Diabetes Mellitus

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Definition of Diabetes

Diabetes is any disorder characterized by excessive urine excretion. The most common form of diabetes is diabetes mellitus, a metabolic disorder in which there is an inability to maintain carbohydrate and lipid homeostasis due to disturbances in insulin function, resulting hyerglycemia and excess urinary excretion of glucose as well as hyperlipidemia. Diabetes mellitus is characterized by chronic hyperglycemia and the potential for episodic ketoacidosis. Additional symptoms of diabetes mellitus include excessive thirst, (polydipsia) glucosuria, polyuria, lipemia and hunger (polyphagia). There are two primary forms of diabetes mellitus, type 1 and type 2. Type 1 is defined by the loss of insulin production by the pancreas and type 2 is defined by loss of peripheral responses to insulin. If left untreated type 1 diabetes can lead to fatal ketoacidosis. Of the two major forms of diabetes mellitus, type 2 represents the prevalent form of the disease. Indeed, in the US type 2 diabetes could easily be considered at epidemic proportions.

Other forms of diabetes include diabetes insipidus, brittle diabetes, and bronze diabetes. Diabetes insipidus is charaterized by the excess output (3–20 liters per day; normal is less than 3 liters per day) of dilute urine. There are four major classifications of diabetes insipidus, each of which is related to the primary site/cause of the excess urine output. These forms are referred to as central, nephrogenic, dipsogenic, and gestational. Central diabetes insipidus relates to pathologies that affect the hypothalamus or the pituitary resulting in defects in vasopressin (antidiuretic hormone, ADH) synthesis or release. Nephrogenic diabetes insipidus results from the loss of, or abnormal, responses of the kidneys to the actions of vasopressin. Dipsogenic diabetes insipidus relates to disturbances in the hypothalamic control of thirst. Gestational diabetes insipidus results from excess maternal production of prostaglandins or it is due to placental synthesis of an enzyme called vasopressinase (leucyl cystinyl aminopeptidase) that results in degradation of vasopressin. Brittle diabetes is a sub-type of type 1 diabetes that is very difficult to control. It is characterized by unexplained oscillations between hyperglycemia, hypoglycemia and acidosis. Bronze diabetes is the term used to describe the hyperglycemia that is frequent in patients with hemochromatosis. This disease is associated with elevated bilirubin deposition in the skin resulting in the yellowing characteristic of jaundice, hence the bronze term.












Criteria, which clinically establish an individual as suffering from type 2 diabetes mellitus, include:

1. having a fasting plasma glucose level in excess of 126mg/dL (7mmol/L). Normal levels should be less than 100mg/dL (5.6mmol/L) or:

2. having plasma glucose levels in excess of 200mg/dL (11mmol/L) at two times points during an oral glucose tolerance test, OGTT, one of which must be within 2 hrs of ingestion of glucose.

Different clinical labs may use different units for the measurement of serum glucose concentrations, either in mmol/L or mg/dL. One can easily interconvert these values using the following formulas:

mg/dL x 0.0555 = mmol/L (or simply divide mg/dL by 18)

mmol/L x 18.0182 = mg/dL (or simply multiply mmol/L by 18)

The earlier a person is diagnosed with diabetes (principally type 2) the better chance the person has of staving off the primary negative consequences which are renal failure, blindness and limb amputations due to circulatory problems. The American Diabetes Association recommends that physicians consider patients to be pre-diabetic if their fasting blood glucose level is above 100mg/dL but less than 125mg/dL and whose glucose levels are at least 140mg/dL but less than 200mg/dL following an oral glucose tolerance test (OGTT).

Glucose tolerance curve following OGTT

Blood glucose curves. These graphs represent typical glucose tolerance curves for a normal person and one with non-insulin-dependent diabetes mellitus (NIDDM, type 2 diabetes: T2D) duriong a typical oral glucose tolerance test (OGTT). The dotted lines indicate the range of glucose concentration expected in a normal individual during an OGTT.

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Types of Diabetes Mellitus

Diabetes mellitus is a heterogeneous clinical disorder with numerous causes. Two main classifications of diabetes mellitus exist, idiopathic and secondary.

