Role of environmental factors in the development of noninsulin-dependent diabetes mellitus

Environmental factors, such as excessive caloric intake leading to obesity, altered dietary composition, physical inactivity, various forms of stress, hormonal imbalance, drugs, toxins, and the process of aging, may contribute to the development of noninsulin-dependent diabetes mellitus in the genetically predisposed subject but do not by themselves cause the disease. Both abnormal pancreatic beta-cell function and decreased sensitivity to insulin are present in most patients with noninsulin-dependent diabetes mellitus, and the degree of carbohydrate intolerance is dependent on the interaction between these two factors. Efforts to prevent or treat noninsulin-dependent diabetes mellitus should be aimed primarily towards eliminating factors associated with the development of insulin resistance and promoting those that increase insulin sensitivity. Obesity, the composition of the diet, and level of physical training are all important in this regard and are the major environmental factors discussed herein.

Thermic effect of infused glucose and insulin in man. Decreased response with increased insulin resistance in obesity and noninsulin-dependent diabetes mellitus

The thermic effect of infused glucose and insulin was measured by combining the hyperinsulinemic euglycemic clamp technique with indirect calorimetry, in 10 normal weight volunteers (group I), 7 obese subjects with normal glucose tolerance (group II), and 13 obese subjects with abnormal glucose tolerance or noninsulin-dependent diabetes mellitus before (group IIIa) and after weight loss of 10.8 +/- 0.4 kg (group IIIb). During hyperinsulinemia (760-1,100 pmol/liter), total glucose disposal from combined endogenous production and glucose infusion was 545 +/- 49, 441 +/- 70, 233 +/- 35, 231 +/- 31 mg/min and energy expenditure changed by + 0.476 +/- 0.080, +0.293 +/- 0.095, -0.114 +/- 0.063, and +0.135 +/- 0.082 kJ/min in group I, II, IIIa, and IIIb, respectively. The increased energy expenditure correlated with glucose storage (measured cost of processing the glucose: 1.33 kJ/g). In group IIIa there was no increase in energy expenditure in response to glucose and insulin infusions. After therapy (group IIIb) there was a significant recovery (P less than 0.05) of the thermic effect of infused glucose although total glucose disposal was unchanged. It is proposed that the recovered thermic effect of infused insulin/glucose is due to the different contributions of gluconeogenesis in the fasting state and during the glucose clamp before and after weight loss. In addition we hypothesize that some of the lower thermic effect of food reported in obese noninsulin-dependent diabetics may be explained by decreased energy expenditure due to a greater suppression of hepatic gluconeogenesis as well as by lower storage rate.

Effects of carbohydrate-containing and carbohydrate-restricted hypocaloric and eucaloric diets on serum concentrations of retinol-binding protein, thyroxine-binding prealbumin and transferrin

The effects of diet on the serum concentrations of albumin, transferrin, thyroxine-binding prealbumin (TBPA) and retinol-binding protein (RBP) were studied in 3 groups of obese subjects (Groups I-III) and 1 group of normal weight subjects (Group IV). Group I subjects ate either a 830 kcal carbohydrate-containing diet (CCD) or carbohydrate-restricted diet (CRD), Group II and III subjects ate a hypocaloric CRD. Subjects in Group IV ate a eucaloric CRD. Serum albumin concentrations did not change in any of the 4 groups. Only the subjects in Group II had a statistically significant decrease in serum transferrin concentration 6 wk after starting the hypocaloric, CRD. Group I individuals eating the CRD and the subjects in Groups II, III and IV had significant decreases in the serum concentrations of TBPA and RBP after 1 wk which persisted without further change during the remaining 3-5 wk of the diets. Group I subjects eating the CCD had a significant decrease in TBPA concentration at 1 and 6 wk. The RBP serum concentration was significantly decreased after 1 wk on the diet, but was not significantly different from the control diet period at 6 wk. The magnitude of the decreases in serum concentrations of TBPA and RBP in the Group I subjects eating the CRD were significantly greater than in the Group I subjects eating the CCD. Thus, ingestion of a hypocaloric, CRD by obese individuals results in decreased serum concentrations of TBPA and RBP. Isocaloric substitution of carbohydrate for fat reduces this effect. Dietary carbohydrate apparently modulates the serum concentrations of TBPA and RBP, independently of caloric intake, since ingestion of a eucaloric CRD by normal weight individuals also decreased the serum concentration of the two visceral proteins.

