Diabetes: the genetic connections

Opiate modulation of glucose turnover in dogs

We examined the effect of opiate infusion and of opiate blockage on glucose turnover in the basal state, using isotope dilution techniques in trained conscious dogs (n = 5). After a primed-continuous infusion of 3-3H glucose to steady state specific activity (90 minutes), infusion of one of the following was given: D-met2 pro5 enkephalinamide (DMPE), a potent morphine-like opiate, 0.5 mus g/kg/min; naloxone, an opiate antagonist, 1.25 mg followed by 10 mus g/min; or saline control. Infusion of DMPE led to a fall in glucose from 92 +/- 3 to 87 +/- 3 mg/dL by 60 minutes (P less than 0.05), associated with a rise in glucose utilization (Rd) from 3.0 +/- 0.4 to 3.9 +/- 0.6 mg/kg/min by 30 minutes (P less than 0.05); a transient rise in glucose production (Ra; from 3.2 +/- 0.4 to 4.3 +/- 0.4 mg/kg/min; P less than 0.05). Changes in counterregulatory hormones did not account for these findings; insulin was unchanged during all infusions; glucagon showed small late rises at 75 minutes during both DMPE and naloxone infusion; cortisol rose by 30 and 15 minutes, respectively, of DMPE and naloxone infusion; epinephrine rose transiently after 5 minutes of naloxone but was unchanged during DMPE, and norepinephrine was unchanged throughout. Saline infusion had no effects on any of these indices. We conclude that a potent opiate with morphine-like effects (DMPE) can lower glucose in dogs by enhancing peripheral glucose utilization independently of hormonal changes.

[3H]ouabain binding and sodium content in lymphocyte sub-populations and the demonstration of increased binding in type 2 diabetes mellitus

The number of specific [3H]ouabain binding sites in T-lymphocytes was determined and linear Scatchard plots were obtained. The number of sites was 30088 +/- 3039 (mean +/- SD) per lymphocyte in 14 healthy males and 33939 +/- 3185 in 11 males with type 2 diabetes (P less than 0.01). No difference between the dissociation constants were found (Kd = 3.91 and 3.86 mmol/l). The number of binding sites in lymphocytes from 15 healthy males with normal glucose tolerance but with a strong family history of type 2 diabetes did not differ from the controls. In T-lymphocytes a significantly higher number of specific ouabain binding sites was found than in non-T-lymphocytes (P less than 0.01). There was no difference between the dissociation constants. (Kd = 3.69 and 3.97 mmol/l). Intra-lymphocytic sodium was measured in 18 healthy individuals and the mean content was 8.1 +/- 2.3 mmol/kg lymphocytes. A lower content of sodium in T- compared to non-T-lymphocytes was also found (5.9 +/- 0.8 mmol/kg vs 15.5 +/- 0.8 mmol/kg, P less than 0.001). There was no correlation between lymphocytes and erythrocytes concerning [3H]ouabain binding sites or sodium concentration.

The genetics of type I and type II diabetes: analysis by recombinant DNA methodology