Idiopathic diabetes is divided into two main types; insulin dependent and non-insulin-dependent. Insulin-dependent diabetes mellitus, IDDM (more commonly referred to as type 1 diabetes) is defined by the development of ketoacidosis in the absence of insulin therapy. See the Diabetic Ketoacidosis diagnosis and treatment page. Type 1 diabetes most often manifests in childhood (hence, also called juvenile onset diabetes) and is the result of an autoimmune destruction of the β-cells of the pancreas. Non-insulin-dependent diabetes mellitus, NIDDM (more commonly referred to as type 2 diabetes) is characterized by persistent hyperglycemia but rarely leads to ketoacidosis. Type 2 diabetes generally manifests after age 40 and therefore has the obsolete name of adult onset-type diabetes. However, due to the rising rates of adolescent obesity in industrialized countries there is an increasing incidence of type 2 diabetes in pre- and postpubescent children. Type 2 diabetes can also result from genetics defects that cause both insulin resistance and insulin deficiency. There are two main forms of type 2 diabetes:

1. Late onset associated with obesity.

2. Late onset not associated with obesity.

There is a strong correlation between obesity and the onset of type 2 diabetes with its associated insulin resistance. It should be pointed out that in the United States the proportion of the population under 40 that can be clinically defined as obese now exceeds 25%. Many children are obese and are developing type 2 diabetes at an alarming epidemic rate. The dramatic rise in obesity in the US has lead to an equally alarming increase in the percentage of the population who suffer from the metabolic syndrome. The metabolic syndrome is a clustering of atherosclerotic cardiovascular disease risk factors, one of which involves insulin resistance characteristic in type 2 diabetes. It should be pointed out that obesity alone does not always lead to insulin resistance as some individuals who are obese do not experience insulin resistance and conversely, some individuals who manifest insulin resistance are not obese. These latter observations point to the added role of genetics in the acquisition of insulin resistance.

Secondary, or other specific types of diabetes mellitus are the result of many causes including:

1. Maturity onset type diabetes of the young (MODY) was previously considered to be a third form of type 2 diabetes. However, with the discovery of specific mutations leading to MODY, it is now classified under secondary or other specific types of diabetes. MODY is characterized by onset prior to age 25. All cases to date have shown impaired β-cell function. Patients may also exhibit insulin resistance and late β-cell failure. Evidence indicates that mutations in at least 14 different genes have been correlated with the development of various forms of MODY. Mutations in the 10 genes described here are all clearly correlated to MODY:

MODY1: The transcription factor identified as hepatic nuclear factor-4α (HNF-4α; gene symbol: HNF4A). This gene is also known as transcription factor-14 (TCF14). HNF-4α is a member of the nuclear receptor family of transcription factors, specifically identified as NR2A1. Expression of HNF-4α is associated with the growth and normal functioning of the pancreas. Many genes are known to be regulated by HNF-4α including those encoding HNF-1α, PPARα, insulin, glucose-6-phosphatase, GLUT2, the liver pyruvate kinase isoform (L-PK) which is also expressed in the pancreas, glyceraldehyde-3-phosphate dehydrogenase (GAPDH), aldolase B and uncoupling protein 2, UCP2.

MODY2: Autosomal dominant disorder resulting from mutations in the glucokinase (GCK) gene.

MODY3: The transcription factor HNF-1α (gene symbol: HNF1A). This gene is also known as hepatocyte transcription factor-1 (TCF1). HNF-1α is involved in a regulatory loop with HNF-4α controlling many genes involved in liver function such as the GLUT2 and L-PK genes.

MODY4: The homeodomain transcription factor insulin promoter factor-1 (IPF-1). This gene is more commonly called PDX1 which is derived from pancreas duodenum homeobox-1.

MODY5: The transcription factor HNF-1β (gene symbol: HNF1B). This gene is also known as hepatocyte transcription factor-2 (TCF2). HNF-1β is a critical regulator of a transcriptional network that controls the specification, growth, and differentiation of the embryonic pancreas. In humans, mutations in the HNF1B gene are associated with pancreatic hypoplasia, defective kidney development and genital malformations.