Physical training of lean and genetically obese Zucker rats: effect on fat cell metabolism

The effects of 6-wk treadmill training program on the metabolism of isolated adipose cells from obese (fa/fa) and lean (Fa/?) Zucker rats were studied. Glucose metabolism and transport, insulin binding, and lipolysis were measured in adipose cells prepared from sedentary control and exercise-trained (ET) lean and/or obese rats. Two- to threefold increases in glucose metabolism were observed in cells from lean and obese ET rats compared with their respective controls. However, the insulin concentrations giving half-maximal stimulation (measuring insulin sensitivity) did not change (approximately 8 microunits/ml in lean and approximately 45 microunits/ml in obese rats). In lean ET rats, glucose transport and maximal glucose metabolic capacity (transport not rate-limiting) were increased twofold and sensitivity of lipolysis to epinephrine was increased three- to fourfold. These were not measured in obese rats. The results suggest that training of both lean and obese Zucker rats increases glucose utilization in adipose cells by increasing both glucose transport and intracellular glucose metabolism. Increased triglyceride turnover is also suggested by the increased sensitivity of lipolysis to epinephrine.

Impact of hydrogen ion on fasting ketogenesis: feedback regulation of acid production

To determine whether acid-base balance regulates hydrogen ion production, seven obese volunteers were given NaHCO3 and NH4Cl (2 mmol.kg-1.day-1) during two separate 7-day fasts. On days 5-7 plasma bicarbonate was lower in the NH4Cl fasts (14.0 +/- 1.4 mM) than in the NaHCO3 fasts (18.3 +/- 1.1 mM), while urine pH and net acid excretion did not differ. Acid production (acid excretion minus intake) was greater by 204 mmol/day in the NaHCO3 fasts (274 +/- 16 mmol/day) than in the NH4Cl fasts (70 +/- 19 mmol/day). Ketoacid excretion, which reflected net ketoacid production, paralleled acid production, decreasing from 213 +/- 24 mmol/day in the NaHCO3 fasts to 67 +/- 18 mmol/day in the NH4Cl fasts. Thus, during starvation, alterations in hydrogen ion intake and the associated changes in acid-base balance modify the net production of endogenous acid by influencing the synthesis or utilization of ketoacids. Although the specific site of this metabolic regulation is undefined, these results indicate that systemic acid-base status can exert feedback control over hydrogen ion production.

Effects of loop diuretics on carbohydrate metabolism and electrolyte excretion

The effects of two loop diuretics, bumetanide and furosemide, on carbohydrate metabolism and electrolyte balance were assessed in 11 normal male subjects in a double-blind manner. Glucose, insulin, glucagon, and growth hormone responses to 5-hour glucose tolerance test and arginine infusion were measured during the control and drug treatment periods. Three other non-insulin-dependent diabetic subjects, receiving diuretic drug for six weeks, underwent a similar protocol. Kaliuresis and natriuresis due to diuretic administration were significant only on day 1 of treatment. There were no significant changes in total body potassium by 40K counting; net potassium loss by balance study was minimal in both the acutely treated subjects and the chronically treated patients. Effects of bumetanide and furosemide on water and electrolyte excretion did not differ. Glucose tolerance was significantly improved with bumetanide but not with furosemide. Plasma insulin, glucagon, and growth hormone levels during the oral glucose tolerance test were unaffected by either drug. Insulin levels with arginine infusion were significantly increased, and growth hormone levels decreased with bumetanide but not with furosemide. No evidence of impaired carbohydrate metabolism in the three chronically treated diabetic subjects was seen. It is concluded that the effects of bumetanide and furosemide on potassium balance and glucose utilization were minimal in this experimental setting.

