Triglyceride metabolism in acute starvation: the role of secretin and glucagon

Tumour catabolism independent of malnutrition and inflammation in upper GI cancer patients revealed by longitudinal metabolomics

BACKGROUND

The detrimental impact of malnutrition and cachexia in cancer patients subjected to surgical resection is well established. However, how systemic and local metabolic alterations in cancer patients impact the serum metabolite signature, thereby leading to cancer-specific differences, is poorly defined. In order to implement metabolomics as a potential tool in clinical diagnostics and disease follow-up, targeted metabolite profiling based on quantitative measurements is essential. We hypothesized that the quantitative metabolic profile assessed by ¹ H nuclear magnetic resonance (NMR) spectroscopy can be used to identify cancer-induced catabolism and potentially distinguish between specific tumour entities. Importantly, to prove tumour dependency and assess metabolic normalization, we additionally analysed the metabolome of patients' sera longitudinally post-surgery in order to assess metabolic normalization.

METHODS

Forty two metabolites in sera of patients with tumour entities known to cause malnutrition and cachexia, namely, upper gastrointestinal cancer and pancreatic cancer, as well as sera of healthy controls, were quantified by ¹ H NMR spectroscopy.

RESULTS

Comparing serum metabolites of patients with gastrointestinal cancer with healthy controls and pancreatic cancer patients, we identified at least 15 significantly changed metabolites in each comparison. Principal component and pathway analysis tools showed a catabolic signature in preoperative upper gastrointestinal cancer patients. The most specifically upregulated metabolite group in gastrointestinal cancer patients was ketone bodies (3-hydroxybutyrate, P < 0.0001; acetoacetate, P < 0.0001; acetone, P < 0.0001; false discovery rate [FDR] adjusted). Increased glycerol levels (P < 0.0001), increased concentration of the ketogenic amino acid lysine (P = 0.03) and a significant correlation of 3-hydroxybutyrate levels with branched-chained amino acids (leucine, P = 0.02; isoleucine, P = 0.04 [FDR adjusted]) suggested that ketone body synthesis was driven by lipolysis and amino acid breakdown. Interestingly, the catabolic signature was independent of the body mass index, clinically assessed malnutrition using the nutritional risk screening score, and systemic inflammation assessed by CRP and leukocyte count. Longitudinal measurements and principal component analyses revealed a quick normalization of key metabolic alterations seven days post-surgery, including ketosis.

CONCLUSIONS

Together, the quantitative metabolic profile obtained by ¹ H NMR spectroscopy identified a tumour-induced catabolic signature specific to upper gastrointestinal cancer patients and enabled monitoring restoration of metabolic homeostasis after surgery. This approach was critical to identify the obtained metabolic profile as an upper gastrointestinal cancer-specific signature independent of malnutrition and inflammation.

Pleiotropic Effects of Secretin: A Potential Drug Candidate in the Treatment of Obesity?

Secretin is the first hormone that has been discovered, inaugurating the era and the field of endocrinology. Despite the initial focus, the interest in its actions faded away over the decades. However, there is mounting evidence regarding the pleiotropic beneficial effects of secretin on whole-body homeostasis. In this review, we discuss the evidence from preclinical and clinical studies based on which secretin may have a role in the treatment of obesity.

Effects of timed food availability on reproduction and metabolism in zebra finches: Molecular insights into homeostatic adaptation to food-restriction in diurnal vertebrates

Food availability affects metabolism and reproduction in higher vertebrates including birds. This study tested the idea of adaptive homeostasis to time-restricted feeding (TRF) in diurnal zebra finches by using multiple (behavioral, physiological and molecular) assays. Adult birds were subjected for 1 week or 3 weeks to food restriction for 4 h in the evening (hour 8-12) of the 12 h light-on period, with controls on ad lib feeding. Birds on TRF showed enhanced exploratory behavior and plasma triglycerides levels, but did not show differences from ad lib birds in the overall food intake, body mass, and plasma corticosterone and thyroxine levels. As compared to ad lib feeding, testis size and circulation testosterone were reduced after first but not after third week of TRF. The concomitant change in the mRNA expression of metabolic and reproductive genes was also found after week 1 of TRF. Particularly, TRF birds showed increased expression of genes coding for gonadotropin releasing hormone (GnRH) in hypothalamus, and for receptors of androgen (AR) and estrogen (ER-alpha) in both hypothalamus and testes. However, genes coding for the deiodinases (Dio2, Dio3) and gonadotropin inhibiting hormone (GnIH) showed no difference between feeding conditions in both hypothalamus and testes. Further, increased Sirt1, Fgf10 and Ppar-alpha, and decreased Egr1 expression in the liver suggested TRF-effects on the overall metabolism. Importantly, TRF-effects on gene expressions by week 1 seemed alleviated to a considerable extent by week 3. These results on TRF-induced reproductive and metabolic effects suggest homeostatic adaptation to food-restriction in diurnal vertebrates.