MODY6: The bHLH transcription factor NeuroD1 (gene symbol: NEUROD1). NeuroD1 was first identified as a neural fate-inducing gene. The hamster β2 gene, shown to regulate insulin transcription is identical to NeuroD1 so the gene is often referred to as NeuroD/β2. MODY6 is a rare form of MODY

MODY7: The Krupple-like factor 11 (gene symbol: KLF11) protein is a zinc-finger transcription factor that is involved in activation of the insulin promoter. KLF11 is a TGF-β-inducible transcription factor.

MODY8: The carboxyl-ester lipase gene (symbol: CEL) which is involved in lipid metabolism. Frameshift deletions in the variable number tandem repeats (VNTR) of the CEL gene are associated with MODY8 which is characterized by pancreatic exocrine and β-cell dysfunction. MODY8 is a rare form of MODY.

MODY9: The paired box transcription family gene, PAX4. The PAX4 encoded protein is involved in islet cell development.

MODY10: The insulin gene (symbol: INS).

2. Pancreatic disease: Pancreatectomy leads to the clearest example of secondary diabetes. Cystic fibrosis and pancreatitis can also lead to destruction of the pancreas.

3. Endocrine disease: Some tumors can produce counter-regulatory hormones that oppose the action of insulin or inhibit insulin secretion. These counter-regulatory hormones are glucagon, epinephrine, growth hormone and cortisol.

a. Glucagonomas are pancreatic cancers that secrete glucagon.

b. Pheochromocytomas secrete epinephrine.

c. Cushing syndrome results from excess cortisol secretion.

d. Acromegaly results in excess growth hormone production.

4. Drug-induced diabetes; treatment with glucocorticoids and diuretics can interfere with insulin function.

5. Anti-insulin receptor autoantibodies (Type B insulin resistance).

6. Mutations in the insulin receptor gene (INSR) which lead to the family of three syndromes listed below. Common clinical features in all three syndromes that result from mutations in the insulin receptor gene including severe insulin resistance, acanthosis nigricans and hyperandrogenism (the latter being observed only in females).

a. Donohue syndrome (also referred to as Leprachaunism), represents the most severe form of this family of disorders, most children die before the age of 2

b. Rabson-Mendenhall syndrome, symptoms appear in early childhood, most patients die in their teens or early twenties

c. Type A insulin resistance syndrome is a rare disorder of severe insulin resistance, symptoms usually do not appear until puberty or later

7. Gestational diabetes; this syndrome sets in during pregnancy and usually resolves itself following childbirth.

8. Many other genetic syndromes have either diabetes or impaired glucose tolerance associated with them; lipoatrophic diabetes, Wolfram syndrome, Down syndrome, Klinefelter syndrome (XXY males), Turner syndrome, myotonic dystrophy, muscular dystrophy, Huntington disease, Friedreich ataxia, Prader-Willi syndrome, Werner syndrome, Cockayne syndrome, and others such as those indicated above.

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Insulin-Dependent Diabetes Mellitus (IDDM) Type 1

Etiology of Type 1 Diabetes

Type 1 diabetes has been shown to be the result of an autoimmune reaction to antigens of the islet cells of the pancreas. There is a strong association between IDDM and other endocrine autoimmunities (e.g. Addison disease). Additionally, there is an increased prevalence of autoimmune disease in family members of IDDM patients.

Types of Autoantibodies

1. Islet cell cytoplasmic antibodies: The primary antibodies found in 90% of type 1 diabetics are against islet cell cytoplasmic proteins (termed ICCA, islet cell cytoplasmic antibodies). In non-diabetics ICCA frequency is only 0.5%–4%. The presence of ICCA is a highly accurate predictor of future development of IDDM. ICCA are not specific for the β-cells and recognize antigens in other cell types in the islet. However, the autoimmune attack appears to selectively destroy β-cells. Therefore, the antibodies may play a primary role in the destruction of islet cells. It is an equally likely possibility that the production of anti-islet antibodies occurs as a result of the destruction of β-cells. Whether a direct cause or an effect of islet cell destruction, the titer of the ICCA tends to decline over time.