Comparison of carbohydrate-containing and carbohydrate-restricted hypocaloric diets in the treatment of obesity. Endurance and metabolic fuel homeostasis during strenuous exercise

Eight untrained, obese females (greater than 30% body fat), ages 25-33 yr, were studied before, at 1 wk, and after 6 wk while taking either of two 830-kcal/d diets: carbohydrate-containing (CC) group (n = 4): 35% protein, 29% fat, 36% carbohydrate-restricted (CR) group (n = 4): 35% protein, 64% fat, 1% carbohydrate. Endurance, at approximately 75% of VO2max (maximum oxygen uptake) on a cycle decreased from base line by 50% at 1 and 6 wk in the CR group, but there was no change in the CC group. Preexercise muscle glycogen (vastus lateralis) did not change significantly in the CC group, but was decreased by 49% in the CR group after 1 wk, and by 51% after 6 wk. There was a close correlation between percent decrease in resting muscle glycogen and percent decrease in endurance (r = 0.79, P less than 0.01). The mean fasting and exercise plasma glucose concentration was lower in the CR group than in the CC group after 6 wk, but no subject became hypoglycemic during exercise. Serum FFA, lactate, pyruvate, beta-hydroxybutyrate, acetoacetate, insulin, and glucagon changed similarly in the two groups during exercise at base line, 1 and 6 wk. Glycerol concentration was higher in the CR group during exercise only after 6 wk. Increases in serum lactate concentrations, and a mean exercise respiratory quotient of 0.93 suggested that cycle exercise at approximately 75% VO2max used predominantly glucose as a fuel.

CONCLUSIONS

Resting muscle glycogen and endurance, during cycle exercise at approximately 75% VO2max, were maintained during a 36% carbohydrate, 830-kcal/d diet. In contrast, significant decreases, occurred in resting muscle glycogen and endurance, during similar exercise, after 6 wk of a 1% carbohydrate, 830-kcal/d diet.

Effect of prolonged experimental protein malnutrition and of refeeding on growth, adipose tissue development and body composition in rats

The effect of experimental protein malnutrition and of subsequent refeeding at various ages on growth, adipose tissue development, body composition and serum triiodothyronine (T3) concentration were studied in weanling, male Sprague-Dawley rats fed isoenergetic diets containing 22% casein (controls) or 8% casein (PM-3) from 3 until 33 weeks of age. In addition, groups of control rats were switched to the 8% casein diet at 7 weeks of age (PM-7), and groups of PM-3 rats were refed the control diet from 7 (RF-7) or 11 (RF-11) weeks of age. At 33 weeks of age, PM-3 rats were 56% and PM-7 rats 82% the weight of controls, while RF-7 rats were 84% and RF-11 77% the weight of controls, respectively. Carcass fat and energy content corresponded to body weight in all groups. The weights of the epididymal fat pads of control rats did not increase after 24 weeks of age. The epididymal fat pad weights of all other groups remained smaller than those of controls, but continued to increase throughout the study. Epididymal adipocyte numbers did not change after 11 weeks of age in control rats or after 17 weeks of age in PM-7 and RF-7 rats, but continued to increase throughout the 33 weeks in the PM-3 and RF-11 rats. Adipocyte size increased with age in all groups but remained smaller throughout in PM-3 rats. Serum T3 concentrations were greatest in the PM-3 rats, intermediate in the PM-7 rats and became normalized in both RF groups by 33 weeks of age. These studies confirm that the postweaning protein deprivation impairs the growth of lean tissues and indicate that its primary effect on adipose tissue is a decrease in adipocyte proliferation and/or differentiation which may not recover with refeeding.

