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Physiologic Insulin Resensitization as a Treatment Modality for Insulin Resistance Pathophysiology. Int J Mol Sci 2022; 23:ijms23031884. [PMID: 35163806 PMCID: PMC8836751 DOI: 10.3390/ijms23031884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/28/2022] [Accepted: 02/03/2022] [Indexed: 12/10/2022] Open
Abstract
Prevalence of type 2 diabetes increased from 2.5% of the US population in 1990 to 10.5% in 2018. This creates a major public health problem, due to increases in long-term complications of diabetes, including neuropathy, retinopathy, nephropathy, skin ulcers, amputations, and atherosclerotic cardiovascular disease. In this review, we evaluated the scientific basis that supports the use of physiologic insulin resensitization. Insulin resistance is the primary cause of type 2 diabetes. Insulin resistance leads to increasing insulin secretion, leading to beta-cell exhaustion or burnout. This triggers a cascade leading to islet cell destruction and the long-term complications of type 2 diabetes. Concurrent with insulin resistance, the regular bursts of insulin from the pancreas become irregular. This has been treated by the precise administration of insulin more physiologically. There is consistent evidence that this treatment modality can reverse the diabetes-associated complications of neuropathy, diabetic ulcers, nephropathy, and retinopathy, and that it lowers HbA1c. In conclusion, physiologic insulin resensitization has a persuasive scientific basis, significant treatment potential, and likely cost benefits.
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Howard SW, Zhang Z, Linomaz J, Lam W, Qian Z, Thurman J, BeLue R. Efficacy Evaluation Study for Microburst Insulin Infusion: A Novel Model of Care. Front Public Health 2021; 9:600906. [PMID: 34458216 PMCID: PMC8387654 DOI: 10.3389/fpubh.2021.600906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 07/05/2021] [Indexed: 11/25/2022] Open
Abstract
Objectives: This study aims to evaluate the impact of Microburst Insulin Infusion (MII) treatment on Type 1 and 2 diabetic patients' HbA1c, lipids, peripheral neuropathy, and patient-reported health status. Methods: We reviewed clinical charts, including lab results, for more than 80 diabetic and pre-diabetic patients treated at one U.S. outpatient clinic in St. Louis, Missouri between February 2017 and December 2019. Data included patient demographics, treatment data, lab and neuropathy tests, and self-reported patient health status questions. The explanatory variable was number of months of MII treatment. Treatments are 3–4 h in length, with two intensive infusions the first week and one treatment each week thereafter, usually for 12 weeks total. Lab tests were at 12-week intervals. Generalized linear modeling and t-tests assessed the significance of differences between patients' baseline lab values, neuropathy measures, and health status before treatment vs. after final treatment. Results: Number of MII treatments per patient ranged from 1 to 262, over 1–24 months. Time in MII treatment was significantly associated with reductions in HbA1c by nearly 0.04 points per month, and triglycerides declined 3 points per month. Neuropathy measures of large toe vibratory sensation (clanging tuning fork) improved significantly, as did patient-reported health and feelings of improvement since beginning treatment. Discussion: The MII therapy appears to be efficacious in treating diabetic patients, particularly those with complications like neuropathy. Our findings affirmed several other studies. We uniquely incorporated patient health questionnaires, and empirically studied MII treatment efficacy for diabetes in a population large enough to permit statistically valid inferences. With multiple waves of data for over 80 patients, this is one of the most extensive quantitative studies of microburst insulin infusion therapy conducted to date, with protocols more uniformly implemented and survey instruments more consistently administered by the same clinical team. Given the advances in insulin infusion therapy brought by MII, and early indications of its efficacy, the time is right for more in-depth studies of the outcomes patients can achieve, the physiological mechanisms by which they occur, MII's comparative effectiveness vis-à-vis traditional treatments, and cost-effectiveness.