2. Islet cell surface antibodies: Autoantibodies directed against cell-surface antigens (ICSA) have also been described in as many as 80% of type 1 diabetics. Similar to ICCA, the titer of ICSA declines over time. Some patients with type 2 diabetes have been identified that are ICSA positive.

3. Specific antigenic targets of islet cells: Antibodies to glutamic acid decarboxylase (GAD) have been identified in over 80% of patients newly diagnosed with IDDM. Like ICCA, anti-GAD antibodies decline over time in type 1 diabetics. There are two GAD genes in humans identified as GAD1 and GAD2. The GAD isoforms produced by these two genes are identified as GAD67 (GAD1 gene: GAD67) and GAD65 (GAD2 gene: GAD65) which is reflective of their molecular weights. Both the GAD1 and GAD2 genes are expressed in the brain and GAD2 expression also occurs in the pancreas. The presence of anti-GAD antibodies (both anti-GAD65 and anti-GAD67) is a strong predictor of the future development of IDDM in high-risk populations. Anti-insulin antibodies (IAA) have been identified in IDDM patients and in relatives at risk to develop IDDM. These IAA are detectable even before the onset of insulin therapy in type 1 diabetics. IAA are detectable in around 40% of young children with IDDM.

Pathophysiology of Type 1 Diabetes

The autoimmune destruction of pancreatic β-cells leads to a deficiency of insulin secretion. It is this loss of insulin secretion that leads to the metabolic derangements associated with IDDM. In addition to the loss of insulin secretion, the function of pancreatic α-cells is also abnormal. There is excessive secretion of glucagon in IDDM patients. Normally, hyperglycemia leads to reduced glucagon secretion. However, in patients with IDDM, glucagon secretion is not suppressed by hyperglycemia. The resultant inappropriately elevated glucagon levels exacerbates the metabolic defects due to insulin deficiency (see below). The most pronounced example of this metabolic disruption is that patients with IDDM rapidly develop diabetic ketoacidosis in the absence of insulin administration. If somatostatin is administered to suppress glucagon secretion, there is a concomitant suppression in the rise of glucose and ketone bodies. Particularly problematic for long term IDDM patients is an impaired ability to secrete glucagon in response to hypoglycemia. This leads to potentially fatal hypoglycemia in response to insulin treatment in these patients.

Although insulin deficiency is the primary defect in IDDM, in patients with poorly controlled IDDM there is also a defect in the ability of target tissues to respond to the administration of insulin. There are multiple biochemical mechanisms that account for this impairment of tissues to respond to insulin. Deficiency in insulin leads to elevated levels of free fatty acids in the plasma as a result of uncontrolled lipolysis in adipose tissue. Free fatty acids suppress glucose metabolism in peripheral tissues such as skeletal muscle. This impairs the action of insulin in these tissues, i.e. the promotion of glucose utilization. Additionally, insulin deficiency decreases the expression of a number of genes necessary for target tissues to respond normally to insulin such as glucokinase in liver and the GLUT 4 class of glucose transporters in adipose tissue. The major metabolic derangements which result from insulin deficiency in IDDM are impaired glucose, lipid and protein metabolism.

Glucose Metabolism: Uncontrolled IDDM leads to increased hepatic glucose output. First, liver glycogen stores are mobilized then hepatic gluconeogenesis is used to produce glucose. Insulin deficiency also impairs non-hepatic tissue utilization of glucose. In particular in adipose tissue and skeletal muscle, insulin stimulates glucose uptake. This is accomplished by insulin-mediated movement of glucose transporter proteins to the plasma membrane of these tissues. Reduced glucose uptake by peripheral tissues in turn leads to a reduced rate of glucose metabolism. In addition, the level of hepatic glucokinase is regulated by insulin. Therefore, a reduced rate of glucose phosphorylation in hepatocytes leads to increased delivery to the blood. Other enzymes involved in anabolic metabolism of glucose are affected by insulin (primarily through covalent modifications). The combination of increased hepatic glucose production and reduced peripheral tissues metabolism leads to elevated plasma glucose levels. When the capacity of the kidneys to absorb glucose is surpassed, glucosuria ensues. Glucose is an osmotic diuretic and an increase in renal loss of glucose is accompanied by loss of water and electrolytes, termed polyuria. The result of the loss of water (and overall volume) leads to the activation of the thirst mechanism (polydipsia). The negative caloric balance which results from the glucosuria and tissue catabolism leads to an increase in appetite and food intake (polyphagia).

