Regulation of net hepatic glycogenolysis and gluconeogenesis during exercise: impact of type 1 diabetes

Diagnosis of hepatic glycogenosis in poorly controlled type 1 diabetes mellitus

Hepatic glycogenosis (HG) in type 1 diabetes is a underrecognized complication. Mauriac firstly described the syndrome characterized by hepatomegaly with altered liver enzymes, growth impairment, delay puberty and Cushingoid features, during childhood. HG in adulthood is characterized by the liver disorder (with circulating aminotransferase increase) in the presence of poor glycemic control (elevation of glycated hemoglobin, HbA1c levels). The advances in the comprehension of the metabolic pathways driving to the hepatic glycogen deposition point out the role of glucose transporters and insulin mediated activations of glucokinase and glycogen synthase, with inhibition of glucose-6-phosphatase. The differential diagnosis of HG consists in the exclusion of causes of liver damage (infectious, metabolic, obstructive and autoimmune disease). The imaging study (ultrasonography and/or radiological examinations) gives information about the liver alterations (hepatomegaly), but the diagnosis needs to be confirmed by the liver biopsy. The main treatment of HG is the amelioration of glycemic control that is usually accompanied by the reversal of the liver disorder. In selected cases, more aggressive treatment options (transplantation) have been successfully reported.

A Bayesian network for modelling blood glucose concentration and exercise in type 1 diabetes

This article presents a new statistical approach to analysing the effects of everyday physical activity on blood glucose concentration in people with type 1 diabetes. A physiologically based model of blood glucose dynamics is developed to cope with frequently sampled data on food, insulin and habitual physical activity; the model is then converted to a Bayesian network to account for measurement error and variability in the physiological processes. A simulation study is conducted to determine the feasibility of using Markov chain Monte Carlo methods for simultaneous estimation of all model parameters and prediction of blood glucose concentration. Although there are problems with parameter identification in a minority of cases, most parameters can be estimated without bias. Predictive performance is unaffected by parameter misspecification and is insensitive to misleading prior distributions. This article highlights important practical and theoretical issues not previously addressed in the quest for an artificial pancreas as treatment for type 1 diabetes. The proposed methods represent a new paradigm for analysis of deterministic mathematical models of blood glucose concentration.

Expression of gluconeogenic enzymes and 11β-hydroxysteroid dehydrogenase type 1 in liver of diabetic mice after acute exercise

During acute exercise, normoglycemia is maintained by a precise match between hepatic glucose production and its peripheral utilization. This is met by a complex interplay of hepatic responses and glucose uptake by muscle. However, the effect of a single bout of exercise on hepatic gluconeogenesis, corticosterone (CORT) secretion, and glucose homeostasis in the db/db mouse model of type 2 diabetes is poorly understood. Diabetic db/db and lean control littermates were subjected to a 30 minute session of treadmill running and sacrificed either immediately after exercise or 8 hours later. Plasma glucose levels were markedly increased in db/db mice after exercise, whereas no change in glucose was observed in lean mice. Post-exercise measurements revealed that plasma CORT levels were also significantly increased in db/db mice compared to lean mice. Plasma hypothalamic corticotropin releasing hormone and pituitary adrenocorticotropic hormone levels were reciprocally decreased in both db/db and lean mice after exercise, indicating intact feedback mechanisms. Protein expression, determined by Western blot analysis, of the glucocorticoid receptor in liver was significantly increased in db/db mice subjected to prior exercise. In liver of db/db mice, a significant increase in the expression of phosphoenolpyruvate carboxykinase was noted compared to lean mice after exercise. However, no change in the expression of glucose-6-phosphatase (G6Pase) α or β was observed in db/db mice. Expression of 11β-hydroxysteroid dehydrogenase type 1 was increased significantly in db/db mice compared to lean mice after exercise. Our results show differences in plasma glucose and protein expression of gluconeogenic enzymes after acute exercise between lean and diabetic db/db mice. The db/db diabetic mouse is hyperglycemic after acute exercise. This hyperglycemic state may be explained, in part, by enhanced endogenous CORT secretion and regulated hepatic phosphoenolpyruvate carboxykinase and 11β-hydroxysteroid dehydrogenase type 1 protein expression.

Closed-loop artificial pancreas systems: physiological input to enhance next-generation devices

To provide an understanding of both the preclinical and clinical aspects of closed-loop artificial pancreas systems, we provide a discussion of this topic as part of this two-part Bench to Clinic narrative. Here, the Bench narrative provides an in-depth understanding of insulin-glucose-glucagon physiology in conditions that mimic the free-living situation to the extent possible in type 1 diabetes that will help refine and improve future closed-loop system algorithms. In the Clinic narrative, Doyle and colleagues compare and evaluate technology used in current closed-loop studies to gain further momentum toward outpatient trials and eventual approval for widespread use.

