Interaction of fat-stimulated gastric inhibitory polypeptide on pancreatic alpha and beta cell function

Hyperinsulinaemic-hypoglycaemic glucose clamps in human research: a systematic review of the literature

AIMS/HYPOTHESIS

The hyperinsulinaemic-hypoglycaemic glucose clamp technique has been developed and applied to assess effects of and responses to hypoglycaemia under standardised conditions. However, the degree to which the methodology of clamp studies is standardised is unclear. This systematic review examines how hyperinsulinaemic-hypoglycaemic clamps have been performed and elucidates potential important differences.

METHODS

A literature search in PubMed and EMBASE was conducted. Articles in English published between 1980 and 2018, involving adults with or without diabetes, were included.

RESULTS

A total of 383 articles were included. There was considerable variation in essential methodology of the hypoglycaemic clamp procedures, including the insulin dose used (49-fold difference between the lowest and the highest rate), the number of hypoglycaemic steps (range 1-6), the hypoglycaemic nadirs (range 2.0-4.3 mmol/l) and the duration (ranging from 5 to 660 min). Twenty-seven per cent of the articles reported whole blood glucose levels, most venous levels. In 70.8% of the studies, a dorsal hand vein was used for blood sampling, with some form of hand warming to arterialise venous blood in 78.8% of these. Key information was missing in 61.9% of the articles.

CONCLUSIONS/INTERPRETATION

Although the hyperinsulinaemic-hypoglycaemic clamp procedure is considered the gold standard to study experimental hypoglycaemia, a uniform standard with key elements on how to perform these experiments is lacking. Methodological differences should be considered when comparing results between hypoglycaemic clamp studies.

PROSPERO REGISTRATION

This systematic review is registered in PROSPERO (CRD42019120083).

Quantifying insulin sensitivity and entero-insular responsiveness to hyper- and hypoglycemia in ferrets

Ferrets are an important emerging model of cystic fibrosis related diabetes. However, there is little documented experience in the use of advanced techniques to quantify aspects of diabetes pathophysiology in the ferret. Glycemic clamps are the gold standard technique to assess both insulin sensitivity and insulin secretion in humans and animal models of diabetes. We therefore sought to develop techniques for glycemic clamps in ferrets. To assess insulin sensitivity, we performed euglycemic hyperinsulinemic clamps in 5–6 week old ferrets in the anesthetized and conscious states. To assess insulin secretion, we performed hyperglycemic clamps in conscious ferrets. To evaluate responsiveness of ferret islet and entero-insular hormones to low glucose, a portion of the hyperglycemic clamps were followed by a hypoglycemic clamp. The euglycemic hyperinsulinemic clamps demonstrated insulin responsiveness in ferrets similar to that previously observed in humans and rats. The anesthetic isoflurane induced marked insulin resistance, whereas lipid emulsion induced mild insulin resistance. In conscious ferrets, glucose appearance was largely suppressed at 4 mU/kg/min insulin infusion, whereas glucose disposal was progressively increased at 4 and 20 mU/kg/min insulin. Hyperglycemic clamp induced first phase insulin secretion. Hypoglycemia induced a rapid diminishment of insulin, as well as a rise in glucagon and pancreatic polypeptide levels. The incretins GLP-1 and GIP were affected minimally by hyperglycemic and hypoglycemic clamp. These techniques will prove useful in better defining the pathophysiology in ferrets with cystic fibrosis related diabetes.

Mechanisms of early improvement/resolution of type 2 diabetes after bariatric surgery

Bariatric surgery represents the main option for obtaining substantial and long-term weight loss in morbidly obese subjects. In addition, malabsorptive (biliopancreatic diversion, BPD) and restrictive (roux-en-Y gastric bypass, RYGB) surgery, originally devised to treat obesity, has also been shown to help diabetes. Indeed, type 2 diabetes is improved or even reversed soon after these operations and well before significant weight loss occurs. Two hypotheses have been proposed to explain the early effects of bariatric surgery on diabetes--namely, the hindgut hypothesis and the foregut hypothesis. The former states that diabetes control results from the more rapid delivery of nutrients to the distal small intestine, thereby enhancing the release of hormones such as glucagon-like peptide-1 (GLP-1). The latter theory contends that exclusion of the proximal small intestine reduces or suppresses the secretion of anti-incretin hormones, leading to improvement of blood glucose control as a consequence. In fact, increased GLP-1 plasma levels stimulate insulin secretion and suppress glucagon secretion, thereby improving glucose metabolism. Recent studies have shown that improved intestinal gluconeogenesis may also be involved in the amelioration of glucose homoeostasis following RYGB. Although no large trials have specifically addressed the effects of bariatric surgery on the remission or reversal of type 2 diabetes independent of weight loss and/or caloric restriction, there are sufficient data in the literature to support the idea that this type of surgery--specifically, RYGB and BPD--can lead to early improvement of glucose control independent of weight loss.