Susceptibility to IDDM is linked to the HLA-D locus on the short arm of chromosome 6, a region believed to be involved in the process of communication between cells which determines immune responses. Presumably an HLA molecule encoded by this region, unable to present a particular antigenic pathogen to the immune system, is inherited. The HLA-DR locus is quite complex, however. The gene which codes for this defective molecule may be identified by a combination of use of monoclonal antibodies and cloned gene probes which specifically hybridize to various portions of this region. Investigators are searching for HLA-DR4 containing chromosomes in IDDM which show similar patterns of restriction enzyme polymorphism. Hopefully, complete structural analysis of these related sequences will provide information about the mechanisms which confer susceptibility to develop IDDM. A strong genetic component is involved in NIDDM evidenced by a high concordance in monozygotic twins. Nevertheless, there is much evidence of genetic heterogeneity. At the present time no clear cut genetic marker has been defined. The human insulin gene has been cloned and by Southern blot hybridization analysis of peripheral leukocyte DNA, the insulin gene locus is being evaluated as a possible contributor to the genetic defect. Population studies at the present time have not identified any particular polymorphic insulin allele associated with NIDDM. Population studies are complicated by heterogeneity of NIDDM, racial and ethnic differences, and heterogeneity of insulin alleles. Linkage analysis in family studies will provide an alternative approach to population studies to determine what role if any the insulin gene plays in the genetic component of this disease. Because NIDDM is heterogeneous and perhaps polygenic in nature, these linkage analyses in families with NIDDM can be extended to other genes when they are cloned such as that coding for the insulin receptor. The familial aggregation of diabetes has long been noted (see ref. 1 for review). In relatives of diabetics, the prevalence ranges from 10-30%, while it is variously estimated to be between 0.1-3% in the general population. But familial aggregation of a trait may be caused either by genetic or environmental factors. One approach to dissecting the contribution of these factors is the study of concordance in twins. Pyke and associates observed that overall identical twins always show a higher concordance rate than dizygotic twins, irrespective of their age of diagnosis. Furthermore, they noted that identical twins of younger onset are often discordant for diabetes while identical twins of older onset are usually concordant.(ABSTRACT TRUNCATED AT 400 WORDS)

Heterogeneity within type II and MODY diabetes

The heterogeneity within Type II diabetes (NIDDM) and within Maturity-Onset type Diabetes of Young people (MODY), a subset of NIDDM which is inherited in an autosomal dominant fashion, is discussed. Aspects of the definition and phenotypic expression of MODY are reviewed. Within NIDDM there are differences in patterns of inheritance between subgroups. HLA antigen associations are not found in most NIDDM populations but exist in three specific population groups with Type II diabetes. Within NIDDM and within MODY there are differences in the magnitude of insulin responses to glucose, differences in target tissue responsiveness to insulin in vivo, and differences in receptor and post-receptor effects of insulin. Structurally abnormal variant and biologically defective insulin molecules have been found in some Type II diabetic patients and in members of certain MODY families. The presence or absence of obesity may mark heterogeneous groups of Type II diabetic patients, in addition to the importance of obesity in uncovering an insulin secretory defect by causing insulin resistance. There is heterogeneity in susceptibility to vascular disease within NIDDM and MODY. The natural history of carbohydrate metabolism and of insulin secretory responses to glucose in early Type I diabetes and in MODY with low insulin secretory responses are illustrated and similarities and dissimilarities compared and contrasted. Failure to recognize young patients with MODY may contribute to incorrect diagnosis, management, and assignment of prognosis of this form of diabetes in the young by many practicing physicians. The recognition that Type I or insulin-dependent diabetes (IDDM) and Type II or noninsulin-dependent (NIDDM) differ from each other not only phenotypically but also in etiology and pathogenesis led the National Diabetes Data Group (NDDG) to devise the present nomenclature and classification of diabetes mellitus. These were adopted by the World Health Organization. As suggested by the NDDG report, the classification should be reexamined periodically to reflect improved understanding of the disease, to stimulate further research, and to be of help to practicing physicians.

[Facial vasomotor flushing due to alcohol-chlorpropamide. Prevalence in diabetic and non-diabetic patients]

Using a standard test (sherry 40 ml 12 hours and 36 hours after 250 mg chlorpropamide), chlorpropamide-alcohol flush (CPAF) prevalence was 34 p. 100 (19/56) in non insulin-dependent diabetics (NIDD), 10 p. 100 (3/30) in insulin-dependent diabetics and 7 p. 100 (2/27) in controls. Family history of diabetes was not associated with CPAF trait. Conflicting results in the literature might be explained by bias in patients selection or methodology.