Environmental hypertonicity causes induction of gluconeogenesis in the air-breathing singhi catfish, Heteropneustes fossilis

The air-breathing singhi catfish (Heteropneustes fossilis) is frequently being challenged by different environmental insults such as hyper-ammonia, dehydration and osmotic stresses in their natural habitats throughout the year. The present study investigated the effect of hyperosmotic stress, due to exposure to hypertonic environment (300 mM mannitol) for 14 days, on gluconeogenesis in this catfish. In situ exposure to hypertonic environment led to significant stimulation of gluconeogenic fluxes from the perfused liver after 7 days of exposure, followed by further increase after 14 days in presence of three different potential gluconeogenic substrates (lactate, pyruvate and glutamate). Environmental hypertonicity also caused a significant increase of activities of key gluconeogenic enzymes, namely phosphoenolpyruvate carboxykinase, fructose 1, 6-bisphosphatase and glucose 6-phosphatase by about 2-6 fold in liver, and 3-6 fold in kidney tissues. This was accompanied by more abundance of enzyme proteins by about 1.8–3.7 fold and mRNAs by about 2.2–5.2 fold in both the tissues with a maximum increase after 14 days of exposure. Hence, the increase in activities of key gluconeogenic enzymes under hypertonic stress appeared to be as a result of transcriptional regulation of genes. Immunocytochemical analysis further confirmed the tissue specific localized expression of these enzymes in both the tissues with the possibility of expressing more in the same localized places. The induction of gluconeogenesis during exposure to environmental hypertonicity possibly occurs as a consequence of changes in hydration status/cell volume of different cell types. Thus, these adaptational strategies related to gluconeogenesis that are observed in this catfish under hypertonic stress probably help in maintaining glucose homeostasis and also for a proper energy supply to support metabolic demands mainly for ion transport and other altered metabolic processes under various environmental hypertonic stress-related insults.

Exercise and type 1 diabetes (T1DM)

Physical exercise is firmly incorporated in the management of type 1 diabetes (T1DM), due to multiple recognized beneficial health effects (cardiovascular disease prevention being preeminent). When glycemic values are not excessively low or high at the time of exercise, few absolute contraindications exist; practical guidelines regarding amount, type, and duration of age-appropriate exercise are regularly updated by entities such as the American Diabetes Association and the International Society for Pediatric and Adolescent Diabetes. Practical implementation of exercise regimens, however, may at times be problematic. In the poorly controlled patient, specific structural changes may occur within skeletal muscle fiber, which is considered by some to be a disease-specific myopathy. Further, even in well-controlled patients, several homeostatic mechanisms regulating carbohydrate metabolism often become impaired, causing hypo- or hyperglycemia during and/or after exercise. Some altered responses may be related to inappropriate exogenous insulin administration, but are often also partly caused by the "metabolic memory" of prior glycemic events. In this context, prior hyperglycemia correlates with increased inflammatory and oxidative stress responses, possibly modulating key exercise-associated cardio-protective pathways. Similarly, prior hypoglycemia correlates with impaired glucose counterregulation, resulting in greater likelihood of further hypoglycemia to develop. Additional exercise responses that may be altered in T1DM include growth factor release, which may be especially important in children and adolescents. These multiple alterations in the exercise response should not discourage physical activity in patients with T1DM, but rather should stimulate the quest for the identification of the exercise formats that maximize beneficial health effects.

Physical fitness in children with type 1 diabetes measured with six-minute walk test

Aim/Hypothesis. To examine whether children with DMT1 are less physically fit than healthy children and to assess whether an elevated level of HbA1c was associated with decreased physical fitness among children with diabetes. Methods. The study was conducted using case-control methodology. The cases were 100 children with T1DM, 7-17,9 years. Study subjects underwent a 6MWT, where distance measured, heart rate, and oxygen saturation was recorded. Results. Results of the 6MWT for children with T1DM and controls were 601.3 ± 86.1 meters versus 672.1 ± 60.6 meters, respectively (P < 0.001). The cases were divided into two subgroups, one with HbA1c levels >8% and one with HbA1c <8%. Results for both groups were inferior to the controls (P < 0.001). The posttest pulse rate in all subjects was higher than the pretest pulse rate (P < 0.001). Pulse oxygen levels were lower than controls at the pretest measurement (P < 0.001), and for both cases and controls, pulse oxygen levels decreased after test (P = 0.004). However, the change in oxygen saturation did not differ between the groups (P = 0.332). Conclusions. Children with T1D are less fit than matched controls. The level of HbA1c did not affect the physical fitness of children with T1D.

Autonomic control and bariatric procedures

The sudden improvement of metabolic profile and the remission of type 2 diabetes after bariatric surgery, well before weight loss, raise important new questions regarding glycemic control. Currently, various types of bariatric procedures target type 2 diabetes in obese and non-obese patients. Nevertheless, the origin of the dramatic metabolic improvements, including glucose homeostasis, is poorly understood, and the role of the gastrointestinal (GI) tract remains relatively speculative, as well as why these procedures are variably effective. One neglected explanation is that such interventions disrupt neural networks mediating GI-brain communication and could alter the autonomic output to the visceral organs, including the liver. Incretins, e.g., glucagon-like peptide 1 (GLP-1), have major influence on the central nervous system. Moreover, the level of GLP-1 is observed to significantly increase after bariatric surgery and could be a key factor in the weight-independent, anti-diabetic effect. Therefore, this review will evaluate the effect of GLP-1 on the central nervous system, with emphasis on the cellular effects of GLP-1, and will provide an overview of the autonomic control of the liver.