Expression pattern and histone acetylation of energy metabolic genes in Xenopus laevis liver in response to diet statuses

Amphibians can survive without food for relatively longer periods by reducing the locomotor activity and metabolic rate and can recover quickly with refeeding from a dormant state. To clarify the molecular mechanism underlying this survival strategy, we investigated serum biochemical parameters, the transcript levels of energy metabolic genes, and global and gene-specific histone modifications in the liver of adult male Xenopus laevis, which were fed, fasted, or refed after fasting. Glucose, triglyceride, cholesterol, and free fatty-acid levels in sera decreased with fasting for 22 days, with only glucose levels recovered with 1 day of refeeding. The transcript levels of two-thirds of energy metabolic genes tested decreased with fasting for 22 days and partially recovered with 1 day of refeeding. The transcript levels of gluconeogenesis and lipid catabolism genes did not increase with fasting for 22 days. The Western blot analysis revealed no significant differences in the amounts of acetylated and methylated histones in the liver among the three groups on Day 22. The amounts of acetylated histone H4 did not change in diet-response genes, although the transcript levels of these genes quickly responded to fasting and refeeding. Our results indicate that Xenopus liver may respond to fasting toward an overall decrease in transcriptional activity and to refeeding toward quick recovery, despite no significant changes in histone acetylation level. This unusual unresponsiveness of histone acetylation to diet conditions may serve as an effective adaptation strategy to minimize energy demands during fasting and to quickly respond to refeeding.

The circulating metabolome of human starvation

The human adaptive starvation response allows for survival during long-term caloric deprivation. Whether the physiology of starvation is adaptive or maladaptive is context dependent: activation of pathways by caloric restriction may promote longevity, yet in the context of caloric excess, the same pathways may contribute to obesity. Here, we performed plasma metabolite profiling of longitudinally collected samples during a 10-day, 0-calorie fast in humans. We identify classical milestones in adaptive starvation, including the early consumption of gluconeogenic amino acids and the subsequent surge in plasma nonesterified fatty acids that marks the shift from carbohydrate to lipid metabolism, and demonstrate findings, including (a) the preferential release of unsaturated fatty acids and an associated shift in plasma lipid species with high degrees of unsaturation and (b) evidence that acute, starvation-mediated hypoleptinemia may be a driver of the transition from glucose to lipid metabolism in humans.

Effect of dietary forage: concentrate ratio on the behaviour, rumen fermentation and circulating concentrations of IGF-1, insulin, glucagon and metabolites of beef steers and their potential effects on carcass composition

In an investigation of factors responsible for the lower efficiency of carcass lean gain seen previously in steers offered grass silage diets 18 Simmental × British Friesian steers (361 (s.e. 5-35) kg) were offered one of three diets: a perennial ryegrass silage ad libitum and alone (S) or supplemented with rolled barley at 300 g/kg of total dry matter (SC) or supplemented as described but restricted (SCr) in quantity so as to provide the same dry matter (DM) and digestible energy (DE) intakes as for S. Eating (Eb), ruminating (Rb), standing (Sb) or lying (Lb) behaviour was quantified during four 24-h periods of manual observation. Eb was noted in more detail in a second experiment using computerized Calan-Broadbent gates and load cells to monitor times and rates of eating. Blood was taken via temporary indwelling jugular catheters at 30 to 60 min intervals on each of 4 days 1 month apart. Rumen fluid was sampled hourly for three 24-h periods from three rumen-cannulated steers given the same three diets in a separate 3 x 3 change-over design experiment.

Steers offered the restricted diet SCr ate most of their food in one extended meal within 6 h of feeding while two peak eating periods (morning and evening) were observed in steers offered the other two diets. Steers offered SCr spent more time in Sb (P < 0.05), and less time in Eb (P < 0·001) and Rb (P < 0·05) activities than did animals offered the two diets ad libitum (SC and S). Mean 24 h insulin-like growth factor-1 (IGF-1) concentrations and postprandial insulin concentrations were significantly higher with diet SCr than with diet S (P < 0·001) despite equal daily DM and DE intakes from each. Insulin appearance in the jugular vein reflected the pattern of food intake on all treatments. Rumen fermentation characteristics were largely unaffected by diet. Mean 24 h rumen volatile fatty acid, pH and ammonia concentrations did not differ between diets but post-prandial rumen pH tended to be lower in animals offered the SC and SCr diets.

Differences in patterns of food intake between animals offered food ad libitum and at a restricted level are likely to determine patterns of nutrient absorption and the secretion of nutritionally regulated splanchnic hormones. The higher proportions of Sb and Rb activities in steers offered the restricted diet represent an energy cost to these animals while the higher plasma IGF-1 and insulin concentrations also seen in these animals may collectively influence the partitioning of nutrients to the peripheral tissues and contribute to the increased efficiency of carcass lean deposition previously shown in animals offered such diets.

Extended longevity and survivorship during amino-acid starvation in a Drosophila Sir2 mutant heterozygote

The regulation of energy homeostasis is pivotal to survive periods of inadequate nutrition. A combination of intricate pathways and proteins are responsible for maximizing longevity during such conditions. The sirtuin deacetylase Sir2 is well conserved from single-celled yeast to mammals, and it controls a number of downstream targets that are active during periods of extreme stress. Overexpression of Sir2 has been established to enhance survival of a number of model organisms undergoing calorie restriction, during which insulin receptor signalling (IRS) is reduced, a condition that itself can enhance survivorship during starvation. Increased Sir2 expression and reduced IRS result in an increase in the activity of the transcription factor foxo, an advantageous activation during stress but lethal when overly active. We have found that a lowered gene dosage of Sir2, in mutant heterozygotes, can extend normal longevity and greatly augment survivorship during amino-acid starvation in Drosophila. Additionally, these mutants, in either heterozygous or homozygous form, do not appear to have any disadvantageous effects upon development or cell growth of the organism unlike IRS mutants. These results may advance the understanding of the biological response to starvation and allow for the development of a model organism to mimic the ability of individuals to tolerate nutrient deprivation.