Responses of blood glucose and serum insulin to peroral glucose load in normoglycemic twins

Fasting blood glucose and serum immunoreactive insulin (IRI) and the responses of blood glucose and serum IRI to peroral glucose challenge were investigated in middle-aged normoglycemic male twins of 17 monozygotic (MZ) and 18 dizygotic (DZ) pairs recruited from the Finnish Twin Cohort Study. Also, the role of obesity and diet in the regulation of glucose and insulin metabolism was estimated. The fasting and 2 hr postprandial (PP) glucose showed higher pairwise correlations in MZ (r = 0.78 and 0.56) than DZ (r = 0.08 and -0.05) pairs whereas fasting and PP insulin levels and the areas under the PP glucose and insulin curves were weakly and similarly correlated in MZ and DZ twins. The pairwise correlations of the 1/2 hr and 1 hr, but not the fasting and 2 hr insulin/glucose ratios, were somewhat higher in MZ (R = 0.51 and 0.53) than DZ (r = = 0.28 and 0.30) pairs. In MZ twins, the intrapair differences in the body mass index were significantly correlated with those in the fasting and 2 hr PP glucose and insulin levels and those in the fasting and 1/2 hr insulin/glucose ratios (r from 0.47 to 0.76). Also, the intrapair differences in the dietary fat calories were correlated positively, but those in the calories derived from carbohydrates negatively, with the intrapair differences in several parameters of the glucose and insulin metabolism. These data suggest that the environmental contribution to the regulation of glucose and insulin metabolism in subjects within the normoglycemic range may be quite strong.(ABSTRACT TRUNCATED AT 250 WORDS)

Studies on mutant human insulin genes: identification and sequence analysis of a gene encoding [SerB24]insulin

Both alleles of the insulin gene of a patient with mild diabetes [maturity-onset-diabetes-of-the-young (MODY)-type syndrome] associated with hyperinsulinemia have been cloned, and the sequences have been determined. One allele contained a mutation (single nucleotide transition) in the coding sequence for the B chain at position 24 (TTC leads to TCC), resulting in the loss of a restriction enzyme (Mbo II) cleavage site in the gene. This mutation results in the substitution of serine for phenylalanine in a critically important region of the insulin molecule that is intimately involved in receptor binding. Both insulin alleles were of the alpha type and, aside from a single nucleotide deletion in the 5' region of the normal allele, their sequences were identical to those previously determined.

Characterization of the chlorpropamide-alcohol-flush in patients with type 1 and type 2 diabetes

The aim of the present paper was to evaluate the prevalence of the chlorpropamide-alcohol-flush (CPAF) in patients with type 2 and with type 1 diabetes. Ninety-seven patients with type 2 diabetes and 33 with type 1 diabetes drank 40 ml vermouth 12 h after placebo and again 12 h after 1 tablet of chlorpropamide (250 mg) or 12 h after the last of repeated administrations of chlorpropamide (250 mg b.i.d. for 2 days). Skin temperature was recorded in all patients by a thermocouple probe connected to the left cheek. In 47 patients serum concentrations of chlorpropamide and of its metabolite CBSU were also determined. The prevalence of CPAF was similar in type 1 and type 2 diabetes, was greater in women than in men, and was significantly greater after repeated administrations than after one single administration of chlorpropamide. The increase of skin temperature during a 30-min period was significantly higher in patients with CPAF than in patients without CPAF. Serum concentrations of chlorpropamide and of its metabolite CBSU were more elevated after 4 than after 1 tablet of chlorpropamide, but were not significantly different in patients with and without CPAF. These data indicate that both genetic factors and the amount of chlorpropamide used affect the appearance of CPAF. To assess the possible role of serotonin and of dopamine in the CPAF, some patients with CPAF were tested again after treatment with metergoline, an antiserotonin agent, or with bromocriptine, a dopamine-agonist. Neither drug influenced the CPAF, indicating that the two neurotransmitters are not involved in the CPAF.

Maturity onset diabetes of the young is not linked to the insulin gene

Maturity onset diabetes of the young is inherited as an autosomal dominant condition. Two families with the disease were studied to determine whether the inheritance of this type of diabetes was linked to the insulin gene. A cloned insulin gene probe was hybridised to DNA from the family members and the insulin gene on each chromosome identified by a different fragment length polymorphism. The results showed no linkage between the insulin gene and the inheritance of maturity onset diabetes of the young.