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Affiliation(s)
- Steven W Howard
- Department of Health Management and Policy, College for Public Health and Social Justice at Saint Louis University, St. Louis, MO, United States
| | - Zidong Zhang
- Department of Health Management and Policy, College for Public Health and Social Justice at Saint Louis University, St. Louis, MO, United States
| | - Jacob Linomaz
- Department of Health Management and Policy, College for Public Health and Social Justice at Saint Louis University, St. Louis, MO, United States
| | - Wing Lam
- Department of Health Management and Policy, College for Public Health and Social Justice at Saint Louis University, St. Louis, MO, United States
| | - Zhengmin Qian
- Department of Epidemiology and Biostatistics, Saint Louis University, St. Louis, MO, United States
| | | | - Rhonda BeLue
- Department of Health Management and Policy, College for Public Health and Social Justice at Saint Louis University, St. Louis, MO, United States
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Gu N, Dong A, Gao L, Xie C, Hou P, Wang W, Zhu S, Yao C, Zhang J, Guo X. Effectiveness and safety of pulsatile intravenous insulin therapy for the improvement of respiratory quotient in Chinese patients with diabetes mellitus. Exp Ther Med 2020; 19:3069-3075. [PMID: 32256794 PMCID: PMC7086298 DOI: 10.3892/etm.2020.8563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 12/20/2019] [Indexed: 11/18/2022] Open
Abstract
Pulsatile intravenous insulin therapy (PIVIT) is a means of imitating naturally occurring insulin pulses artificially. It is thought to improve carbohydrate metabolism, which can be assessed using the respiratory quotient (RQ). The aim of this present study was to assess the efficacy and safety of PIVIT for the improvement of RQ in Chinese patients with diabetes mellitus (DM). This 12-week, multi-center, prospective, randomized, open-label, parallel-group study involved 110 DM patients (both type 1 and type 2) whose RQ was <0.8. Of these, 53 patients formed the control group, in which standard anti-diabetic therapy was maintained, and 54 patients formed the treatment group, which underwent weekly PIVIT in addition to the administration of standard anti-diabetic therapy. RQ was evaluated monthly in control subjects, and before and after every PIVIT treatment in the treatment group. After weekly PIVIT for 12 weeks, the mean RQ increased from 0.70 to 0.90 in the treatment group, but did not change in the control group. The percentage of subjects reporting adverse events (AEs) was 31.5% (17/54) in the treatment group and 9.43% (5/53) in the control group (P=0.0053). The most frequently reported AE (by 12 subjects) was a gastroenteric reaction when these individuals were receiving 50% glucose during the PIVIT treatment. The majority of AEs were mild and did not interfere with the ongoing treatment. Thus, PIVIT can be viewed as tolerated and effective for the improvement of RQ in Chinese DM patients. This study was retrospectively registered with the Chinese Clinical Trial Registry (http://www.chictr.org.cn) on November 13th 2019 (registration no. ChiCTR1900027510).
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Affiliation(s)
- Nan Gu
- Department of Endocrinology, Peking University First Hospital, Beijing 100034, P.R. China
| | - Aimei Dong
- Department of Endocrinology, Peking University First Hospital, Beijing 100034, P.R. China
| | - Lei Gao
- Institute of Clinical Pharmacology, Peking University First Hospital, Beijing 100034, P.R. China
| | - Chenying Xie
- Department of Endocrinology, Peking University First Hospital, Beijing 100034, P.R. China
| | - Peiyi Hou
- Department of Endocrinology, Peking University First Hospital, Beijing 100034, P.R. China
| | - Wenbo Wang
- Department of Endocrinology, Peking University Shougang Hospital, Beijing 100144, P.R. China
| | - Sainan Zhu
- Department of Biostatistics, Peking University First Hospital, Beijing 100034, P.R. China
| | - Chen Yao
- Department of Biostatistics, Peking University First Hospital, Beijing 100034, P.R. China
| | - Junqing Zhang
- Department of Endocrinology, Peking University First Hospital, Beijing 100034, P.R. China
| | - Xiaohui Guo
- Department of Endocrinology, Peking University First Hospital, Beijing 100034, P.R. China
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Dong S, Lau H, Chavarria C, Alexander M, Cimler A, Elliott JP, Escovar S, Lewin J, Novak J, Lakey JRT. Effects of Periodic Intensive Insulin Therapy: An Updated Review. Curr Ther Res Clin Exp 2019; 90:61-67. [PMID: 31193369 PMCID: PMC6527898 DOI: 10.1016/j.curtheres.2019.04.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 04/25/2019] [Indexed: 12/15/2022] Open
Abstract