Chronic desensitization of the glucose-dependent insulinotropic polypeptide receptor in diabetic rats

Rats were rendered diabetic by streptozotocin, after which serum glucose-dependent insulinotropic polypeptide (GIP) levels, duodenal mucosal GIP content, and GIP mRNA levels were nine times, 50% and 80%, respectively, greater than in control rats. To determine whether an increase in GIP gene expression might induce chronic desensitization of its receptor, normal rats were subjected to continuous intravenous GIP infusion. Serum GIP levels increased gradually in GIP-infused rats, and by 4 h a threefold increase was detected. In response to GIP infusion, the serum insulin concentration increased at 30 min, followed by a gradual decrease, and at 4 h, no increase in insulin levels was detected despite a sustained elevated serum GIP level. The response to glucagon-like peptide-1 (GLP-1) was preserved, a reporter cell line (LGIPR2) stably transfected with rat GIP receptor cDNA was studied. GIP stimulated adenosine 3', 5'-cyclic monophosphate (cAMP) production in LGIPR2 cells, which was first detected after 1 h of stimulation, reached maximum level at 4 h, and returned to basal concentrations by 16 h. Additional stimulation with GIP at 16 h did not affect cAMP generation, indicating desensitization of the GIP receptor by the ligand. In contrast, a response to prostaglandin E1 or forskolin in GIP-desensitization was a receptor-specific process. The results of these studies indicate that GIP gene expression is enhanced in diabetic animals and that elevated serum GIP level induces chronic desensitization of the GIP receptor in vivo and in a stably transfected cell line.

Feedback regulation of glucose-dependent insulinotropic polypeptide (GIP) secretion by insulin in conscious rats

Feedback regulation of glucose-dependent insulinotropic polypeptide (GIP) was studied in a conscious rat model. Male Wistar rats were preconditioned to partial restraint, the tail artery and vein were cannulated under local anesthesia. All animals received 1 g/kg oral glucose by gavage and were divided into 3 groups: One group ('euglycemic hyperinsulinemic', EH) underwent rapid induction of hyperinsulinemia by i.v. insulin infusion from 5 min prior to oral glucose until 120 min after (mean plasma insulin = 2285 +/- 108 pM +/- S.E.M., n = 5); a second group ('hyperglycemic hyperinsulinemic', HH) underwent rapid induction of both hyperinsulinemia and hyperglycemia (mean serum glucose = 12.9 +/- 0.4 mM +/- S.E.M., mean plasma insulin 3160 +/- 109 pM, n = 5). A third group ('control') underwent saline infusion alone (n = 5). Arterial blood was collected for GIP estimation at -10, 0, 10, 20, 30, 50, 70, 90 and 120 min after oral glucose. In the control group GIP rose by 96% from a mean basal concentration of 114 +/- 12 pM to a peak of 224 +/- 14 pM by 20 min, and returned to baseline within 70 min. In EH, the GIP rise was blunted and the peak (146 +/- 31 pM) occurred at 10 min, while in HH GIP peaked at 192 +/- 32 pM 10 min after oral glucose (a 92% increase over basal). Compared to controls, total area under the curve for GIP was less for EH (598 +/- 112 versus 971 +/- 94 pmol/l/h +/- S.E.M., P < 0.034). GIP response in HH was similar to the control group at 853 +/- 134 pmol/l/h.(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of body weight, age and glucose tolerance on the relationship between GIP secretion and beta-cell function in man

The aim of the present study was to examine the association between insulin and gastric inhibitory polypetide (GIP) secretion in conditions characterized by insulin resistance, i.e. obesity, impaired glucose tolerance (IGT), non-insulin dependent diabetes mellitus (NIDDM) and aging. Obesity, IGT and aging were associated with an increased insulin/C-peptide response to a test meal. The GIP response to the test meal was 'blunted' in the obese subjects but normal in older subjects and patients with IGT, thereby refuting the hypothesis that GIP is involved in the hyperinsulinaemia of these conditions. In contrast, lean NIDDM subjects showed both a reduced insulin/C-peptide repsonse and a decreased GIP response to the test meal indicating that dysfunction of GIP secretion could be involved in the impaired beta-cell function in NIDDM. The data, therefore, suggest that hypersecretion of GIP does not contribute to hyperinsulinaemia and hyper-C-peptidaemia in insulin-resistant states. In contrast, hyposecretion of GIP may be involved in hypoinsulinaemia/hypo-C-peptidaemia observed in NIDDM.