Insulin secretory capacity, beta-thromboglobulin and blood viscosity in long standing, non-insulin dependent diabetics with and without microangiopathy

A comparison was made of insulin secretion in response to i.v. glucose between noninsulin dependent diabetics with and without severe microangiopathy. During i.v. glucose tolerance testing those with complications had significantly lower serum insulin concentration (at 40 and 60 min 15.2 +/- 2.9 and 11.7 +/- 2.5 mU-1 respectively) than those without (26.1 +/- 4.7 and 24.3 +/- 3.6 mU-1, p less than 0.01). The differences were also significant when insulin increment above basal was determined. All subjects had raised plasma beta-thromboglobulin concentration (indicating increased tendency to platelet aggregation), but with no significant difference between the two groups. There was also no difference in fasting glucose, kg values, HbAl or blood viscosity. We conclude that non-insulin dependent diabetics with severe microangiopathy have significantly reduced insulin secretory capacity in response to i.v. glucose when compared with those without.

Chlorpropamide-alcohol flushing, malar thermal circulation index, and baseline malar temperature

Chlorpropamide-alcohol flushing (CPAF) has been advanced and challenged as a specific marker for familial noninsulin dependent diabetes mellitus. The previous studies assay flushing reactions employing arbitrarily defined critical threshold values of rise and rate of rise in facial temperature. Since these methods ignore the curvilinear relationship between skin temperature and cutaneous blood flow, errors of analysis obtained, Further, the role of baseline facial temperature is obfuscated. The method of malar thermal circulation index derived from the relationship between skin temperature and cutaneous blood flow provides a more accurate assay method and permits the characterization of the role of baseline facial temperature. Baseline facial temperature is less in subjects with CPAF and noninsulin dependent diabetes than in normal subjects. The lower baseline facial temperature alone may account for the reported differences in the parameters of the CPAF test.

Incidence of diabetes amongst people aged 18-50 years in nine British towns: a collaborative study

The incidence of diabetes among people aged 18-50 years has been studied prospectively in nine towns, chosen to encompass the range of socio-economic conditions and spread of latitude in England and Wales. The incidence of Type 1 (insulin-dependent) diabetes in this age group varied little between the towns. However, the incidence of Type 2 (non-insulin-dependent) diabetes was markedly higher in the towns with 'worse' socio-economic conditions. The mean incidences were 23 per 100 000 for the three 'worse' towns and 10 per 100 000 for the three 'better' towns. This was not explicable by an association between the disease and social class. This finding has to be reconciled with known and hypothesised influences in the aetiology of Type 2 diabetes.

Type 2 (non-insulin-dependent) diabetes--an epidemiological overview

Despite the use of a wide range of different methodologies and diagnostic criteria, epidemiological studies have shown that Type 2 (non-insulin-dependent) diabetes has a global distribution and its prevalence varies from country to country, in different ethnic groups in the same country, and between the same ethnic group undergoing internal or external migration. Rural-urban and migration studies indicate that change towards a 'Westernized' lifestyle is associated with a dramatic increase in the prevalence rates for Type 2 diabetes. Between populations, comparisons are confounded by a wide range of different ascertainment rates, survey methodologies, and diagnostic criteria for diabetes. However, low prevalence rates for Type 2 diabetes are seen in Eskimos and populations of the Far East, while the highest are seen in American Indians, urbanized Pacific Island populations, and migrant Asian Indians. Available evidence suggests that these latter groups have a genetic susceptibility to Type 2 diabetes ('diabetes genotype') and that the disease is unmasked by environmental factors. There appears to be a spectrum of interaction between genetic and environmental factors--in certain populations the genetic role may be more important than environmental, or vice versa. Epidemiological studies, apart from their value in population screenings and case-finding, have contributed to the new classification and diagnostic criteria for diabetes and our understanding of risk factors and host characteristics in the aetiology of Type 2 diabetes.