Background Traditional insulin treatment for diabetes mellitus with insulin administered subcutaneously yields nonpulsatile plasma insulin concentrations that represent a fraction of normal portal vein levels. Oral hypoglycemic medications result in the same lack of pulsatile insulin response to blood glucose levels. Intensive treatments of significant complications of diabetes are not recommended due to complicated multidrug regimens, significant weight gain, and the high risk of hypoglycemic complications. Consequently, advanced complications of diabetes do not have an effective treatment option because conventional therapy is not sufficient. Intensive insulin therapy (IIT) simulates normal pancreatic function by closely matching the periodicity and amplitude of insulin secretion in healthy subjects; however, the mechanisms involved with the observed improvement are not clearly understood. Objective The current review aims to analyze the pathophysiology of insulin secretion, discuss current therapies for the management of diabetes, provides an updates on the recent advancements of IIT, and proposes its mechanism of action. Methods A literature search on PubMed, MEDLINE, Embase, and CrossRef databases was performed on multiple key words regarding the history and current variations of pulsatile and IIT for diabetes treatment. Articles reporting the physiology of insulin secretion, advantages of pulsatile insulin delivery in patients with diabetes patients, efficacy and adverse effects of current conventional insulin therapies for the management of diabetes, benefits and shortcomings of pancreas and islet transplantation, or clinical trials on patients with diabetes treated with pulsed insulin therapy or advanced IIT were included for a qualitative analysis and categorized into the following topics: mechanism of insulin secretion in normal subjects and patients with diabetes and current therapies for the management of diabetes, including oral hypoglycemic agents, insulin therapy, pancreas and islet transplantation, pulsed insulin therapy, and advances in IIT. Results Our review of the literature shows that IIT improves the resolution of diabetic ulcers, neuropathy, and nephropathy, and reduces emergency room visits. The likely mechanism responsible for this improvement is increased insulin sensitivity from adipocytes, as well as increased insulin receptor expression. Conclusions Recent advancements show that IIT is an effective option for both type 1 diabetes mellitus and type 2 diabetes mellitus patient populations. This treatment resembles normal pancreatic function so closely that it has significantly reduced the effects of relatively common complications of diabetes in comparison to standard treatments. Thus, this new treatment is a promising advancement in the management of diabetes. (Curr Ther Res Clin Exp. 2019; 80:XXX–XXX).
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Affiliation(s)
- Shu Dong
- Department of Surgery, University of California Irvine, Orange, California
| | - Hien Lau
- Department of Surgery, University of California Irvine, Orange, California
| | - Cody Chavarria
- Department of Surgery, University of California Irvine, Orange, California
| | - Michael Alexander
- Department of Surgery, University of California Irvine, Orange, California
| | | | | | | | - Jack Lewin
- Lewin and Associates, New York, New York
| | | | - Jonathan R T Lakey
- Department of Surgery, University of California Irvine, Orange, California.,Department of Biomedical Engineering, University of California Irvine, Irvine, California
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McCarty MF. In type 1 diabetics, high-dose biotin may compensate for low hepatic insulin exposure, promoting a more normal expression of glycolytic and gluconeogenic enyzymes and thereby aiding glycemic control. Med Hypotheses 2016; 95:45-48. [PMID: 27692165 DOI: 10.1016/j.mehy.2016.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 08/09/2016] [Indexed: 10/21/2022]
Abstract
In type 1 diabetics, hepatic exposure to insulin is chronically subnormal even in the context of insulin therapy; as a result, expression of glycolytic enzymes is decreased, and that of gluconeogenic enzymes is enhanced, resulting in a physiologically inappropriate elevation of hepatic glucose output. Subnormal expression of glucokinase (GK) is of particular importance in this regard. Possible strategies for correcting this perturbation of hepatic enzyme expression include administration of small molecule allosteric activators of GK, as well as a procedure known as chronic intermittent intravenous insulin therapy (CIIIT); however, side effects accompany the use of GK activators, and CIIIT is time and labor intensive. Alternatively, administration of high-dose biotin has potential for modulating hepatic enzyme expression in a favorable way. Studies in rodents and in cultured hepatocytes demonstrate that, in the context of low insulin exposure, supra-physiological levels of biotin induce increased expression of GK while suppressing that of the key gluconeogenic enzyme phosphoenolpyruvate carboxykinase. These effects may be a downstream consequence of the fact that biotin down-regulates mRNA expression of FOXO1; insulin's antagonism of the activity of this transcription factor is largely responsible for its modulatory impact on hepatic glycolysis and gluconeogenesis. Hence, high-dose biotin may compensate for subnormal insulin exposure by suppressing FOXO1 levels. High-dose biotin also has the potential to oppose hepatic steatosis by down-regulating SREBP-1 expression. Two pilot trials of high-dose biotin (16 or 2mg per day) in type 1 diabetics have yielded promising results. There is also some reason to suspect that high-dose biotin could aid control of diabetic neuropathy and nephropathy via its stimulatory effect on cGMP production. Owing to the safety, good tolerance, moderate expense, and current availability of high-dose biotin, this strategy merits more extensive evaluation in type 1 diabetes.