The effect of dietary modification and hyperglycaemia on gastric emptying and gastric inhibitory polypeptide (GIP) secretion

1. Five healthy volunteers whose usual fat and energy intakes were moderately high (fat intake 155 (SE 11) g/d; energy intake 13683 (SE 909) kJ/d) were given on two separate occasions (a) 96 g fat and (b) 96 g fat and intravenous (IV) glucose (250 g glucose/l; 100 ml followed by a 2 ml/min infusion for 180 min). 2. Subjects continued on a low-fat diet for 35 d (fat intake 25 (SE 4) g/d; energy intake 6976 (SE 539) kJ/d) and the tests repeated. 3. The gastric inhibitory polypeptide (GIP) response to oral fat was significantly attenuated by IV glucose whilst subjects were consuming their normal diets and the GIP response to fat alone was significantly diminished during the low-fat diet. Post-prandial plasma triglycerides, light scattering indices (LSI; an index of post-prandial chylomicronaemia) and paracetamol levels paralleled the integrated GIP responses on both normal and low-fat diets. 4. The study of oral fat with or without glucose was repeated on seven further volunteers consuming their usual diet, substituting 10 MBq 99Tcm-labelled tin colloid for the paracetamol to investigate the rate of gastric emptying by radionuclide imaging. 5. Plasma GIP, insulin, triglyceride and LSI levels were similar to those found in the first study. IV glucose almost doubled the gastric emptying time of the oral fat load (half emptying time (t1/2) 148 (SE 11) min after fat alone and 224 (SE 18) min after fat and IV glucose). Post-prandial plasma motilin levels were significantly depressed by IV glucose.(ABSTRACT TRUNCATED AT 250 WORDS)

New developments in the incretin concept

Experimental and clinical work over the last 6 years has confirmed and broadened, but also challenged, the incretin concept. The nervous component of the entero-insular axis is still poorly defined, especially the peptidergic nerves, of which several contain insulinotropic regulatory peptides. The incretin effect is preserved after complete denervation of the porcine pancreas. Type 2 (non insulin-dependent) diabetic patients have a significantly decreased incretin effect. GIP (gastric inhibitory polypeptide; glucose dependent insulin releasing peptide) remains the strongest incretin factor. Its secretion depends on the absorption of nutrients. However, the correlation between the GIP response and disturbances of the entero-insular axis in some gastrointestinal diseases and, in particular, Type 2 diabetes, is poor. Furthermore, physiological concentrations of exogenous GIP do not produce fully the incretin effect and injection of GIP antibodies does not abolish the incretin effect. This suggests the existence of additional humoral incretin factors. On the other hand, GIP seems to have direct metabolic effects independent of its insulinotropic activity. The incretin effect of oral glucose is smaller if plasma levels of C-peptide rather than insulin are measured. However, decreased hepatic extraction of insulin after glucose ingestion only accounts partially for the incretin effect. GIP is unlikely to be the gut factor which regulates hepatic insulin extraction.

Influence of ingested load on postprandial insulin secretion. Rôle of gastric inhibitory polypeptide (GIP)

Two standard mixed meals including the same ingredients, and with different caloric values were ingested by 10 normal subjects. The plasma gastric inhibitory polypeptide (GIP) and immunoreactive insulin (IRI) as well as blood glucose (BG) were assayed during these meals at 0 (beginning of the meal) and after 30, 60, 120 and 180 min. BG was not significantly different between the two meals. At 30 min, the GIP peak was significantly higher in the case of the meal with the highest caloric (HC) value (499.5 +/- 112.0 vs. 273.4 +/- 57.5 pg/ml). Insulin was higher as well, although not in a significant way. At 120 min, the IRI was significantly higher (63.0 +/- 9.8 vs. 34.4 +/- 6.2 microU/ml) in the case of the HC meal. The HC meal induced a significantly higher insulinogenic index (0.29 +/- 0.05 vs. 0.14 +/- 0.07 mU litre g-1 ml-1). Integrated IRI and GIP responses of the HC meal were significantly higher than those of the meal with the lowest caloric value (IRI : 7.9 +/- 1.1 vs. 4.9 +/- 0.6 mU ml-1 180 min-1; GIP : 53.3 +/- 20.5 vs. 28.2 +/- 9.9 ng ml-1 180 min-1). The early (30 min) augmentation of IRI secretion after the ingestion of a larger meal is related to the insulinotropic action of the enhanced GIP secretion. The reasons for the late IRI increase are not obvious from this experiment. They might be of neural, nutrient, and/or intestinal origin.