Lipolytic actions of secretin in mouse adipocytes

Secretin (Sct), a classical gut hormone, is now known to play pleiotropic functions in the body including osmoregulation, digestion, and feeding control. As Sct has long been implicated to regulate metabolism, in this report, we have investigated a potential lipolytic action of Sct. In our preliminary studies, both Sct levels in circulation and Sct receptor (SctR) transcripts in adipose tissue were upregulated during fasting, suggesting a potential physiological relevance of Sct in regulating lipolysis. Using SctR knockout and Sct knockout mice as controls, we show that Sct is able to stimulate lipolysis in vitro in isolated adipocytes dose- and time-dependently, as well as acute lipolysis in vivo. H-89, a protein kinase A (PKA) inhibitor, was found to attenuate lipolytic effects of 1 μM Sct in vitro, while a significant increase in PKA activity upon Sct injection was observed in the adipose tissue in vivo. Sct was also found to stimulate phosphorylation at 660^ser of hormone sensitive lipase (HSL) and to bring about the translocation of HSL from cytosol to the lipid droplet. In summary, our data demonstrate for the first time the in vivo and in vitro lipolytic effects of Sct, and that this function is mediated by PKA and HSL.

Metabolic effects of secretin

Secretin (Sct), traditionally a gastrointestinal hormone backed by a century long research, is now beginning to be recognized also as a neuroactive peptide. Substantiation by recent evidence on the functional role of Sct in various regions of the brain, especially on its potential neurosecretion from the posterior pituitary, has revealed Sct's physiological actions in regulating water homeostasis. Recent advances in understanding the functional roles of central and peripheral Sct has been made possible by the development of Sct and Sct receptor (SctR) knockout animal models which have led to novel approaches in research on the physiology of this brain-gut peptide. While research on the role of Sct in appetite regulation and fatty acid metabolism has been initiated recently, its role in glucose homeostasis is unclear. This review focuses mainly on the metabolic role of Sct by discussing data from the last century and recent discoveries, with emphasis on the need for revisiting and elucidating the role of Sct in metabolism and energy homeostasis.

A Randomized Trial Comparing Low-Fat and Low-Carbohydrate Diets Matched for Energy and Protein

Several recent studies have found greater weight loss at 6 months among participants on a very-low-carbohydrate (VLC) weight-loss diet compared with a low-fat (LF) weight-loss diet. Because most of these studies were not matched for calories, it is not clear whether these results are caused by decreased energy intake or increased energy expenditure. It is hypothesized that several energy-consuming metabolic pathways are up-regulated during a VLC diet, leading to increased energy expenditure. The focus of this study was to investigate whether, when protein and energy are held constant, there is a significant difference in fat and weight loss when fat and carbohydrate are dramatically varied in the diet. The preliminary results presented in this paper are for the first four of six postmenopausal overweight or obese participants who followed, in random order, both a VLC and an LF diet for 6 weeks. Other outcome measures were serum lipids, glucose, and insulin, as well as dietary compliance and side effects. Our results showed no significant weight loss, lipid, serum insulin, or glucose differences between the two diets. Lipids were dramatically reduced on both diets, with a trend for greater triglyceride reduction on the VLC diet. Glucose levels were also reduced on both diets, with a trend for insulin reduction on the VLC diet. Compliance was excellent with both diets, and side effects were mild, although participants reported more food cravings and bad breath on the VLC diet and more burping and flatulence on the LF diet.

dSir2 deficiency in the fatbody, but not muscles, affects systemic insulin signaling, fat mobilization and starvation survival in flies

Sir2 is an evolutionarily conserved NAD+ dependent protein. Although, SIRT1 has been implicated to be a key regulator of fat and glucose metabolism in mammals, the role of Sir2 in regulating organismal physiology, in invertebrates, is unclear. Drosophila has been used to study evolutionarily conserved nutrient sensing mechanisms, however, the molecular and metabolic pathways downstream to Sir2 (dSir2) are poorly understood. Here, we have knocked down endogenous dSir2 in a tissue specific manner using gene-switch gal4 drivers. Knockdown of dSir2 in the adult fatbody leads to deregulated fat metabolism involving altered expression of key metabolic genes. Our results highlight the role of dSir2 in mobilizing fat reserves and demonstrate that its functions in the adult fatbody are crucial for starvation survival. Further, dSir2 knockdown in the fatbody affects dilp5 (insulin-like-peptide) expression, and mediates systemic effects of insulin signaling. This report delineates the functions of dSir2 in the fatbody and muscles with systemic consequences on fat metabolism and insulin signaling. In conclusion, these findings highlight the central role that fatbody dSir2 plays in linking metabolism to organismal physiology and its importance for survival.