Liver and muscle glycogen repletion using 13C magnetic resonance spectroscopy following ingestion of maltodextrin, galactose, protein and amino acids

The present study evaluated whether the inclusion of protein (PRO) and amino acids (AA) within a maltodextrin (MD) and galactose (GAL) recovery drink enhanced post-exercise liver and muscle glycogen repletion. A total of seven trained male cyclists completed two trials, separated by 7 d. Each trial involved 2 h of standardised intermittent cycling, followed by 4 h recovery. During recovery, one of two isoenergetic formulations, MD–GAL (0·9 g MD/kg body mass (BM) per h and 0·3 g GAL/kg BM per h) or MD–GAL-PRO+AA (0·5 g MD/kg BM per h, 0·3 g GAL/kg BM per h, 0·4 g whey PRO hydrolysate plus l-leucine and l-phenylalanine/kg BM per h) was ingested at every 30 min. Liver and muscle glycogen were measured after depletion exercise and at the end of recovery using 1H-13C-magnetic resonance spectroscopy. Despite higher postprandial insulin concentations for MD–GAL-PRO+AA compared with MD–GAL (61·3 (se 6·2) v. 29·6 (se 3·0) mU/l, (425·8 (se 43·1) v. 205·6 (se 20·8) pmol/l) P= 0·03), there were no significant differences in post-recovery liver (195·3 (se 2·6) v. 213·8 (se 18·0) mmol/l) or muscle glycogen concentrations (49·7 (se 4·0) v. 51·1 (se 7·9) mmol/l). The rate of muscle glycogen repletion was significantly higher for MD–GAL compared with MD–GAL-PRO+AA (5·8 (se 0·7) v. 3·7 (se 0·6) mmol/l per h, P= 0·04), while there were no significant differences in the rate of liver glycogen repletion (15·0 (se 2·5) v. 13·0 (se 2·7) mmol/l per h). PRO and AA within a MD–GAL recovery drink, compared with an isoenergetic mix of MD–GAL, did not enhance but matched liver and muscle glycogen recovery. This suggests that the increased postprandial insulinaemia only compensated for the lower MD content in the MD–GAL-PRO+AA treatment.

Transient receptor potential vanilloid type 1-dependent regulation of liver-related neurons in the paraventricular nucleus of the hypothalamus diminished in the type 1 diabetic mouse

The paraventricular nucleus (PVN) of the hypothalamus controls the autonomic neural output to the liver, thereby participating in the regulation of hepatic glucose production (HGP); nevertheless, mechanisms controlling the activity of liver-related PVN neurons are not known. Transient receptor potential vanilloid type 1 (TRPV1) is involved in glucose homeostasis and colocalizes with liver-related PVN neurons; however, the functional role of TRPV1 regarding liver-related PVN neurons has to be elucidated. A retrograde viral tracer was used to identify liver-related neurons within the brain-liver circuit in control, type 1 diabetic, and insulin-treated mice. Our data indicate that TRPV1 regulates liver-related PVN neurons. This TRPV1-dependent excitation diminished in type 1 diabetic mice. In vivo and in vitro insulin restored TRPV1 activity in a phosphatidylinositol 3-kinase/protein kinase C-dependent manner and stimulated TRPV1 receptor trafficking to the plasma membrane. There was no difference in total TRPV1 protein expression; however, increased phosphorylation of TRPV1 receptors was observed in type 1 diabetic mice. Our data demonstrate that TRPV1 plays a pivotal role in the regulation of liver-related PVN neurons. Moreover, TRPV1-dependent excitation of liver-related PVN neurons diminishes in type 1 diabetes, thus indicating that the brain-liver autonomic circuitry is altered in type 1 diabetes and may contribute to the autonomic dysfunction of HGP.

Effects of performing resistance exercise before versus after aerobic exercise on glycemia in type 1 diabetes

OBJECTIVE

To determine the effects of exercise order on acute glycemic responses in individuals with type 1 diabetes performing both aerobic and resistance exercise in the same session.

RESEARCH DESIGN AND METHODS

Twelve physically active individuals with type 1 diabetes (HbA(1c) 7.1 ± 1.0%) performed aerobic exercise (45 min of running at 60% V(O(2peak))) before 45 min of resistance training (three sets of eight, seven different exercises) (AR) or performed the resistance exercise before aerobic exercise (RA). Plasma glucose was measured during exercise and for 60 min after exercise. Interstitial glucose was measured by continuous glucose monitoring 24 h before, during, and 24 h after exercise.

RESULTS

Significant declines in blood glucose levels were seen in AR but not in RA throughout the first exercise modality, resulting in higher glucose levels in RA (AR = 5.5 ± 0.7, RA = 9.2 ± 1.2 mmol/L, P = 0.006 after 45 min of exercise). Glucose subsequently decreased in RA and increased in AR over the course of the second 45-min exercise bout, resulting in levels that were not significantly different by the end of exercise (AR = 7.5 ± 0.8, RA = 6.9 ± 1.0 mmol/L, P = 0.436). Although there were no differences in frequency of postexercise hypoglycemia, the duration (105 vs. 48 min) and severity (area under the curve 112 vs. 59 units ⋅ min) of hypoglycemia were nonsignificantly greater after AR compared with RA.

CONCLUSIONS

Performing resistance exercise before aerobic exercise improves glycemic stability throughout exercise and reduces the duration and severity of postexercise hypoglycemia for individuals with type 1 diabetes.