Role of hepatic autoregulation in defense against hypoglycemia in humans

To assess the role of hepatic autoregulation in defense against hypoglycemia, we compared the effects of complete blockade of glucose counterregulation with those of blockade of only neurohumoral counterregulation during moderate (approximately 50 mg/dl) and severe (approximately 30 mg/dl) hypoglycemia induced by physiologic hyperinsulinemia during subcutaneous infusion of insulin in normal volunteers. Compared with observations in control experiments, neurohumoral counterregulatory blockade (somatostatin, propranolol, phentolamine, and metyrapone), during which identical moderate hypoglycemia was achieved using the glucose clamp technique, resulted in suppressed glucose production (0.62 +/- 0.08 vs. 1.56 +/- 0.07 mg/kg per min at 12 h, P less than 0.01) and augmented glucose utilization (2.17 +/- 0.18 vs. 1.57 +/- 0.07 mg/kg per min at 12 h, P less than 0.01). Complete blockade of counterregulation (neurohumoral blockade plus prevention of hypoglycemia) did not further enhance the suppressive effects of insulin on glucose production. However, when severe hypoglycemia was induced during neurohumoral counterregulatory blockade, glucose production was nearly two times greater (1.05 +/- 0.05 mg/kg per min at 9 h) than that observed during complete counterregulatory blockade (0.58 +/- 0.08 mg/kg per min at 9 h, P less than 0.01) and that observed during mere neurohumoral blockade with moderate hypoglycemia (0.59 +/- 0.06 mg/kg per min at 9 h, P less than 0.01). These results demonstrate that glucose counterregulation involves both neurohumoral and hepatic autoregulatory components: neurohumoral factors, which require only moderate hypoglycemia for their activation, augment glucose production and reduce glucose utilization; hepatic autoregulation requires severe hypoglycemia for its activation and may thus serve as an emergency system to protect the brain when other counterregulatory factors fail to prevent threatening hypoglycemia.

Effect of serial test meals on plasma immunoreactive GIP in non-insulin dependent diabetic patients and non-diabetic controls

Previous reports have shown considerable variation in postprandial gastric inhibitory polypeptide (GIP) response in non-insulin-dependent diabetic (NIDD) patients. One reason for this may be the use of different GIP antisera. Employing antiserum R65, which specifically reacts with the 5000-dalton GIP, we investigated the plasma GIP response to serial test meals in 11 NIDD patients and 11 age- and weight-matched non-diabetic controls. The postprandial GIP response was lower in the NIDD patients than in the non-diabetic controls (p less than 0.05). Although the serum insulin concentrations did not differ between diabetic and non-diabetic subjects, the insulin to glucose ratio was lower in the diabetics than in the non-diabetic subjects (p less than 0.05) indicating some degree of relative insulin deficiency in the diabetic patients. The data suggest that the GIP secretory capacity may be impaired in NIDD patients. Whether the impairment of GIP secretion is associated with impaired insulin secretion requires further investigation.

Suppression of basal, but not of glucose-stimulated insulin secretion by human insulin in healthy and obese hyperinsulinemic subjects

To evaluate the suppressive effect of biosynthetic human insulin (BHI; 2.5 U/m2 . h) on basal and glucose-stimulated insulin secretion in healthy and obese hyperinsulinemic subjects, the plasma C-peptide response was measured during maintenance of euglycemia and hyperglycemia by means of the glucose clamp technique. In five healthy subjects in whom arterial insulin concentration was increased to 94 +/- 8 microU/mL, but euglycemia was maintained at the fasting level. C-peptide concentration fell from 1.3 +/- 1.0 ng/mL by 21 +/- 8% (P less than 0.05). When hyperglycemia of 7 mmol/L above basal was induced by a variable glucose infusion, the C-peptide response was similar in the control (5.0 +/- 0.6 ng/mL) and BHI experiments (4.7 +/- 0.6 ng/mL) and was paralleled by an identical increase in plasma insulin above the prevailing insulin concentration. In seven obese patients plasma C-peptide fell from 3.5 +/- 0.4 to 2.8 +/- 0.5 ng/mL (P less than 0.05) when BHI was infused at the same rate of euglycemia maintained as in the lean subjects. As in healthy subjects, however, the plasma C-peptide response to the hyperglycemic stimulus (8.7 +/- 0.9 ng/mL) was not altered by BHI (7.9 +/- 0.8 ng/mL). Glucose utilization as determined by the glucose infusion rate necessary to maintain the desired glucose level was reduced by half in the obese patients compared with that of normal subjects. From these data we conclude that in healthy as well as obese hyperinsulinemic subjects, insulin at concentrations capable of suppressing its basal secretion fails to suppress its glucose-stimulated secretion.

