exchange occurs in humans, resulting in an overestimate of gluconeogenesis and an underestimate of glycogenolysis when measured with the2H2O method. Use of appropriate13C tracers provides a means of correcting for transaldolase exchange.

OBJECTIVE To determine whether deuterium enrichment on carbons 5 and 3 (C5/C3) in plasma glucose is influenced by processes other than gluconeogenesis and, if so, whether these processes are altered by type 2 diabetes. RESEARCH DESIGN AND METHODS In this study, 10 obese diabetic and 10 obese nondiabetic subjects were infused intravenously with [3,5-2H2] galactose enriched at a C5-to-C3 ratio of 1.0 as well as the enrichment of deuterium on C5 and C3 of plasma glucose, measured with nuclear magnetic resonance using the acetaminophen glucuronide method. RESULTS The ratio of deuterium enrichment on C5 and C3 of glucose was &lt;1 (P &lt; 0.001) in all of the diabetic and nondiabetic subjects, resulting in a means ± SE C5-to-C3 ratio that did not differ between groups (0.81 ± 0.01 vs. 0.79 ± 0.01, respectively). CONCLUSIONS That the C5-to-C3 glucose ratio is &lt;1 indicates that transaldolase exchange, selective retention of deuterium at the level of the triose-isomerase reaction, or both occur in humans. This also indicates that the net effect of these processes on the C5-to-C3 ratio is the same in people with and without type 2 diabetes. The possible effects of transaldolase exchange or selective retention of deuterium (or tritium) at the level of the triose-isomerase reaction on tracee labeling and tracer metabolism should be considered when the deuterated water method is used to measure gluconeogenesis or [3-3H] glucose is used to measure glucose turnover in humans.

OBJECTIVE In this study, we sought to determine whether postprandial insulin secretion, insulin action, glucose effectiveness, and glucose turnover were abnormal in type 2 diabetes. RESEARCH DESIGN AND METHODS Fourteen subjects with type 2 diabetes and 11 nondiabetic subjects matched for age, weight, and BMI underwent a mixed-meal test using the triple-tracer technique. Indexes of insulin secretion, insulin action, and glucose effectiveness were assessed using the oral “minimal” and C-peptide models. RESULTS Fasting and postprandial glucose concentrations were higher in the diabetic than nondiabetic subjects. Although peak insulin secretion was delayed (P &lt; 0.001) and lower (P &lt; 0.05) in type 2 diabetes, the integrated total postprandial insulin response did not differ between groups. Insulin action, insulin secretion, disposition indexes, and glucose effectiveness all were lower (P &lt; 0.05) in diabetic than in nondiabetic subjects. Whereas the rate of meal glucose appearance did not differ between groups, the percent suppression of endogenous glucose production (EGP) was slightly delayed and the increment in glucose disappearance was substantially lower (P &lt; 0.01) in diabetic subjects during the first 3 h after meal ingestion. Together, these defects resulted in an excessive rise in postprandial glucose concentrations in the diabetic subjects. CONCLUSIONS When measured using methods that avoid non–steady-state error, the rate of appearance of ingested glucose was normal and suppression of EGP was only minimally impaired. However, when considered in light of the prevailing glucose concentration, both were abnormal. In contrast, rates of postprandial glucose disappearance were substantially decreased due to defects in insulin secretion, insulin action, and glucose effectiveness.