The syndrome of diabetes insipidus, diabetes mellitus, optic atrophy, deafness, and other abnormalities (DIDMOAD-syndrome). Two affected sibs and a short review of the literature (98 cases)

We describe two sibs with DIDMOAD-Syndrome, a 19-year-old girl with diabetes mellitus (type I), optic atrophy, inner-ear deafness, and atonia of the urinary tract, and her 5-year-old brother with diabetes mellitus (type I) and optic atrophy. Studies of red blood cell insulin receptors revealed a normal number of receptors per cell and normal affinity to insulin. The syndrome represents an autosomal recessively inherited type of diabetes mellitus, which remains often undiagnozed since most of the symptoms except diabetes mellitus and optic atrophy occur with varying expressivity. An atonia of the efferent urinary tract often with fatal complications is present in 46% of all patients with this syndrome reported in the literature and is unfortunately not included in the acronym DIDMOAD.

A quantitative, non-invasive method for the characterization of flushing reactions

A new method for the characterization of flushing reactions is established based on the curvilinear relationship between malar skin temperature and an index of cutaneous blood flow in the face. Previous studies relied on the absolute change in malar temperature which overlooks the curvilinear aspect of this relationship. The change in malar thermal circulation index (delta MTCI) is derived from the mathematical model of this curvilinear relationship. There were 71 positive flushing reactions in 162 challenges to a variety of agents. The peak malar temperature, change in malar temperature, and delta MTCI significantly correlated with flushing (p less than 0.001). For the commonly used threshold values for change in malar temperature of 1.1 degrees C and 1.2 degrees C, sensitivity was only 63.4 and 54.9, respectively. The sensitivity, specificity, and predictive value of a positive result for the delta MTCI were 90.1, 95.6 and 94.1, respectively. delta MTCI did not appear to be related to the baseline malar temperature, suggesting that a low malar temperature did not predispose to flushing. Thus, the inverse relationship between change in malar temperature and baseline malar temperature results solely from the curvilinear relationship between malar skin temperature and cutaneous blood flow in the face. Data from 2 previously reported studies are reevaluated employing the delta MTCI method; in both studies the new method is more sensitive without loss in specificity. The results indicate that delta MTCI may be useful as an accurate, noninvasive method for the quantitative characterization of flushing reactions.

Chlorpropamide-alcohol flushing in non insulin-dependent diabetes: prevalence of small and large vessel disease and or risk factors for angiopathy

One hundred and eight non insulin-dependent diabetics were tested for alcohol flushing after chlorpropamide administration (CPAF test). The overall prevalence of patients who flushed at the first challenge was 32%. However, nearly half of them still flushed after alcohol administration, when placebo was given instead of chlorpropamide, so that the prevalence of 'true' flushers was only 17%. Even though the distribution of retinal lesions was similar in 'true' flushers and in non flushers, severe loss of visual acuity was confined to the non flushers and aspecific flushers. The frequency of pathological ECG findings and of peripheral pulse reduction or abolition was significantly higher in the non flushers and aspecific flushers. Blood pressure, serum lipids and hemostatic parameters were similar in the two groups, and therefore do not explain the differences in prevalence of lesions. This study confirms the previous findings of a lower prevalence of large vessel lesions in flushers; however, the prevalence of 'true' CPAF phenomenon in our out-patient population appears to be much lower than previously reported.

Metabolic studies in unaffected co-twins of non-insulin-dependent diabetics

Forty-eight out of 53 non-insulin-dependent diabetic identical twin pairs were concordant for diabetes. In the five discordant pairs the diabetic twin had only recently been diagnosed. Oral glucose tolerance tests were carried out on the unaffected twins of the five pairs and on matched controls. Fasting concentrations of blood glucose (5.5 +/- 0.6 v 3.7 +/- 0.3 mmol/l; 99.1 +/- 10.8 v 66.6 +/- 5.4 mg/100 ml), haemoglobin A1 (mean 9.1%, range 8.8-9.2% v mean 7.9%, range 7.4-8.4%), lactate, alanine, and glycerol (0.090 +/- 0.017 v 0.045 +/- 0.008 mmol/l); and the lactate: pyruvate ratio were significantly higher in the twins than controls. After glucose challenge blood glucose, lactate, alanine, and glycerol concentrations and lactate: pyruvate ratio were increased in the twins. Insulin response was severely impaired, being almost absent in four of the five twins. The non-diabetic members of the discordant non-insulin-dependent diabetic pairs showed noticeable metabolic abnormalities which would later presumably deteriorate to frank diabetes. These findings, taken with the high concordance rate for non-insulin-dependent diabetic twins, suggest that non-insulin-dependent diabetes is predominantly, possibly entirely, inherited.