Lipid Metabolism: One major role of insulin is to stimulate the storage of food energy following the consumption of a meal. This energy storage is in the form of glycogen in hepatocytes and skeletal muscle. Additionally, insulin stimulates hepatocytes to synthesize triglycerides and storage of triglycerides in adipose tissue. In opposition to increased adipocyte storage of triglycerides is insulin-mediated inhibition of lipolysis. In uncontrolled IDDM there is a rapid mobilization of triglycerides leading to increased levels of plasma free fatty acids. The free fatty acids are taken up by numerous tissues (however, not the brain) and metabolized to provide energy. Free fatty acids are also taken up by the liver.

Normally, the levels of malonyl-CoA are high in the presence of insulin. These high levels of malonyl-CoA inhibit carnitine palmitoyltransferase I, the enzyme required for the transport of fatty acyl-CoA's into the mitochondria where they are subject to oxidation for energy production. Thus, in the absence of insulin, malonyl-CoA levels fall and transport of fatty acyl-CoA's into the mitochondria increases. Mitochondrial oxidation of fatty acids generates acetyl-CoA which can be further oxidized in the TCA cycle. However, in hepatocytes the majority of the acetyl-CoA is not oxidized by the TCA cycle but is metabolized into the ketone bodies, acetoacetate and β-hydroxybutyrate. These ketone bodies leave the liver and are used for energy production by the brain, heart and skeletal muscle. In IDDM, the increased availability of free fatty acids and ketone bodies exacerbates the reduced utilization of glucose furthering the ensuing hyperglycemia. Production of ketone bodies, in excess of the organisms ability to utilize them leads to ketoacidosis. In diabetics, this can be easily diagnosed by smelling the breath. A spontaneous breakdown product of acetoacetate is acetone which is volatilized by the lungs producing a distinctive odor.

Normally, plasma triglycerides are acted upon by lipoprotein lipase (LPL), an enzyme on the surface of the endothelial cells lining the vessels. In particular, LPL activity allows fatty acids to be taken from circulating triglycerides for storage in adipocytes. The expression of LPL is regulated by insulin and in its absence a hypertriglyceridemia results.

Protein Metabolism: Insulin regulates the synthesis of many genes, either positively or negatively that then affect overall metabolism. Insulin has a global effect on protein metabolism, increasing the rate of protein synthesis and decreasing the rate of protein degradation. Thus, insulin deficiency will lead to increased catabolism of protein. The increased rate of proteolysis leads to elevated concentrations in plasma amino acids. These amino acids serve as precursors for hepatic and renal gluconeogensis. In liver, the increased gluconeogenesis further contributes to the hyperglycemia seen in IDDM.

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Genetics of Type 1 Diabetes

The majority of genetic loci associated with the development of type 1 diabetes (T1D) map to the human leukocyte antigen (HLA) class II proteins which are encoded for by genes in the major histocompatibility complex (MHC) which is located on chromosome 6p21. The Figure below diagrams a simplified view of the MHC cluster which spans 3.5 megabases of chromosome 6 and encompasses over 200 genes divided into three subregions termed class I, class II and class III.