Capacity for moderate exercise in obese subjects after adaptation to a hypocaloric, ketogenic diet

To study the capacity for moderate endurance exercise and change in metabolic fuel utilization during adaptation to a ketogenic diet, six moderately obese, untrained subjects were fed a eucaloric, balanced diet (base line) for 2 wk, followed by 6 wk of a protein-supplemented fast (PSF), which provided 1.2 g of protein/kg ideal body wt, supplemented with minerals and vitamins. The mean weight loss was 10.6 kg. The duration of treadmill exercise to subjective exhaustion was 80% of base line after 1 wk of the PSF, but increased to 155% after 6 wk. Despite adjusting up to base line, with a backpack, the subjects' exercise weight after 6 wk of dieting, the final exercise test was performed at a mean of 60% of maximum aerobic capacity, whereas the base-line level was 76%. Resting vastus lateralis glycogen content fell to 57% of base line after 1 wk of the PSF, but rose to 69% after 6 wk, at which time no decrement in muscle glycogen was measured after >4 h of uphill walking. The respiratory quotient (RQ) during steady-state exercise was 0.76 during base line, and fell progressively to 0.66 after 6 wk of the PSF. Blood glucose was well maintained during exercise in ketosis. The sum of acetoacetate and beta hydroxybutyrate rose from 3.28 to 5.03 mM during exercise after 6 wk of the PSF, explaining in part the low exercise RQ. The low RQ and the fact that blood glucose and muscle glycogen were maintained during exhausting exercise after 6 wk of a PSF suggest that prolonged ketosis results in an adaptation, after which lipid becomes the major metabolic fuel, and net carbohydrate utilization is markedly reduced during moderate but ultimately exhausting exercise.

Thyroid and growth responses of young Zucker obese and lean rats to a low protein-high carbohydrate diet

Experiments were conducted to study the effects of a low protein-high carbohydrate diet on growth and thyroid function in obese and lean male and female Zucker rats. The nine feeding regimens included animals ad libitum fed either a 22% casein and 59% carbohydrate diet (control) or an 8% casein and 73% carbohydrate diet (low protein) and appropriate pair-fed groups to control for the lean rats eating less than the obese rats and the rats fed the low-protein diet eating less than those fed the control diet. The rats were 4 weeks old at the start of the experiment which lasted 7 weeks. Final body size, tibia length and nonfat dry mass of the lean rats were dependent primarily on the amount of protein consumed, whereas growth of the obese rats was related to total energy intake rather than to protein intake. The relative hyperphagia, decreased efficiency of energy utilization and increased oxygen consumption and serum T3 concentrations in the lean rats fed the low-protein diet were consistent with the development of an adaptive thermogenesis, allowing the excess non-protein energy to be dissipated through excess heat production. There was no evidence for such an adaptive thermogenesis in the obese rats. The suggestion that the obese rats were already overeating for protein and storing the excess energy as fat and that the decreased thyroid response might be part of a protective mechanism against overheating was discussed.

Dietary-induced alterations in thyroid hormone metabolism during overnutrition

Diet-induced alterations in thyroid hormone concentrations have been found in studies of long-term (7 mo) overfeeding in man (the Vermont Study). In these studies of weight gain in normal weight volunteers, increased calories were required to maintain weight after gain over and above that predicted from their increased size. This was associated with increased concentrations of triiodothyronine (T3). No change in the caloric requirement to maintain weight or concentrations of T3 was found after long-term (3 mo) fat overfeeding. In studies of short-term overfeeding (3 wk) the serum concentrations of T3 and its metabolic clearance were increased, resulting in a marked increase in the production rate of T3 irrespective of the composition of the diet overfed (carbohydrate 29.6 +/- 2.1 to 54.0 +/- 3.3, fat 28.2 +/- 3.7 to 49.1 +/- 3.4, and protein 31.2 +/- 2.1 to 53.2 +/- 3.7 microgram/d per 70 kg). Thyroxine production was unaltered by overfeeding (93.7 +/- 6.5 vs. 89.2 +/- 4.9 microgram/d per 70 kg). It is still speculative whether these dietary-induced alterations in thyroid hormone metabolism are responsible for the simultaneously increased expenditure of energy in these subjects and therefore might represent an important physiological adaptation in times of caloric affluence. During the weight-maintenance phases of the long-term overfeeding studies, concentrations of T3 were increased when carbohydrate was isocalorically substituted for fat in the diet. In short-term studies the peripheral concentrations of T3 and reverse T3 found during fasting were mimicked in direction, if not in degree, with equal or hypocaloric diets restricted in carbohydrate were fed. It is apparent from these studies that the caloric content as well as the composition of the diet, specifically, the carbohydrate content, can be important factors in regulating the peripheral metabolism of thyroid hormones.