Fasting increases serum total cholesterol, LDL cholesterol and apolipoprotein B in healthy, nonobese humans

Voluntary fasting is practiced by many humans in an attempt to lose body weight. Conflicting results have been published on the effects of food deprivation on serum lipids. To study the effect of acute starvation on serum lipids, 10 nonobese (93-124% of ideal body weight), healthy adults (6 men, 4 women, 21-38 y old) fasted (no energy) for 7 d. Fasting increased total serum cholesterol from 4.90 +/- 0.23 to 6.73 +/- 0.41 mmol/L (37.3 +/- 5.0%; P < 0.0001) and LDL cholesterol from 2.95 +/- 0.21 to 4.90 +/- 0.36 mmol/L (66.1 +/- 6. 6%; P < 0.0001). Serum apolipoprotein B (apo B) increased from 0.84 +/- 0.06 to 1.37 +/- 0.11 g/L (65.0 +/- 9.2%; P < 0.0001). The increases in serum cholesterol, LDL and apo B were associated with weight loss. Fasting did not affect serum concentrations of triacylglycerol and HDL cholesterol. Serum concentrations of insulin-like growth factor-I (IGF-I) decreased from 246 +/- 29 (prefast) to 87 +/- 10 microg/L after 1 wk of fasting (P < 0.0001). We conclude that, in nonobese subjects, fasting is accompanied by increases in serum cholesterol, LDL and apo B concentrations, whereas IGF-I levels are decreased.

Within- and Between-Subject Variation in Commonly Measured Anthropometric and Biochemical Variables

Background: The biological variation of some commonly assessed metabolic variables in healthy subjects has not been studied extensively. The aim of the study was to assess, in 12 healthy subjects (6 male and 6 female; mean (SD) age; 22.7 (1.5) years) following an overnight fast, the day-to-day variation of body fat (impedance method), triglycerides, nonesterified fatty acid (NEFAs), glycerol, 3-hydroxybutyrate (3-OHB), lactate, glucose, insulin (RIA), C-peptide, and glucagon on 12 consecutive days.

Methods: Between- and within-subject coefficients of variation (CVG and CVW) were estimated using a random effects analysis of variance, and assay variation was subtracted to give the coefficient of within-subject biological variation (CVI). Individuality indices were calculated as CVW/CVG.

Results: The overall means, CVI, and individuality indices were as follows: for body fat, 24.2%, 10%, and 0.3; for triglycerides, 0.61 mmol/L, 21%, and 1.1; for NEFAs, 376 μmol/L, 45%, and 1.4; for glycerol, 48 μmol/L, 36%, and 0.8; for 3-OHB, 43 μmol/L, 61%, and 1.5; for lactate, 0.88 mmol/L, 31%, and 1.1; for glucose, 4.9 mmol/L, 4.8%, and 0.7; for insulin, 52 pmol/L, 26%, and 1.0; for C-peptide, 0.39 nmol/L, 24%, and 0.9; and for glucagon, 53 ng/L, 19%, and 0.8.

Conclusions: The data presented here are necessary for the evaluation of several important metabolic variables in individual and group studies. The biological variation of some metabolites makes it difficult to characterize the status of healthy subjects with a single measurement.

The use of tolbutamide-induced hypoglycemia to examine the intraislet role of insulin in mediating glucagon release in normal humans

Disruption of intraislet mechanisms could account for the impaired glucagon response to hypoglycemia in type 1 diabetes. However, in contrast to animals, there is conflicting evidence that such mechanisms operate in humans. We have used i.v. tolbutamide (T) (1.7 g bolus + 130 mg/h infusion) to create high portal insulin concentrations and compared this with equivalent hypoglycemia using an i.v. insulin infusion (I) (30 mU/m2 x min). Ten normal subjects underwent two hypoglycemic clamps; mean glucose; I (53 +/- 1 mg/dL); and T (53 +/- 1 mg/dL) (2.9 +/- 0.04 mmol/L vs. 2.9 +/- 0.05 mmol/L), held for 30 min. During hypoglycemia, mean peripheral insulin levels were greater with I (59 +/- 4 mU/L) than T (18 +/- 3 mU/L), P < 0.001. Calculated peak portal insulin concentrations were greater during T (282 +/- 28 mU/L) than I (78 +/- 4 mU/L), P < 0.00005. The demonstration of a reduced glucagon response during T-induced hypoglycemia (111 +/- 8 ng/L vs. 135 +/- 12 ng/L, P < 0.05) with higher portal insulin concentrations suggests that intraislet mechanisms may contribute to the release of glucagon during hypoglycemia in man.

Physiological, symptomatic and hormonal responses to acute hypoglycaemia in type 1 diabetic patients with autonomic neuropathy

The effects of peripheral autonomic neuropathy on the symptomatic, physiological, and hormonal responses to acute insulin-induced hypoglycaemia were studied in two groups of patients with Type 1 diabetes, matched for age, duration of diabetes, and prevailing glycaemic control. A group of eight patients who gave a history of normal awareness of hypoglycaemia and had normal cardiovascular autonomic function tests were compared to a group of six patients who had symptoms of autonomic dysfunction and gross abnormalities of cardiovascular autonomic function tests. An additional two patients with autonomic neuropathy who also had hypoglycaemia unawareness were studied. Acute hypoglycaemia was induced by intravenous infusion of insulin (2.5 mU kg-1 min-1) and the onset of the acute autonomic reaction (R) was identified objectively by the sudden rise in heart rate and onset of sweating. Cognitive function and hypoglycaemia symptom scores were estimated serially, and plasma counterregulatory hormones were measured. Acute autonomic activation was observed to occur in all subjects in response to hypoglycaemia and commenced at similar venous plasma glucose concentrations in both groups (neuropathic patients: 1.6 +/- 0.2 mmol l-1 vs non-neuropathic patients 1.6 +/- 0.2 mmol l-1, p = 0.9,). In the neuropathic patients plasma adrenaline responses were significantly lower at all time points from time R until time R + 30 min (MANOVA for repeated measures, F = 19.4, p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Pancreatic and pituitary hormonal responses to insulin-induced hypoglycaemia during muscarinic cholinergic blockade in man