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Affiliation(s)
- Mark F McCarty
- Catalytic Longevity, 7831 Rush Rose Drive, Apt. 316, Carlsbad, CA 92009, United States.
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Skjaervold NK, Östling D, Hjelme DR, Spigset O, Lyng O, Aadahl P. Blood glucose control using a novel continuous blood glucose monitor and repetitive intravenous insulin boluses: exploiting natural insulin pulsatility as a principle for a future artificial pancreas. Int J Endocrinol 2013; 2013:245152. [PMID: 24369461 PMCID: PMC3863478 DOI: 10.1155/2013/245152] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 10/24/2013] [Indexed: 11/18/2022] Open
Abstract
The aim of this study was to construct a glucose regulatory algorithm by employing the natural pulsatile pattern of insulin secretion and the oscillatory pattern of resting blood glucose levels and further to regulate the blood glucose level in diabetic pigs by this method. We developed a control algorithm based on repetitive intravenous bolus injections of insulin and combined this with an intravascular blood glucose monitor. Four anesthetized pigs were used in the study. The animals developed a mildly diabetic state from streptozotocin pretreatment. They were steadily brought within the blood glucose target range of 4.5-6.0 mmol/L in 21 to 121 min and kept within that range for 128 to 238 min (hypoglycemic values varied from 2.9 to 51.1 min). The study confirmed our hypotheses regarding the feasibility of this new principle for blood glucose control, and the algorithm was constantly improved during the study to produce the best results in the last animals. The main obstacles were the drift of the IvS-1 sensor and problems with the calibration procedure, which calls for an improvement in the sensor stability before this method can be applied fully in new studies in animals and humans.
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Affiliation(s)
- Nils K. Skjaervold
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, MTFS, Postbox 8905, 7491 Trondheim, Norway
- Department of Anesthesiology and Intensive Care Medicine, Trondheim University Hospital, Postbox 3250 Sluppen, 7006 Trondheim, Norway
- *Nils K. Skjaervold:
| | - Dan Östling
- Invivosense Norway Ltd., c/o NTNU Technology Transfer, Sem Saelands Vei 14, 7034 Trondheim, Norway
| | - Dag R. Hjelme
- Invivosense Norway Ltd., c/o NTNU Technology Transfer, Sem Saelands Vei 14, 7034 Trondheim, Norway
- Department of Electronics and Telecommunications, Faculty of Information Technology, Mathematics and Electrical Engineering, Norwegian University of Science and Technology, 7491 Trondheim, Norway
- Faculty of Technology, Sør-Trøndelag University College, Postbox 2320, 7004 Trondheim, Norway
| | - Olav Spigset
- Department of Laboratory Medicine, Children's and Women's Health, Norwegian University of Science and Technology, 7491 Trondheim, Norway
- Department of Clinical Pharmacology, Trondheim University Hospital, Postbox 3250 Sluppen, 7006 Trondheim, Norway
| | - Oddveig Lyng
- Unit of Comparative Medicine, Norwegian University of Science and Technology, 7491 Trondheim, Norway
| | - Petter Aadahl
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, MTFS, Postbox 8905, 7491 Trondheim, Norway
- Department of Anesthesiology and Intensive Care Medicine, Trondheim University Hospital, Postbox 3250 Sluppen, 7006 Trondheim, Norway
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Leinung MC. Comments on a pilot study to test the effect of pulsatile insulin infusion on type 1 diabetes mellitus patients with proteinuria. Metabolism 2010; 59:763-4; author reply 764-5. [PMID: 20206368 DOI: 10.1016/j.metabol.2010.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Accepted: 01/22/2010] [Indexed: 11/19/2022]
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Mirbolooki MR, Taylor GE, Knutzen VK, Scharp DW, Willcourt R, Lakey JRT. Pulsatile intravenous insulin therapy: the best practice to reverse diabetes complications? Med Hypotheses 2009; 73:363-9. [PMID: 19446964 DOI: 10.1016/j.mehy.2009.02.042] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2009] [Revised: 02/14/2009] [Accepted: 02/17/2009] [Indexed: 11/24/2022]
Abstract
In the basal state and after oral ingestion of carbohydrate, the normal pancreas secretes insulin into the portal vein in a pulsatile manner. The end organ of the portal vein is the liver, where approximately 80% of pancreatic insulin is extracted during first pass. In Type 1 diabetes, pancreatic insulin secretion is nearly or completely absent whilst in Type 2 diabetes the normal pattern is absent, abnormal, or blunted. Exogenous subcutaneous insulin treatment results in plasma insulin concentrations that are not pulsatile and a fraction of normal portal vein levels. Oral hypoglycemic agents also do not result in normal pulsatile response to a glucose load. Due to hypoglycemia risk, intensive treatment is not recommended after serious complications develop. Consequently, no conventional therapy has proved effective in treating advanced diabetes complications. Beta-cell replacement using whole pancreas or islet transplantation has been utilized to treat certain problems in Type 1 diabetic patients, but still unavailable for all diabetics. Pulsatile intravenous insulin therapy (PIVIT) is an insulin therapy, which mimics the periodicity and amplitude of normal pancreatic function. Numerous studies show PIVIT effective in preventing, reversing, and reducing the severity and progression of diabetes complications, however, the mechanisms involved with the improvement are not clearly understood. Here, we review the cellular basis of normal and abnormal insulin secretion, current treatments available to treat diabetes, the physiologic basis of PIVIT and possible mechanisms of action.