Neural release of glucagon is inhibited by hyperglycemia and enhanced by phentolamine

Using an innervated, cross-perfused, canine pancreas-stomach-duodenum preparation, direct neural effects on the immunoreactive glucagon secretion rate (GSR) were separated from blood-borne influences. Both splanchnic nerves were cut above the diaphragm and stimulated simultaneously for three separate 10-min-long periods, twice before and once during a pancreatic arterial phentolamine infusion. The extent of the decreases in GSR that occurred after nerve section was inversely correlated with the arterial plasma glucose concentration at the time of section. Splanchnic nerve stimulation caused a significant increase in GSR. Similar stimulation during a pancreatic arterial phentolamine infusion caused a significantly greater increase. Rapid infusion of glucose near the end of the experiment caused a significant decrease in GSR, demonstrating the responsiveness of the preparation. These data were collected in conjunction with a study of neural influences on insulin secretion rates. It can be concluded that the central nervous system can alter the secretion rate of glucagon by direct neural means. Alpha-adrenergic blockade, in the presence of splanchnic nerve stimulation, enhances GSR.

Changes in serum concentrations of 3,3',5'-triiodothyronine and 3,5,3'-triiodothyronine during prolonged moderate exercise

The effect of moderate bicycle exercise (3.5 h) on peripheral thyroid hormone metabolism was studied under two conditions (with and without glucose infusion) in four normal males. Serum T3, rT3, total protein, plasma glucose, and FFA were determined. Exercise induced an increase in rT3 from 29 to 40 ng/dl (P less than 0.01), a decrease in T3 from 154 to 147 ng/dl (P less than 0.01), and an increase in T4 from 7.1 to 7.5 micrograms/dl (P less than 0.05). When glucose was infused during exercise, the changes in rT3 were blunted (P less than 0.01) and the changes in T3 and T4 were diminished. During exercise, rT3 correlated with FFA (r = 0.95) and plasma glucose (r = -0.87). When glucose was infused during exercise, these correlations decreased (r = 0.81 and -0.56, respectively). Since moderate, prolonged exercise induces a state of early or acute starvation it is concluded that the changes in peripheral thyroid hormone metabolism reported here are similar to those found in starvation. The temporal changes of rT3, FFA, and plasma glucose during exercise suggest a relationship between thyroid hormone metabolism and the uptake and utilization of FFA and glucose or the mixture of these body fuels.

Characteristics of thyroid function in experimental protein malnutrition

Two experiments were conducted to study the effects of protein malnutrition on thyroid function. Resting oxygen consumption and serum concentrations of triiodothyronine (T3), thyroxine (T4) and thyroid stimulating hormone (TSH) were measured and correlated with thyroid histology, gain in weight, feed efficiency and carcass energy content in male rats fed isoenergetic diets ad libitum containing 22% (control) or 8% (protein malnourished, PM) casein for 28 or 32 days postweaning. A third group was pair-fed to the PM rats with the control diet. In experiment 2 additional groups were pair-fed to the PM rats with 8% casein diets in which the casein was substituted with different mixtures of carbohydrate and fat. Resting oxygen consumption/body weight (0.75) decreased as body weights increased in all groups, but was consistently greatest in PM rats. In PM rats, plasma T3 was 130% of controls after 11 days of the dietary regimen and averaged 215% of controls from days 18 through 32. In experiment 2 both T3 and T4 concentrations were approximately twice controls in all PM groups. TSH concentrations were within the normal range in all groups throughout. Feed efficiency averaged 36 to 40% of controls and mean weight gain was 30 g after 28 days in the PM groups, compared to 114 and 91 g, respectively, in the pair-fed control rats. Carcass energy content of PM rats after 28 days was significantly lower than in control or pair-fed control rats. Thyroid morphology was compatible with increased secretory activity in all the protein-malnourished groups, compared with normal activity in the control and pair-fed control groups. Thermogenesis, as measured by oxygen consumption, was markedly increased in the PM rats compared to controls. These observations are consistent with a diet-induced thermogenesis in the protein-malnourished rats. In contrast to simple under-nutrition where energy expenditure may be conserved by decreases in thyroid function and thermogenesis, increases in thyroid function and thermogenesis in protein malnutrition could provide an energy balancing mechanism whereby unneeded non-protein energy in the diet could be dissipated as heat, and survival enhanced.