To investigate the role of muscarinic cholinergic mechanisms in mediating the pancreatic and pituitary hormonal responses to hypoglycaemia, six normal subjects were studied during acute insulin-induced hypoglycaemia under control conditions, and during blockade with intravenous atropine. During atropine blockade the response of pancreatic polypeptide was suppressed while the maximum response of plasma glucagon was significantly higher. The increment in plasma vasopressin was also increased significantly during cholinergic blockade. During blockade with atropine the responses of plasma prolactin was reduced, with a slight but significant reduction in the growth hormone response, and although a similar maximum response of plasma ACTH was achieved, this rise was delayed. These results implicate involvement of a cholinergic muscarinic inhibitory and stimulatory mechanisms in regulating the responses of pancreatic and pituitary hormones to hypoglycaemia.

Beta-adrenoceptor blockade and hypoglycaemia. A randomised, double-blind, placebo controlled comparison of metoprolol CR, atenolol and propranolol LA in normal subjects

1. The effect of 1 week of treatment with propranolol LA (160 mg), atenolol (100 mg) and metoprolol CR (100 mg) on awareness of and the physiological responses to moderate hypoglycaemia were compared with placebo using a randomised, cross-over design in 12 healthy volunteers. 2. All three beta-adrenoceptor antagonists reduced resting heart rate, systolic blood pressure and heart rate responses to submaximal exercise compared with placebo. 3. Under hyperinsulinaemic (60 mu m-2 min-1) clamp conditions, at a blood glucose of 2.5 mmol l-1, atenolol prevented the rise in systolic and atenolol and metoprolol CR prevented the fall in diastolic blood pressure usually associated with hypoglycaemia. At this level of hypoglycaemia, the expected increase in heart rate was inhibited by atenolol but not metoprolol CR. Pre-treatment with propranolol LA resulted in a significant pressor response and a bradycardia during hypoglycaemia. In addition the normal increase in finger tremor was abolished by propranolol LA. 4. During hypoglycaemia all three beta-adrenoceptor blockers augmented sweating compared with placebo but hypoglycaemic symptoms, awareness and slowing of reaction time were the same with drugs and placebo. 5. The rise in plasma adrenaline and other counter-regulatory hormones during hypoglycaemia was enhanced by beta-adrenoceptor blockade. 6. We conclude that beta-adrenoceptor antagonists modify the physiological and hormonal responses to, but do not adversely affect awareness of, moderate hypoglycaemia in healthy volunteers.

Alcohol causes hypoglycaemic unawareness in healthy volunteers and patients with type 1 (insulin-dependent) diabetes

Both hypoglycaemia and alcohol consumption affect cognitive function but it is unclear whether moderate drinking alters awareness of hypoglycaemia. We have examined this in a single blind randomised hyperinsulinaemic clamp study in eight non-diabetic subjects and seven Type 1 (insulin-dependent) diabetic patients. After 30 min of euglycaemia (blood glucose 4.5 mmol/l) subjects drank either 0.75 g/kg ethanol or a placebo drink after which blood glucose was lowered to 2.5 mmol/l for 40 min. Awareness of hypoglycaemia, reaction time and physiological responses were measured before and after ethanol. At a blood glucose concentration of 4.5 mmol/l, ethanol (producing peak blood levels of 20-25 mmol/l) caused a transient increase in systolic blood pressure (p less than 0.05), a sustained increase in heart rate (p less than 0.01) and a slowing of reaction time in both normal subjects and diabetic patients. During hypoglycaemia in both groups, the slowing of reaction time and increase in sweating were more marked after ethanol than placebo (both p less than 0.05), while the increase in finger tremor (p less than 0.05) was blunted after ethanol, in both groups. Counter regulatory hormone secretion was not affected by ethanol. Despite increases in symptoms during hypoglycaemia, only 2 of 15 individuals "felt hypoglycaemic" after ethanol compared to 11 out of 15 after placebo. We conclude that after moderate drinking non-diabetic subjects and Type 1 diabetic patients are less aware of hypoglycaemia despite exaggerated physiological changes.

Adaptation to mild hypoglycaemia in normal subjects despite sustained increases in counter-regulatory hormones

In diabetes, loss of awareness of and a defective hormonal response to hypoglycaemia have been associated with long disease duration, improved glycaemic control and possibly a change in insulin species. In contrast it is assumed that normal subjects always have symptoms when their blood glucose is low. We have tested this in 7 normal subjects at 3 levels of blood glucose (4.5, 3.5 and 3.0 mmol/l) using a hyperinsulinaemic glucose clamp with a euglycaemic (4.5 mmol/l) clamp as a control. After 60 min at a blood glucose of 3.5 mmol/l adrenaline and glucagon increased slightly but significantly, whereas cortisol, growth hormone and pancreatic polypeptide were unchanged. As soon as glucose was lowered to 3.0 mmol/l adrenaline increased to 1.10 nmol/l and rose further to 1.43 nmol/l after 60 min. Glucagon secretion increased similarly but other counter-regulatory hormones were significantly raised only after 60 min at 3.0 mmol/l. Awareness of hypoglycaemia (symptom score) increased after 40 min at a blood glucose of 3.0 mmol/l but after 60 min decreased to baseline levels with loss of awareness in 5 subjects. Reaction time improved in parallel with the change in symptom score. Thus, despite high levels of adrenaline, normal subjects lose awareness during sustained mild hypoglycaemia. Improved reaction time may reflect cerebral adaptation.