Effect of intraperitoneal selenium administration on liver glycogen levels in rats subjected to acute forced swimming

There are a few of studies examining how selenium, which is known to reduce oxidative damage in exercise, influences glucose metabolism and exhaustion in physical activity. The present study aims to examine how selenium administration affects liver glycogen levels in rats subjected to acute swimming exercise. The study included 32 Sprague-Dawley type male rats, which were equally allocated to four groups: Group 1, general control; Group 2; selenium-supplemented control (6 mg/kg/day sodium selenite); Group 3, swimming control; Group 4, selenium-supplemented swimming (6 mg/kg/day sodium selenite). Liver tissue samples collected from the animals at the end of the study were fixed in 95% ethyl alcohol. From the tissue samples buried into paraffin, 5-µm cross-sections were obtained using a microtome, put on a microscope slide, and stained with PAS. Stained preparations were assessed using a Nikon Eclipse E400 light microscope. All images obtained with the light microscope were transferred to a PC and evaluated using Clemex PE 3.5 image analysis software. The highest liver glycogen levels were found in groups 1 and 2 (p < 0.05). The levels in group 4 were lower than those in groups 1 and 2 but higher than the levels in group 3 (p < 0.05). The lowest liver glycogen levels were obtained in group 3 (p < 0.05). Results of the study indicate that liver glycogen levels that decrease in acute swimming exercise can be restored by selenium administration. It can be argued that physiological doses of selenium administration can contribute to performance.

Effect of long-term intraperitoneal zinc administration on liver glycogen levels in diabetic rats subjected to acute forced swimming

This study aims to examine the effect of zinc administration on liver glycogen levels of rats in which diabetes was induced with streptozotocin and which were subjected to acute swimming exercise. The study was conducted on 80 adult Sprague-Dawley male rats, which were equally allocated to eight groups: group 1, general control; group 2, zinc-administrated control; group 3, zinc-administrated diabetic control; group 4, swimming control; group 5, zinc-administrated swimming; group 6, zinc-administrated diabetic swimming; group 7, diabetic swimming; group 8, diabetic control group. In order to induce diabetes, animals were injected with 40 mg/kg intraperitoneal (ip) streptozotocin. The injections were repeated in the same dose after 24 h. Animals which had blood glucose at or above 300 mg/dl 6 days after the last injections were accepted as diabetic. Zinc was administrated ip for 4 weeks as 6 mg/kg/day per rat. Hepatic tissue samples taken from the animals at the end of the study were fixed in 95% ethyl alcohol. Cross sections of 5 µm thickness, taken by the help of a microtome from the tissue samples buried in paraffin, were placed on a microscope slide and stained with periodic acid-Schiff and evaluated by light microscope. All microscopic images were transferred to a PC and assessed with the help of Clemex PE3.5 image analysis software. The lowest liver glycogen levels in the study were obtained in groups 3, 4, 6, 7, and 8. Liver glycogen levels in group 5 were higher than groups 3, 4, 6, 7, and 8, but lower than groups 1 and 2 (p < 0.05). Groups 1 and 2 had the highest liver glycogen levels. The results obtained from the study indicate that liver glycogen levels which dropped in acute swimming exercise were restored by zinc administration and that diabetes induced in rats prevented the protective effect of zinc.

Fuelling the athlete with type 1 diabetes

People with type 1 diabetes (T1DM) want to enjoy the benefits of sport and exercise, but management of diabetes in this context is complex. An understanding of the physiology of exercise in health, and particularly the control of fuel mobilization and metabolism, gives an idea of problems which may arise in managing diabetes for sport and exercise. Athletes with diabetes need to be advised on appropriate diet to maximize performance and reduce fatigue. Exercise in diabetes is complicated both by hypoglycaemia and hyperglycaemia in particular circumstances and explanations are advanced which can provide a theoretical underpinning for possible management strategies. Management strategies are proposed to improve glycaemic control and performance.

Exercise-related hypoglycemia in diabetes mellitus

Current recommendations are that people with Type 1 and Type 2 diabetes mellitus exercise regularly. However, in cases in which insulin or insulin secretagogues are used to manage diabetes, patients have an increased risk of developing hypoglycemia, which is amplified during and after exercise. Repeated episodes of hypoglycemia blunt autonomic nervous system, neuroendocrine and metabolic defenses (counter-regulatory responses) against subsequent episodes of falling blood glucose levels during exercise. Likewise, antecedent exercise blunts counter-regulatory responses to subsequent hypoglycemia. This can lead to a vicious cycle, by which each episode of either exercise or hypoglycemia further blunts counter-regulatory responses. Although contemporary insulin therapies cannot fully mimic physiologic changes in insulin secretion, people with diabetes have several management options to avoid hypoglycemia during and after exercise, including regularly monitoring blood glucose, reducing basal and/or bolus insulin, and consuming supplemental carbohydrates.

Risks of marathon running and hypoglycaemia in Type 1 diabetes

BACKGROUND

Exercise-induced hypoglycaemia is common in people with insulin-treated diabetes and if severe can provoke neurological morbidity including coma and seizures. Depending on the duration and demands of the physical activity, various strategies can be used to limit the risk of hypoglycaemia with strenuous exercise. However, metabolic events occurring in the 48 h before the exercise can influence the risk and responses to exercise-induced hypoglycaemia.

CASE REPORT

A 27-year-old man with Type 1 diabetes suffered an episode of nocturnal hypoglycaemia which provoked a tonic-clonic seizure. Despite this he ran in a marathon the following day during which he collapsed with severe hypoglycaemia and a further associated seizure. He subsequently developed severe myalgia accompanied by a pronounced and persistent elevation of plasma creatine kinase, indicating rhabdomyolysis, and deranged liver function, suggestive of hypoxic hepatitis. The biochemical abnormalities and symptoms lasted for several weeks.