Schematic of the genes in the MHC cluster

Simplified view of the MHC cluster genes. The class I genes encode α peptide chains, which associate with β2 microglobulin to form the class I molecules. Class I molecules are expressed on the surface of all nucleated cells where they are involved in the restriction of cytotoxic T cell activity. The class II (HLA-D) loci are subdivided into at least one A and one B gene which encode the α and β peptide chains, respectively. The class II proteins combine to form heterodimeric molecules that are expressed on antigen presenting cells, B cells, and activated T cells. The HLA-DP, HLA-DQ, and HLA-DR molecules are involved in the activation of helper T cells. There are nine B genes in the DR cluster identified as DRB1–DRB9. There are five distinct DR haplotypes in humans identified as DR1 (composed of the DRB1, DRB6, and DRB9 genes), DR51 (composed of the DRB1, DRB6, DRB5, and DRB9 genes), DR52 (composed of the DRB1, DRB2, DRB3, and DRB9 genes), DR8 (composed of the DRB1 and DRB9 genes), and DR53 (composed of the DRB1, DRB7, DRB8, DRB4, and DRB9 genes). The current MHC nomenclature arranges the DR sequences into different allelic groups. DRB1 sequences are arranged into 13 different allelic groups that through phylogenetic analyses cluster within the five haplotypes outlined above. These allelic groups are denoted: *01 and *10 (the DR1 group), *08 (the DR8 group), *15 and *16 (the DR51 group), *03, *11, *12, *13, and *14 (the DR52 group), and *04, *07, and *09 (the DR53 group). The second expressed DRB loci (DRB3, DRB4, and DRB5) exhibit limited polymorphisms in the human genome. The class III genes encode a range of molecules with a variety of functions, including complement components, tumor necrosis factor (TNF), and heat shock protein, Hsp70.

This is not to say that all genetic associations in T1D are due to mutations in HLA genes as more than 40 additional T1D susceptibility loci have been identified that are not HLA genes. The most frequently observed non-HLA genes associated with T1D are the insulin (INS), protein tyrosine phosphatase, non-receptor type 22 (PTPN22), cytotoxic T-lymphocyte-associated protein 4 (CTLA4), interleukin-2 receptor alpha (IL2RA), and interferon-induced with helicase C domain 1 (IFIH1) genes. The INS gene is on chromosome 11p15.5, the PTPN22 gene is on chromosome 1p13, the CTLA4 gene is on chromosome 2q33, the IL2RA gene is on chromosome 10p15.1, and the IFIH1 gene is on chromosome 2q24.

Polymorphisms in the INS gene account for approximately 10% of genetic susceptibilities to T1D. All of the INS gene polymorphisms reside outside the coding region of the gene indicating that susceptibility to T1D is related to modulation of expression of the INS gene. The PTPN22 gene encodes a protein identified as lymphoid-specific phosphatase (LYP) which is involved in the prevention of spontaneous T cell activation. One of the polymorphisms in the PTPN22 gene that is associated with T1D susceptibility is also associated with other autoimmune diseases such as systemic lupus erythematosus (SLE), Graves disease, and rheumatoid arthritis (RA). The protein encoded by the CTLA4 gene is also involved in regulating T cell activation and like polymorphisms in the PTPN22 gene, polymorphisms in CTLA4 are associated with other autoimmune disorders such as Addison disease and Graves disease.

The highest risk population for the development of T1D are children born with the HLA DR3/4–DQ8 serotype allele which accounts for almost 50% of all children who develop antibodies against pancreatic islet cells and thus develop T1D by the age of 5. HLA DR serotype alleles are molecules that recognize different DR gene products. The DR3 serotype recognizes the DRB1*03 gene products and the DR4 serotype recognizes the DRB1*04 gene products. Children with the high risk HLA alleles DR3/4–DRQ or DR4/DR4 and who have a family history of T1D have a nearly 1 in 5 chance of developing islet cell autoantibodies resulting in T1D. These same children born into a family with no history of T1D still have a 1 in 20 chance of developing T1D. It should be pointed out that although there are these strong genetic associations to T1D over 85% of all children who develop the disease do not have a family history associated with T1D. The class II HLA molecules that are associated with increased risk of T1D have been shown to bind peptides derived from the currently identified autoantigens described above and present these peptides to CD4+ T cells which then activate CD8+ cytotoxic T cells resulting in killing of islet β cells.

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Non-Insulin-Dependent Diabetes Mellitus (NIDDM): Type 2

Etiology of Type 2 Diabetes

Type 2 diabetes is characterized by a lack of the need for insulin to prevent ketoacidosis. Type 2 diabetes refers to the common form of idiopathic NIDDM. Type 2 diabetes is not an autoimmune disorder, however, there is a strong genetic correlation to the susceptibility to this form of diabetes. The susceptibility genes that predispose one to NIDDM have not been identified in most patients. This is due in part to the heterogeneity of the genes responsible for the susceptibility to type 2 diabetes. Obesity is a major risk factor that predisposes one to type 2 diabetes. Genetic studies in mice and rats have demonstrated a link between genes responsible for obesity and those that cause diabetes mellitus.