Effect of carbohydrate refeeding on free fatty acids after a fast in obese diabetic and obese non-diabetic females

The metabolic effects of refeeding with oral or intravenous carbohydrate were studied in obese women after ten or 14 days of fasting. Seven patients were refed with protein-free fruit juice for a total of 250 g of carbohydrate (1,000 kcal) over ten hours. The juice was sipped continuously throughout this time, causing a drop in free fatty acids (FFA) from 1.07 +/- 0.08 to 0.61 +/- 0.05 mmol/L (P less than .01) over the first four hours. Over the next four hours, despite continuous ingestion of the carbohydrate and elevated plasma glucose (132 +/- 9 mg/dL) and insulin (2.81 +/- 0.86 ng/mL) (1 ng/mL = 25 microU/mL), FFA rose to 0.99 mmol/L (P less than .01). Similar results were obtained in five patients refed with similar amounts of oral glucose and four patients who received an equivalent amount of glucose intravenously (IV). Refeeding with carbohydrate of obese diabetic and non-diabetic women after a two-week fast caused an abrupt decrease in FFA that was followed after four hours by an increase in FFA and glycerol, despite continued ingestion of carbohydrate glucose and insulin.

Counterregulatory hormonal responses to hypoglycaemia in type 1 (insulin-dependent) diabetes: evidence for diminished hypothalamic-pituitary hormonal secretion

Acute insulin-induced hypoglycaemia in humans provokes autonomic neural activation and counterregulatory hormonal secretion mediated in part via hypothalamic stimulation. Many patients with Type 1 (insulin-dependent) diabetes have acquired deficiencies of counterregulatory hormonal release following hypoglycaemia. To study the integrity of the hypothalamic-pituitary and the sympatho-adrenal systems, the responses of pituitary hormones, beta-endorphin, glucagon and adrenaline to acute insulin-induced hypoglycaemia (0.2 units/kg) were examined in 16 patients with Type 1 diabetes who did not have autonomic neuropathy. To examine the effect of duration of diabetes these patients were subdivided into two groups (Group 1: 8 patients less than 5 years duration; Group 2: 8 patients greater than 15 years duration) and were compared with 8 normal volunteers (Group 3). The severity and time of onset of hypoglycaemia were similar in all 3 groups, but mean blood glucose recovery was slower in the diabetic groups (p less than 0.01). The mean responses of glucagon, adrenaline, adrenocorticotrophic hormone, prolactin and beta-endorphin were similar in all 3 groups, but the mean responses of growth hormone were lower in both diabetic groups than in the normal group (p less than 0.05). The mean increments of glucagon and adrenaline in the diabetic groups were lower than the normal group, but these differences did not achieve significance; glucagon secretion was preserved in several diabetic patients irrespective of duration of disease. Various hormonal responses to hypoglycaemia were absent or diminished in individual diabetic patients, and multiple hormonal deficiencies could be implicated in delaying blood glucose recovery.(ABSTRACT TRUNCATED AT 250 WORDS)

Counterregulation in type 2 (non-insulin-dependent) diabetes mellitus. Normal endocrine and glycaemic responses, up to ten years after diagnosis

We have examined hormonal and metabolic responses to insulin-induced hypoglycaemia in 10 Type 2 (non-insulin-dependent) diabetic patients treated with tablets and 10 age, sex and weight matched control subjects. Diabetic patients were under 110% ideal body weight, had no autonomic neuropathy and were well controlled (HbA1, 7.1 +/- 0.2%). After the diabetic patients were kept euglycaemic by an overnight insulin infusion, hypoglycaemia was induced in both groups by intravenous insulin at 30 mU.m-2.min-1 for 60 min and counterregulatory responses measured for 150 min. There were no significant differences between diabetic patients and control subjects in the rate of fall (3.3 +/- 0.3 vs 4.0 +/- 0.3 mmol.l-1.h-1), nadir (2.4 +/- 0.2 vs 2.3 +/- 0.1 mmol/l) and rate of recovery (0.027 +/- 0.002 vs 0.030 +/- 0.003 mmol.l-1.min-1) of blood glucose. Increments of glucagon (60.5 +/- 5.7 vs 70 +/- 9.2 ng/l) and adrenaline (1.22 +/- 0.31 vs 1.45 +/- 0.31 nmol/l) were similar in both groups. When tested using this model, patients with Type 2 diabetes, without microvascular complications and taking oral hypoglycaemic agents show no impairment of the endocrine response and blood glucose recovery following hypoglycaemia.

Hypoglycemia during adrenergic beta-blockade: evidence against mediation via a deficiency of lactate for gluconeogenesis

Acute hypoglycemia was induced using intravenous inulin in three groups of normal volunteers: (1) seventeen control subjects, (2) six subjects under beta-adrenergic blockade with propranolol, and (3) eight subjects given propranolol plus sodium lactate as an exogenous substrate for gluconeogenesis. Under propranolol blockade the recovery from hypoglycemia was significantly impaired. This impairment was not prevented by the infusion of sodium lactate despite the production of an adequate elevation of blood lactate concentrations. These findings suggest that the impaired recovery from hypoglycemia during beta-adrenergic blockade is not mediated via a deficiency of lactate as substrate for hepatic gluconeogenesis.