CONCLUSIONS

The case highlights the dangers of intense and prolonged physical exercise following severe hypoglycaemia, demonstrating the risks of acute damage to skeletal muscle and to organs such as the liver, in addition to the risk of severe neuroglycopenia and the induction of seizures. The mechanisms underlying these problems are discussed. People with insulin-treated diabetes should be advised not to undertake prolonged intensive exercise after severe hypoglycaemia.

Regulation of net hepatic glycogenolysis and gluconeogenesis by epinephrine in humans

The relative contributions of net hepatic glycogenolysis (NHG) and gluconeogenesis to rates of glucose production during a physiological increment in plasma epinephrine concentrations, independent of changes in plasma insulin concentrations, were determined in seven fasting, healthy young subjects. Plasma insulin concentrations were kept constant by infusing somatostatin (0.1 microg.kg(-1).min(-1)) and replacing basal insulin (24 pmol.m(-2).min(-1)). Epinephrine (1.2 microg.m(-2).min(-1)) was infused for 90 min while NHG was assessed directly by (13)C magnetic resonance spectroscopy. The rate of glucose production was assessed using [6,6-(2)H(2)]glucose, and gluconeogenesis was calculated as the difference between the rate of glucose production and NHG. Plasma epinephrine concentrations increased rapidly from approximately 100 to approximately 2,000 pmol/l (P < 0.00001) accompanied by an increase in plasma glucose concentrations from 4.3 +/- 0.2 to 13.3 +/- 0.3 mmol/l at 90 min (P = 0.00001). This increase in plasma epinephrine concentration resulted in a 2.5-fold increase in glucose production (from 14.4 +/- 1.0 micromol.kg(-1).min(-1) to 35.7 +/- 2.0 micromol.kg(-1).min(-1), P < 0.0001), which lasted for approximately 60 min (phase 1), after which glucose production decreased to 31.2 +/- 1.9 micromol.kg(-1).min(-1) (P < 0.0001 vs. basal) during the last 30 min of the epinephrine infusion (phase 2). Hepatic glycogen concentrations decreased almost linearly during phase 1, and rates of NHG were 19.9 +/- 3.0 micromol.kg(-1).min(-1) (P = 0.005 vs. basal), which could account for approximately 60% of glucose production. During phase 2, NHG decreased to 7.3 +/- 2.8 micromol.kg(-1).min(-1) (P = 0.02 vs. peak), accounting for only approximately 20% of glucose production. In conclusion, in the presence of basal plasma insulin and glucagon concentrations, a physiological increase in plasma epinephrine concentrations stimulates glucose production with an initial, 60-min transient phase caused by stimulation of NHG and a second phase that can mostly be attributed to a twofold increase in rates of gluconeogenesis.

Dietary glycemic index influences lipid oxidation but not muscle or liver glycogen oxidation during exercise

The glycemic index (GI) of dietary carbohydrates influences glycogen storage in skeletal muscle and circulating nonesterified fatty acid (NEFA) concentrations. We hypothesized that diets differing only in GI would alter intramuscular lipid oxidation and glycogen usage in skeletal muscle and liver during subsequent exercise. Endurance-trained individuals (n = 9) cycled for 90 min at 70% Vo(2peak) and then consumed either high- or low-GI meals over the following 12 h. The following day after an overnight fast, the 90-min cycle was repeated. (1)H and (13)C magnetic resonance spectroscopy was used before and after exercise to assess intramuscular lipid and glycogen content of the vastus muscle group and liver. Blood and expired air samples were collected at 15-min intervals throughout exercise. NEFA availability was reduced during exercise in the high- compared with the low-GI trial (area under curve 44.5 +/- 6.0 vs. 38.4 +/- 7.30 mM/h, P < 0.05). Exercise elicited an approximately 55% greater reduction in intramyocellular triglyceride (IMCL) in the high- vs. low-GI trial (1.6 +/- 0.2 vs. 1.0 +/- 0.3 mmol/kg wet wt, P < 0.05). There was no difference in the exercise-induced reduction of the glycogen pool in skeletal muscle (76 +/- 8 vs. 68 +/- 5 mM) or in liver (65 +/- 8 vs. 71 +/- 4 mM) between the low- and high-GI trials, respectively. High-GI recovery diets reduce NEFA availability and increase reliance on IMCL during moderate-intensity exercise. Skeletal muscle and liver glycogen storage or usage are not affected by the GI of an acute recovery diet.

Diabetes management for intense exercise

PURPOSE OF REVIEW

People with type 1 diabetes want to enjoy the benefits of sport and exercise, but management of diabetes in this context is complex. An understanding of the physiology of exercise in health, and particularly the control of fuel mobilization and metabolism, gives an idea of problems that may arise in managing diabetes for sport and exercise.

RECENT FINDINGS

Exercise is complicated both by hypoglycaemia and hyperglycaemia in particular circumstances. Recent data demonstrate both early and late hypoglycaemia associated with endurance exercise and also give new insights into fuel use during exercise in diabetes. These data also provide potential explanations for the reduction in maximal exercise capacity sometimes observed in people with diabetes, although it should be noted that this observation is by no means universal.