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Affiliation(s)
- M Reza Mirbolooki
- Department of Surgery, University of California, Irvine, CA 92868, USA
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Abstract
The mechanisms and clinical importance of pulsatile insulin release are presented against the background of more than half a century of companionship with the islets of Langerhans. The insulin-secreting beta-cells are oscillators with intrinsic variations of cytoplasmic ATP and Ca(2+). Within the islets the beta-cells are mutually entrained into a common rhythm by gap junctions and diffusible factors (ATP). Synchronization of the different islets in the pancreas is supposed to be due to adjustment of the oscillations to the same phase by neural output of acetylcholine and ATP. Studies of hormone secretion from the perfused pancreas of rats and mice revealed that glucose induces pulses of glucagon anti-synchronous with pulses of insulin and somatostatin. The anti-synchrony may result from a paracrine action of somatostatin on the glucagon-producing alpha-cells. Purinoceptors have a key function for pulsatile release of islet hormones. It was possible to remove the glucagon and somatostatin pulses with maintenance of those of insulin with an inhibitor of the P2Y(1) receptors. Knock-out of the adenosine A(1) receptor prolonged the pulses of glucagon and somatostatin without affecting the duration of the insulin pulses. Studies of isolated human islets indicate similar relations between pulses of insulin, glucagon, and somatostatin as found during perfusion of the rodent pancreas. The observation of reversed cycles of insulin and glucagon adds to the understanding how the islets regulate hepatic glucose production. Current protocols for pulsatile intravenous infusion therapy (PIVIT) should be modified to mimic the anti-synchrony between insulin and glucagon normally seen in the portal blood.
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Affiliation(s)
- Bo Hellman
- Department of Medical Cell Biology, Uppsala University, Uppsala, Sweden.
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Abstract
This article, which is partly biographical and partly scientific, summarizes a life in academic medicine. It relates my progress from benchside to bedside and then to academic and research administration, and concludes with the teaching of human biology to college undergraduates. My experience as an intern (anno 1953) treating a youngster in diabetic ketoacidosis underscored our ignorance of the controls in human fuel metabolism. Circulating free fatty acids were then unknown, insulin could not be measured in biologic fluids, and beta-hydroxybutyric acid, which was difficult to measure, was considered by many a metabolic poison. The central role of insulin and the metabolism of free fatty acids, glycerol, glucose, lactate, and pyruvate, combined with indirect calorimetry, needed characterization in a near-steady state, namely prolonged starvation. This is the main topic of this chapter. Due to its use by brain, D-beta-hydroxybutyric acid not only has permitted man to survive prolonged starvation, but also may have therapeutic potential owing to its greater efficiency in providing cellular energy in ischemic states such as stroke, myocardial insufficiency, neonatal stress, genetic mitochondrial problems, and physical fatigue.
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Affiliation(s)
- George F Cahill
- Department of Medicine, Harvard Medical School, Boston, Massachusetts 02115, USA.
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Abstract
An important observation of the experiments of George Collier is that animals normally prefer to maintain their body weight by eating a large number of small meals each day. However, as the effort to obtain access to food increases, the animals adapt by changing to a schedule of eating a small number of large meals each day. A strong implication of this is that there is a hidden cost to eating large meals, and this is the basis of the eating paradox that states that although food is a necessary commodity, the act of ingesting it poses certain metabolic problems for animals. Experiments on cephalic insulin secretion, conditioned insulin secretion and meal feeding are discussed to make the point that the economy demonstrated by rats in Collier's paradigm is dictated in part by predictions of the eating paradox.
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Affiliation(s)
- Stephen C Woods
- Department of Psychiatry, University of Cincinnati Medical Center, Cincinnati, OH 45267, USA.
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