Increased plasma triglycerides, cholesterol and apolipoprotein E during prolonged fasting in normal subjects

Plasma lipid and high density lipoprotein (HDL) levels were studied in 20 normal, healthy, non-obese males while fasting (150 kcal/d with free intake of water) for 6 d in a hunger strike. Plasma triglyceride and cholesterol levels were increased by 18% after 6 d of fasting. HDL-cholesterol concentration was not significantly changed for 4 d, but decreased by 22% after 6 d. Platelet aggregation induced by adenosine diphosphate (ADP) or collagen after 6 d of fasting was in the normal range. In 3 subjects fasted for 9 d, a complete plasma lipoprotein analysis was done. Very low and low density lipoprotein (VLDL and LDL) levels were elevated, whereas HDL was reduced after 9 d of fasting. On isoelectric focusing analysis, a marked reduction in apolipoprotein (apo) E concentration in both VLDL and HDL was noted. Liver function tests showed a reduction in hepatic enzyme activity; and since apo E is of hepatic origin also, we suggest that long fasting inhibits liver function in normal subjects.

Lipids, lipoproteins and fatty acid composition in obese adolescents undergoing a very low calorie diet

Sixteen obese adolescents (mean +/- SD age: group I 12.5 +/- 2.1 and group II 12.0 +/- 2.5 years) were treated at least 3 weeks with two different very low calorie diet (VLCD) regimens. The VLCD in group I contained 33g proteins, 25.5g carbohydrates and 0.7g fat (240 kcal, 1004KJ) and in group II 44g protein, 33g carbohydrates and 0.9g fat (320 kcal, 1339KJ). After the 3 weeks treatment total serum cholesterol decreased from 180 +/- 34 mg/dl in group I and 184 +/- 34 mg/dl in group II respectively, to 125 + 16 mg/dl and 120 + 22 mg/dl. This fall was mainly due to the highly significant decrease of LDL-cholesterol. VLDL-cholesterol, HDL-cholesterol and triglycerides in group I remained almost unchanged. In group II triglycerides increased significantly from 81 +/- 19 mg/dl to 104 +/- 19 mg/dl and HDL-cholesterol decreased slightly. The LDL-C HDL-C- ratio in both groups improved considerably. Fatty acid composition of the serum lipids changed only slightly: In total serum linoleic acid levels declined slightly in group I and remained constant in group II. Linoleic acid content in cholesterylesters declined moderately in group I from 37.5 +/- 5.6% to 34.8 +/- 5.6% whereas arachidonic acid increased slightly in both groups. In phospholipids, oleic acid declined in both groups significantly, linoleic acid declined significantly in group I and arachidonic acid increased in group I significantly. Similar changes occurred in triglycerides. After 3 weeks treatment with a practically fat free alimentation no biochemical signs of essential fatty acid deficiency could be detected.

Physiological circulating levels of secretin-like immunoreactivity in the human do not stimulate free fatty acid production

An in vivo study was carried out to establish whether infused secretin, which achieves physiological levels of secretin-like immunoreactivity (SLI), promotes lipolysis. Six healthy volunteers received two infusions after separate 8 h overnight fasts. The paired infusions of either 500 ml of normal saline or 150 C.U. of porcine secretin in 500 ml of normal saline were infused at a constant rate of 1.38 ml/min. Venous blood was sampled at 0, 1, 2, 3, 4, 5 and 6 h after the infusion started. Mean plasma concentrations of SLI were significantly higher after infusion of saline with secretin in comparison to infusion of saline alone but remained within the physiological range. Mean serum free fatty acid (FFA) and 3-hydroxybutyrate concentrations rose significantly with time during both infusions but the mean FFA and 3-hydroxybutyrate concentrations did not differ significantly between infusions at each time of assessment. We conclude that a lipolytic role for secretin has not been shown to be of importance in relation to the in vivo rise in FFA concentrations observed in the fasting normal subject.

The plasma concentrations of secretin and vasoactive intestinal polypeptide (VIP) after long-term, strenuous exercise

Twelve subjects (aged 21-38 years) participated in a 90-km cross-country ski race lasting 4.45-6.50 h. In order to investigate a metabolic role for secretin and vasoactive intestinal polypeptide (VIP) during long-term strenuous exercise, seven of the subjects were given an oral hypertonic glucose solution while the others had no nutrient intake immediately after the race. The plasma concentrations of secretin and VIP were greatly increased immediately after the race, and the levels were not normalized within 140 min, though there was a significant decrease after 80 min with rest. The post-race plasma levels of secretin and VIP showed a rapid and very marked decrease 15 min after ingestion of glucose, and the plasma levels had returned to control levels 60 min and 15 min respectively after glucose loading. The results indicate some metabolic function for secretin and VIP during long-term physical exercise.