SUMMARY

Advances in the understanding of exercise physiology allow the development of management strategies that aim to help athletes with diabetes achieve appropriate metabolic control during exercise. These metabolic strategies, coupled with observations from each athlete's own experience, give a basis for individualized advice that will help athletes with diabetes to fulfil their full potential.

Recent advances in adaptive thermogenesis: potential implications for the treatment of obesity

Large inter-individual differences in cold-induced (non-shivering) and diet-induced adaptive thermogenesis exist in animals and humans. These differences in energy expenditure can have a large impact on long-term energy balance and thus body weight (when other factors remain stable). Therefore, the level of adaptive thermogenesis might relate to the susceptibility to obesity; efforts to increase adaptive thermogenesis might be used to treat obesity. In small mammals, the main process involved is mitochondrial uncoupling in brown adipose tissue (BAT), which is regulated by the sympathetic nervous system. For a long time, it was assumed that mitochondrial uncoupling is not a major physiological contributor to adaptive thermogenesis in adult humans. However, several studies conducted in recent years suggest that mitochondrial uncoupling in BAT and skeletal muscle tissue in adult humans can be physiologically significant. Other mechanisms besides mitochondrial uncoupling that might be involved are futile calcium cycling, protein turnover and substrate cycling. In conjunction with recent advances on signal transduction studies, this knowledge makes manipulation of adaptive thermogenesis a more realistic option and thus a pharmacologically interesting target to treat obesity.

Effect of physical training on metabolic responses of pregnant rats submitted to swimming under thermal stress

BACKGROUND

The aim of this study is to assess the effect of pre-pregnancy physical training on metabolic responses and its effects on offspring.

METHODS

Three groups of rats (n = 7 in each group): sedentary pregnant rats (PS), exercised during pregnancy (PE) and pregnant rats trained before and during pregnancy (PT) were compared. They were separated into three subgroups regarding water temperature: 28°C, 35°C or 39°C. Plasma triglycerides and glucose levels, weight gain during pregnancy and rectal temperature pre and post exercise (swim), as well as the offspring size and weight were analysed.

RESULTS

Rectal temperature post exercise was lower than pre exercise at 28°C and 35°C, and higher at 39°C. Weight gain was lower at 39°C for the PT group and at 35°C for the PT and PE groups compared to the PS group. Plasma glucose, at 28°C and 39°C for PS and PE groups, was higher than those obtained at 35°C, while triglycerides were lower. For trained rats, plasma glucose and triglycerides were similar at all water temperatures. Trained rats presented lower triglyceride values at 35°C, and higher triglyceride values at 39°C compared to PS group. Glucose presented inverse results. None of the groups presented fetal reabsorption. However, in the PS group, the offspring presented lower weight gain at 28°C than at 35°C and 39°C.

CONCLUSIONS

These results suggest that pre-pregnancy physical training induces steady values of triglycerides and glucose during exercise at all water temperatures.

Splanchnic regulation of glucose production

The liver plays a key role for the maintenance of blood glucose homeostasis under widely changing physiological conditions. In the overnight fasted state, breakdown of hepatic glycogen and synthesis of glucose from lactate, amino acids, glycerol, and pyruvate contribute about equally to hepatic glucose production. Postprandial glucose uptake by the liver is determined by the size of the glucose load reaching the liver, the rise in insulin concentration, and the route of glucose delivery. Hepatic glycogen stores are depleted within 36 to 48 hours of fasting, but gluconeogenesis continues to provide glucose for tissues with an obligatory glucose requirement. Glucose output from the liver increases during exercise; during short-term intensive exertion, hepatic glycogenolysis is the primary source of extra glucose for skeletal muscle, and during prolonged exercise, hepatic gluconeogenesis becomes gradually more important in keeping with falling insulin and rising glucagon levels. Type 1 diabetes is accompanied by diminished hepatic glycogen stores, augmented gluconeogenesis, and increased basal hepatic glucose production in proportion to the severity of the diabetic state. The hyperglycemia of type 2 diabetes is in part caused by an overproduction of glucose from the liver that is secondary to accelerated gluconeogenesis.

Hyperinsulinaemia during exercise does not suppress hepatic glycogen concentrations in patients with type 1 diabetes: a magnetic resonance spectroscopy study

AIMS/HYPOTHESIS

We compared in vivo changes in liver glycogen concentration during exercise between patients with type 1 diabetes and healthy volunteers.

METHODS

We studied seven men with type 1 diabetes (mean +/- SEM diabetes duration 10 +/- 2 years, age 33 +/- 3 years, BMI 24 +/- 1 kg/m(2), HbA(1c) 8.1 +/- 0.2% and VO(2) peak 43 +/- 2 ml [kg lean body mass](-1) min(-1)) and five non-diabetic controls (mean +/- SEM age 30 +/- 3 years, BMI 22 +/- 1 kg/m(2), HbA(1c) 5.4 +/- 0.1% and VO(2) peak 52 +/- 4 ml [kg lean body mass](-1) min(-1), before and after a standardised breakfast and after three bouts (EX1, EX2, EX3) of 40 min of cycling at 60% VO(2) peak. (13)C Magnetic resonance spectroscopy of liver glycogen was acquired in a 3.0 T magnet using a surface coil. Whole-body substrate oxidation was determined using indirect calorimetry.