The endocrinology of the opiates and opioid peptides

Since the isolation of the enkephalins five yr ago, there has been an explosive increase in knowledge concerning the effects of the opiates and opioid peptides. This review deals with the interactions of opiates with the endocrine system in rat and man. The opioid peptides have been demonstrated to exert a variety of effects on pituitary hormone secretion in rat and man. In the rat, opiates stimulate growth hormone, prolactin and ACTH release and inhibit the release of the glycoprotein hormones. In man, the physiologic role of the endogenous opiates appears to be involved predominantly in ACTH and gonadotrophin regulation. Opiate effects are mainly exerted at the level of the hypothalamus but further modulating effects may occur at the pituitary and at end-organs. Opiate-induced hormonal effects appear to be mediated through dopaminergic and/or serotonergic mechanisms. Recent studies have also suggested a possible local neuromodulatory role for the opioid peptides in the control of carbohydrate metabolism and reproductive processes.

The genetics of the glucose intolerance disorders

Genetic heterogeneity, the concept that diabetes can have many different causes, was first suggested by the existence of rare genetic syndromes with diabetes, ethnic differences in clinical features and genetic heterogeneity of animal models. Genetic heterogeneity is now considered to be firmly established by family, twin, metabolic, immunologic and HLA disease association studies that separate idiopathic diabetes into insulin-dependent types (juvenile-onset type) and noninsulin-dependent types (maturity-onset type). Further heterogeneity is being demonstrated within each of these broad groups of disorders--within insulin-dependent diabetes using the HLA antigens and immunologic studies, and within noninsulin-dependent diabetes using such criteria as obesity, insulin response, age of onset and chlorpropamide-primed alcohol-induced flushing. This heterogeneity has major implications for the research and care of our diabetic patients since the precise etiology, risk of complications and genetic counseling are likely to vary among these different disorders that result in diabetes.

The chlorpropamide alcohol flush. Lack of specificity for familial non-insulin dependent diabetes

A facial flush provoked by alcohol in chlorpropamide treated diabetics has been described as a genetic marker for a dominantly inherited type of non-insulin dependent diabetes. In this study a chlorpropamide alcohol flush was observed in 16.9% of control subjects (n = 154), 23.3% of insulin dependent diabetics (n = 437) and 16.5% of patients with non-insulin dependent diabetes (n = 145). Among the non-insulin dependent diabetics no difference in the frequency of the chlorpropamide alcohol flush was found between those with and without a family history of diabetes. Specificity was not improved by skin temperature measurement or additional placebo tests. According to these data the chlorpropamide alcohol flush does not seem to be specific for non-insulin dependent diabetes and hypotheses about the aetiology of this type of diabetes based on the chlorpropamide alcohol flush should be regarded with caution.

Effect of enkephalins and morphine on insulin secretion from isolated rat islets

The direct effects of an enkephalin analogue, (D-Ala2/MePhe4/Met/(O)-o1) enkephalin (DAMME), on insulin release from isolated islets of Langerhans of the rat have been investigated. DAMME had a dose-dependent effect on insulin secretion: low concentrations (10(-10) to 10(-8) mol/l) were stimulatory while high concentrations (10(-5) mol/l) were inhibitory in the presence of 8 mmol/l glucose. Similar effects were found with met-enkephalin, and with the longer acting alanine substituted met-enkephalin. Morphine sulphate (5 X 10(-7) mol/l) also stimulated insulin release. The effects of enkephalin and morphine were blocked by the specific opiate antagonist naloxone hydrochloride (1.2 X 10(-6) mol/l). The insulin secretory response of perifused islets to enkephalins and morphine was rapid, corresponding to the first phase of glucose induced insulin release. These observations suggest that there may be opiate receptors in islets, and that opioid peptides could modulate insulin release.