Pathophysiology of insulin secretion in diabetes mellitus

In normal man, glucose serves to regulate basal insulin secretion by its participation with insulin in a feedback loop. In addition, glucose stimulates insulin secretion directly and potentiates insulin responses to nonglucose stimuli such as amino acids, beta-adrenergic stimuli, and gut hormones. Maximal glycemic potentiation of the acute insulin response to IV arginine occurs at a glucose level of approx. 450 mg/dl. In patients with noninsulin dependent diabetes mellitus (NIDDM), basal insulin levels have usually been reported as normal, but if plasma glucose is lowered to normal levels, a deficiency of basal insulin becomes apparent. In addition, the first phase (0-10 min) insulin response to IV glucose is absent in virtually all patients with overt NIDDM. In contrast, the second-phase (greater than 10 min) response is often preserved in NIDDM due to its maintenance by ambient hyperglycemia. Similarly, insulin responses to nonglucose stimuli such as arginine often appear normal in NIDDM because of potentiation by hyperglycemia. However, insulin responses to arginine are lower than those of nondiabetic controls when compared at multiple matched glucose levels. Indeed, maximal potentiation by glucose of the insulin response to arginine is markedly subnormal in NIDDM, suggesting a loss of functional B cell secretory capacity. In patients with long-standing insulin-dependent diabetes mellitus (IDDM), basal insulin secretion and insulin responses to all stimuli are virtually absent. However, in a remission phase, or in IDDM of short duration, basal insulin secretion and insulin responses to nonglucose stimuli may be relatively preserved. Therefore, islet dysfunction in IDDM and NIDDM, while etiologically different, share some common pathophysiological features.

Effect of pretreatment with a high fat diet on the gastric inhibitory polypeptide and insulin responses to oral triolein and glucose in rats

Male Wistar rats were pretreated with 3 ml triolein orally for 4 days in addition to their normal diet. A similar control group were allowed free access to normal laboratory food. When given an oral fat load (1 ml triolein) plasma gastric inhibitory polypeptide (GIP) and triglyceride levels were significantly higher in the fat pretreated group. Inhibition of fat-stimulated GIP release by exogenous insulin was demonstrated in the untreated control group (plasma GIP: 663 +/- 49 versus 853 +/- 92 ng/l, mean +/- SEM p less than 0.025), but pretreatment with an oral fat load abolished this effect (plasma GIP: 1008 +/- 95 versus 1116 +/- 100 ng/l, p NS). Plasma glucose levels were significantly higher in fat pretreated rats given oral fat and intraperitoneal insulin compared with untreated controls (plasma glucose nadir 2.6 +/- 0.48 versus 1.6 +/- 0.15 mmol/l, p less than 0.05). Fat-pretreated rats showed significantly higher insulin and glucose levels compared with the untreated rats when given oral glucose (plasma insulin: 6.2 +/- 1.2 versus 2.5 +/- 0.59 micrograms/l, p less than 0.01; plasma glucose: 10.2 +/- 0.39 versus 8.9 +/- 0.41 mmol/l, p less than 0.025). Pretreatment of rats on a high fat diet causes (1) increased GIP secretion in response to an oral fat load, (2) abolition of the feed-back inhibition of exogenous insulin on fat-stimulated GIP release, and (3) some degree of insulin resistance.

Effect of intraduodenal and intravenous triglyceride infusions on plasma gastric inhibitory polypeptide and insulin in fetal and neonatal pigs

The responses of gastric inhibitory polypeptide (GIP) and insulin to intraduodenal and IV triglyceride infusions were measured in 11 late fetal and 10 neonatal pigs. Basal plasma glucose, insulin, and GIP concentrations were lower in fetal than in neonatal pigs. In the fetal pigs, plasma glucose increased slightly during intraduodenal and IV triglyceride infusions, whereas plasma insulin remained unchanged during the tests. No significant changes were observed in plasma GIP concentration following intraduodenal triglyceride infusion in the fetal pigs, but plasma GIP fell during the IV infusion of triglyceride in these pigs (p less than 0.01). In the neonatal pigs, plasma glucose and insulin remained unaffected by intraduodenal and triglyceride infusions. Plasma GIP did not change during the IV triglyceride infusion, but exhibited a paradoxical decline after the intraduodenal triglyceride infusion (p less than 0.05). It is concluded that the GIP-cell response to an oral triglyceride load is suppressed in late fetal and neonatal pigs. The abolished GIP response to oral triglycerides could play a causal role in the inactivity of the enteroinsular axis which is seen in both human and animal neonates.