RESULTS

Blood glucose and serum insulin concentrations were significantly higher (p < 0.05) in the fasting state, during the postprandial period and during EX1 and EX2 in subjects with type 1 diabetes compared with controls. Serum insulin concentration was still different between groups during EX3 (p < 0.05), but blood glucose concentration was similar. There was no difference between groups in liver glycogen concentration before or after the three bouts of exercise, despite the relative hyperinsulinaemia in type 1 diabetes. There were also no differences in substrate oxidation rates between groups.

CONCLUSIONS/INTERPRETATION

In patients with type 1 diabetes, hyperinsulinaemic and hyperglycaemic conditions during moderate exercise did not suppress hepatic glycogen concentrations. These findings do not support the hypothesis that exercise-induced hypoglycaemia in patients with type 1 diabetes is due to suppression of hepatic glycogen mobilisation.

Diabetes-induced alterations of adenosine receptors expression level in rat liver

Diabetes mellitus is associated with metabolic, functional, and structural changes in the liver. Adenosine has been demonstrated to play an important regulatory role in the liver, and its action has been associated with all four adenosine receptors (ARs) subtypes. The goal of this study was to evaluate the impact of streptozotocin-induced diabetes on expression level of ARs in rat liver. Performed analyses (real-time PCR, Western blots) revealed detectable levels of mRNA and protein of A(1)-AR, A(2A)-AR, A(2B)-AR, and A(3)-AR in the rat liver. Development of diabetes resulted in a significant increase of A(2A)-AR and A(3)-AR mRNA levels. This was associated with elevated ARs protein content. The level of A(2B)-AR mRNA in diabetic liver decreased approximately 40% and was accompanied by 60% drop in A(2B)-AR protein in liver membranes. Diabetes did not affect the expression level of A(1)-AR in the liver. Administration of insulin for four days to diabetic rats resulted in returning of the ARs expression to the levels observed in liver of normal rat. The changes in ARs genes expression and receptors protein content could be related to some pathological changes taking place in diabetic liver. This might suggest involvement of ARs in pathogenesis of liver disease.

Cytosolic phosphoenolpyruvate carboxykinase does not solely control the rate of hepatic gluconeogenesis in the intact mouse liver

When dietary carbohydrate is unavailable, glucose required to support metabolism in vital tissues is generated via gluconeogenesis in the liver. Expression of phosphoenolpyruvate carboxykinase (PEPCK), commonly considered the control point for liver gluconeogenesis, is normally regulated by circulating hormones to match systemic glucose demand. However, this regulation fails in diabetes. Because other molecular and metabolic factors can also influence gluconeogenesis, the explicit role of PEPCK protein content in the control of gluconeogenesis was unclear. In this study, metabolic control of liver gluconeogenesis was quantified in groups of mice with varying PEPCK protein content. Surprisingly, livers with a 90% reduction in PEPCK content showed only a approximately 40% reduction in gluconeogenic flux, indicating a lower than expected capacity for PEPCK protein content to control gluconeogenesis. However, PEPCK flux correlated tightly with TCA cycle activity, suggesting that under some conditions in mice, PEPCK expression must coordinate with hepatic energy metabolism to control gluconeogenesis.

Glucose requirements to maintain euglycemia after moderate-intensity afternoon exercise in adolescents with type 1 diabetes are increased in a biphasic manner

CONTEXT

Exercise increases the risk of hypoglycemia in type 1 diabetes.

OBJECTIVE

This study aimed to investigate how the amount of glucose required to prevent an exercise-mediated fall in glucose level changes over time in adolescents with type 1 diabetes.

SETTING

The study took place at a tertiary pediatric referral center.

DESIGN, PARTICIPANTS, AND INTERVENTION

Nine adolescents with type 1 diabetes mellitus (five males, four females, aged 16 +/- 1.8 yr, diabetes duration 8.2 +/- 4.1 yr, hemoglobin A1c 7.8 +/- 0.8%, mean +/- SD) were subjected on two different occasions to a rest or 45 min of exercise at 95% of their lactate threshold. Insulin was administered iv at a rate based on their usual insulin dose, with similar plasma insulin levels for both studies (82.1 +/- 19.0, exercise vs. 82.7 +/- 16.4 pmol/liter, rest). Glucose was infused to maintain euglycemia for 18 h.

MAIN OUTCOME MEASURES

Glucose infusion rates required to maintain euglcycemia and levels of counterregulatory hormones were compared between rest and exercise study nights.

RESULTS

Glucose infusion rates to maintain stable glucose levels were elevated during and shortly after exercise, compared with the rest study, and again from 7-11 h after exercise. Counterregulatory hormone levels were similar between exercise and rest studies except for peaks in the immediate postexercise period (epinephrine, norepinephrine, GH, and cortisol peaks: 375.6 +/- 146.9 pmol/liter, 5.59 +/- 0.73 nmol/liter, 71.9 +/- 14.8 mIU/liter, and 558 +/- 69 nmol/liter, respectively).

CONCLUSIONS

The biphasic increase in glucose requirements to maintain euglycemia after exercise suggests a unique pattern of early and delayed risk for nocturnal hypoglycemia after afternoon exercise.