Hormonal and substrate responses during recovery from hypoglycaemia in man during beta 1-selective and non-selective beta-adrenergic blockade

Recovery from acute hypoglycaemia induced by the injection of insulin has been examined in six human subjects under control conditions, under non-selective beta blockade (propranolol) and under selective beta 1 blockade (metoprolol). The normal blood glucose recovery was biphasic with an initial rapid and a slower subsequent phase of recovery. The early recovery mechanism was unaffected by either form of beta blockade, but with propranolol the late phase of recovery was significantly prolonged. Rises in blood lactate and plasma free fatty acids following hypoglycaemia were markedly reduced by propranolol but to a much lesser degree with metoprolol. The counterregulatory hormonal responses of glucagon, cortisol and growth hormone were augmented appropriately for the prolonged hypoglycaemia associated with propranolol. Non-selective beta adrenergic blockade with propranolol is associated with an impairment of the late phase of blood glucose recovery from hypoglycaemia. The possible mechanisms of this impairment are discussed.

Autonomic neural control mechanisms of substrate and hormonal responses to acute hypoglycaemia in man

The contributions of adrenergic and cholinergic mechanisms to recovery from acute hypoglycaemia induced by insulin (0.15 units/kg i.v.) were examined in eleven normal subjects, six subjects with a pre-ganglionic sympathectomy (adrenergic denervation) and six sympathectomized subjects given atropine (combined adrenergic denervation and cholinergic blockade). Blood glucose recovery was impaired only in the sympathectomized subjects given atropine. The blood lactate response was reduced and the rise in free fatty acids was delayed in both groups of sympathectomized subjects, in whom the normal rises of plasma cyclic AMP and noradrenaline were absent. The plasma pancreatic glucagon response was appropriate to the prevailing blood glucose concentrations in all three groups. The cortisol response was impaired and the pattern of ACTH secretion was abnormal in sympathectomized subjects given atropine. Growth hormone levels were higher in both sympathectomized groups. Blood glucose homeostasis was impaired during combined adrenergic denervation and cholinergic blockade. Glucagon secretion was activated independently of vagal control. In the sympathectomized group given atropine, the rise in plasma cortisol was blunted despite a greater degree of hypoglycaemia. A blockade of central cholinergic receptors producing impaired activation of ACTH secretion at hypothalamic level may explain, at least in part, this delayed restoration of normoglycaemia.

Acute hypoglycemia in man: neural control of pancreatic islet cell function

Acute hypoglycemia is associated with stimulation of the pancreatic alpha cells and a concurrent, prolonged suppression of insulin secretion by the beta cells. The islets receive a rich autonomic innervation and may therefore be subject to control by adrenergic and cholinergic mechanisms. The role of such neuroregulation of pancreatic islets in response to hypoglycemia has been examined in normal subjects, in subjects with a preganglionic sympathectomy due to traumatic tetraplegia, and in tetraplegic subjects given atropine to induce effective dual autonomic denervation. The normal rise of plasma norepinephrine following hypoglycemia was absent in both groups of tetraplegic subjects, providing evidence of a complete sympathectomy. Blood glucose recovery was significantly impaired only in the group of tetraplegic patients given atropine. Changes in plasma C-terminal glucagon-like immunoreactivity (C-GLI) and C-peptide immunoreactivity (CPR) following hypoglycemia were commensurate with blood glucose levels and were not significantly influenced by islet denervation. These observations suggest that neuroregulation of human islet cell function in response to hypoglycemia may be of limited importance and that stimulation of glucagon secretion may occur independent of cholinergic vagal control.

Effects of caloric restriction on lipid metabolism in man: changes of tissue lipoprotein lipase activities and of serum lipoproteins

Heparin-releasable lipoprotein lipase (LPL) activity was measured in biopsy samples of adipose tissue and skeletal muscle of 8 normal healthy females, first during an isocaloric diet and then after 2 and 7 days on a 400-kcal diet. In adipose tissue the LPL activity expressed per tissue weight fell to 38% and to 22% of the initial level after 2 and 7 days' caloric restriction, respectively. In skeletal muscle the LPL activity rose slightly after two days (+24%) but decreased to 49% of the initial value after seven days on diet. The estimated total body LPL activity decreased to 50% and to 20% of the baseline value after 2 and 7 days, respectively, but the relative contribution of skeletal muscle to the total LPL increased from 10 to 30%. The triglyceride and VLDL triglyceride concentrations were not significantly changed during the low calorie diet but the LDL triglyceride increased and the HDL cholesterol decreased significantly (P less than 0.01). It is concluded that substantial restriction of calorie intake results in a decrease of over-all triglyceride removal capacity but in an increase of the fraction removed by skeletal muscle. The decrease of HDL cholesterol is probably a consequence of the low turnover of exogenous and endogenous triglyceride-rich lipoproteins.

Relative insensitivity to glucagon of sterol synthesis in cultured rat aortic smooth muscle cells. Effect of dibutyryl cyclic AMP

The smooth muscle cell plays an important role in the process of atherogenesis. In these experiments the effect of glucagon and dibutyryl cyclic AMP on sterol synthesis in cultured rat arterial smooth muscle cells was studied. Glucagon in concentrations of 1 X 10(-9) mol/l inhibited the incorporation of sodium (2(-14)C)acetate into non-saponifiable lipids and digitonin precipitable sterols but lower concentrations of glucagon had no effect. In cells which were exposed to serum, dibutyryl cyclic AMP also resulted in a decrease in the incorporation of labelled acetate into sterols but when the cells were grown in serum free medium, dibutyryl cyclic AMP had no inhibitory effect on sterol synthesis. These results provide further evidence that sterol metabolism in arterial smooth cells may be influenced by hormones but suggest that glucagon is relatively less important than insulin in this respect.