Adipose tissue development, growth, and food consumption in protein-malnourished rats

Effects of protein malnutrition on adipose tissue development were studied in weanling male Sprague-Dawley rats fed isocaloric diets ad libitum containing either 22% (controls) or 8% (protein-malnourished rats) casein, and in rats pair-fed to the protein-malnourished rats with the 22% casein diet. After 32 days on the diet, protein-malnourished rats were 37% and pair-fed 67% the weight of the controls, while torso length was 37% and 73% of controls, respectively. Food consumption relative to body weight was greatest in protein-malnourished rats. Compared to control rats, the distal epididymal adipocyte number in the protein-malnourished rats was decreased in proportion to the decrease in body size and was more closely related to the protein intake than to the total calories consumed. After 32 days on diet, mean adipocyte number per 2 distal pads was 11.7 x 10(6) in controls and 4.3 x 10(6) in protein-malnourished rats. In pair-fed rats, cell number lagged behind controls at 4 and 11 days, but was normal at 32 days (11.4 x 10(6) cells). The distal epididymal pad adipocyte size and percent lipid were similar in all groups during the first 25 days of dietary treatment. Adipocyte size was increased significantly in controls at day 32 compared to the other two groups. At each time studied through day 25 on diet, epididymal pad weight was related to the adipose cell number rather than the cell size. It is concluded that severe restriction of dietary protein during the postweaning period of growth in rats results in decreased epididymal adipocyte proliferation and/or differentiation concomitant with generalized growth retardation, whereas isocaloric feeding of a diet of normal protein content is associated with only a transient delay in adipose tissue development.

The effect of furosemide and bumetanide on warfarin metabolism and anticoagulant response

In a study of 11 normal subjects who received either furosemide or bumetanide, response to warfarin was unaffected by either diuretic. The mean prothrombin times after a single oral dose of 50 mg warfarin were 18.8 +/- 0.7 sec before and 19.6 +/- 1.7 sec during furosemide administration, and 18.3 +/- 1.4 sec before and 19.7 +/- 1.3 sec during bumetanide administration. Mean plasma warfarin half-lives were 43.2 +/- 2.8 hr before and 37.8 +/- 1.7 hr during furosemide treatment and 39.9 +/- 9.5 hr before and 37.4 +/- 2.4 hr during bumetanide treatment. Hypoprothrombinemic responses, plasma warfarin concentrations, and warfarin half-lives were not significantly influenced by treatment with either diuretic. Both loop diuretics furosemide and bumetanide can be safely administered during warfarin anticoagulant therapy without risk of clinically significant interaction.

Glucagonoma syndrome. Report of two cases and literature review

The glucagonoma syndrome is characterized by dermatitis, stomatitis, elevated serum glucagon levels, abnormal glucose tolerance, weight loss, and anemia--all in association with a glucagon-secreting alpha-cell tumor of the pancreas. A review of 21 cases showed strikingly similar features. A generalized, symmetrical dermatitis initially appeared to be asteatotic or eczematous over the perineum, buttocks, and lower extremities. Gradually, a more characteristic migratory necrolytic erythema with transient bulla formation and erosions developed in intertriginous and dependent areas. Histologically, the most specific features included necrolysis of the upper epidermis, with liquefaction necrosis of the granular cell layer and subcorneal clefting or blister formation. The dermatologist is often first to examine such patients; early recognition of this syndrome with prompt surgical removal of the primary pancreatic lesion may afford cure of the neoplasm.