Noninvasive analysis of hepatic glycogen kinetics before and after breakfast with deuterated water and acetaminophen

The contributions of hepatic glycogenolysis to fasting glucose production and direct pathway to hepatic glycogen synthesis were quantified in eight type 1 diabetic patients and nine healthy control subjects by ingestion of (2)H(2)O and acetaminophen before breakfast followed by analysis of urinary water and acetaminophen glucuronide. After overnight fasting, enrichment of glucuronide position 5 relative to body water (G5/body water) was significantly higher in type 1 diabetic patients compared with control subjects, indicating a reduced contribution of glycogenolysis to glucose production (38 +/- 3 vs. 46 +/- 2%). Following breakfast, G5/body water was significantly higher in type 1 diabetic patients, indicating a smaller direct pathway contribution to glycogen synthesis (47 +/- 2 vs. 59 +/- 2%). Glucuronide hydrogen 2 enrichment (G2) was equivalent to body water during fasting (G2/body water 0.94 +/- 0.03 and 1.02 +/- 0.06 for control and type 1 diabetic subjects, respectively) but was significantly lower after breakfast (G2/body water 0.78 +/- 0.03 and 0.82 +/- 0.05 for control and type 1 diabetic subjects, respectively). The reduced postprandial G2 levels reflect incomplete glucose-6-phosphate-fructose-6-phosphate exchange or glycogen synthesis from dietary galactose. Unlike current measurements of human hepatic glycogen metabolism, the (2)H(2)O/acetaminophen assay does not require specialized on-site clinical equipment or personnel.

Role of hepatic glycogen breakdown in defective counterregulation of hypoglycemia in intensively treated type 1 diabetes

Impairment of hypoglycemic counterregulation in intensively treated type 1 diabetes has been attributed to deficits in counterregulatory hormone secretion. However, because the liver plays a critical part in recovery of plasma glucose, abnormalities in hepatic glycogen metabolism per se could also play an important role. We quantified the contribution of net hepatic glycogenolysis during insulin-induced hypoglycemia in 10 nondiabetic subjects and 7 type 1 diabetic subjects (HbA1c 6.5 +/- 0.2%) using 13C nuclear magnetic resonance spectroscopy, during 2 h of either hyperinsulinemic euglycemia (plasma glucose 92 +/- 4 mg/dl) or hypoglycemia (plasma glucose 58 +/- 3 mg/dl). In nondiabetic subjects, hypoglycemia was associated with a brisk counterregulatory hormone response (plasma epinephrine 246 +/- 38 vs. 2,785 +/- 601 pmol/l during hypoglycemia, plasma norepinephrine 1.9 +/- 0.2 vs. 2.5 +/- 0.3 nmol/l, and glucagon 38 +/- 7 vs. 92 +/- 17 pg/ml, respectively, P < 0.001 in all), and a relative increase in endogenous glucose production (EGP 0.83 +/- 0.14 mg x kg(-1) x min(-1) during euglycemia yet approximately 50% higher with hypoglycemia [1.30 +/- 0.20 mg x kg(-1) x min(-1)], P < 0.001). Net hepatic glycogen content declined progressively during hypoglycemia to 22 +/- 3% below baseline (P < 0.024). By the final 30 min of hypoglycemia, hepatic glycogen fell from 301 +/- 14 to 234 +/- 10 mmol/l (P < 0.001) and accounted for approximately 100% of EGP. In marked contrast, after an overnight fast, hepatic glycogen concentration in type 1 diabetic subjects (215 +/- 23 mmol/l) was significantly lower than in nondiabetic subjects (316 +/- 19 mmol/l, P < 0.001). Furthermore, the counterregulatory response to hypoglycemia was significantly reduced with small increments in plasma epinephrine and norepinephrine (126 +/- 22 vs. 448 +/- 16 pmol/l in hypoglycemia and 0.9 +/- 0.3 vs. 1.6 +/- 0.3 nmol/l, respectively, P < 0.05 for both) and no increase in plasma glucagon. EGP decreased during hypoglycemia with no recovery (1.3 +/- 0.5 vs. 1.2 +/- 0.3 mg x kg(-1) x min(-1) compared with euglycemia, P = NS), and hepatic glycogen concentration did not change significantly with hypoglycemia. We conclude that glycogenolysis accounts for the majority of EGP during the first 90 min of hypoglycemia in nondiabetic subjects. In intensively treated type 1 diabetes, despite some activation of counterregulation, hypoglycemia failed to stimulate hepatic glycogen breakdown or activation of EGP, factors that may contribute to the defective counterregulation seen in such patients.

Methodological approaches to the study of metabolism across individual tissues in man

PURPOSE OF REVIEW

This article is intended to briefly overview available methodological approaches for the study of regional metabolism in man in vivo, and to summarize recent advances in this field of research.

RECENT FINDINGS

Several methods have been developed and currently allow for the qualitative and quantitative assessment of energy interconversions and substrate fluxes across individual tissues of man, including the measurement of arteriovenous concentration differences, microdialysis, and nuclear magnetic resonance spectroscopy of carbon, hydrogen, and phosphorus isotopes. Each method alone has been used rather extensively to examine certain aspects of organ and tissue metabolism under a variety of experimental conditions, and has contributed novel information in this regard. The most exciting development appears to be the combined use of more than one investigational technique, across one or more tissues simultaneously. A handful of recent studies have employed complex experimental designs or hybrid methodologies, ultimately demonstrating the potential for a more detailed assessment of metabolism at the local level.

SUMMARY

Clearly, advances in the use, performance, and applications of available methods are expected to provide improved and more powerful tools for the metabolic investigation of organs and tissues in humans in vivo.