Pathophysiology of Type 2 Diabetes

Unlike patients with type 1 diabetes, those with type 2 diabetes have detectable levels of circulating insulin. On the basis of oral glucose tolerance testing the essential elements of type 2 diabetes can be divided into 4 distinct groups; those with normal glucose tolerance, chemical diabetes (called impaired glucose tolerance), diabetes with minimal fasting hyperglycemia (fasting plasma glucose <140 mg/dL), and diabetes mellitus in association with overt fasting hyperglycemia (fasting plasma glucose >140 mg/dL). In patients with the highest levels of plasma insulin (impaired glucose tolerance group) there was also elevated plasma glucose. This indicates that these individuals are resistant to the action of insulin. In the progression from impaired glucose tolerance to diabetes mellitus the level of insulin declines indicating that patients with type 2 diabetes have decreased insulin secretion.

Additional studies have subsequently demonstrated that both insulin resistance and insulin deficiency is common in the average type 2 diabetic patient. Many experts conclude that insulin resistance is the primary cause of type 2 diabetes, however, others contend that insulin deficiency is the primary cause because a moderate degree of insulin resistance is not sufficient to cause type 2 diabetes. As indicated above, most patients with the common form of type 2 diabetes have both defects.

The major clinical complications of type 2 diabetes are the result of persistent hyperglycemia which leads to numerous pathophysiological consequences. As the glucose level rises in the blood the blood becomes more viscous which makes circulation of the blood in the small capillaries difficult. The reduced circulation results in progressive vascular complications leading to diabetic retinopathy (referred to as diabetic blindness), peripheral neuropathy (resulting in numbness in the extremities and tingling in fingers and toes), poor wound healing, and erectile dysfunction. In addition to these major clinical complications, the body reacts by increasing the level of glucose excretion by the kidneys leading to frequent urination which is called polyuria. As the glucose is excreted there is a concomitant loss of water to maintain normal osmolarity of the urine. The water loss leads to excessive thirst called polydypsia.

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Measurement of HbA1c Levels

The development of hypoglycemia inducing drugs is the major pharmacological focus of type 2 diabetes therapies. Assessment of therapeutic efficacy in the treatment of the hyperglycemia in type 2 diabetes is accomplished by routine measurement of the circulating levels of glycated hemoglobin, designated as the level of HbA1c, often designated as just A1C. Glycation of hemoglobin (as well as numerous other porteins and macromolecules) occurs as a result of non-enzymatic covalent sugar attachment to the proteins of hemoglobin. Glycation can involve fructose or glucose but in the context of hemoglobin glycation it is almost exclusively glucose that is attached to the hemoglobin proteins. Glycation of hemoglobin is sometimes referred to as glycosylation but it is a non-enzymatic attachment of the sugar so the use of the term glycosylated hemoglobin is incorrect as it infers an enzyme catalyzed reaction.

HbA1 is the major form of adult hemoglobin in the blood and the "c" refers to the glycated form of the protein. Since hemoglobin is present in red blood cells and these cells have a limited life span of 120 days in the circulation, measurement of HbA1c levels is a relatively accurate measure of the amount of glucose in the blood and the length of time the level has been elevated. Typical values for HbA1c measurement (using the previous standard Diabetes Control and Complications Trial, DCCT units of %) are shown in the Table below. Beginning in 2011 a new international standard (International Federation of Clinical Chemistry, IFCC units) for the measurement of HbA1c levels will be utilized. This new standard equates the mmole of HbA1c per mole of total measured hemoglobin, Hb (mmol/mol). The method for calculating the relationship between these two measurement values is to use the following formula:

IFCC-HbA1c (mmol/mol) = [DCCT-HbA1c (%) - 2.15] × 10.929.

To calculate the estimated average glucose (eAG) level in the blood using the DCCT (%) values one would use the following formula:

eAG(mg/dl) = 28.7 × A1C − 46.7 (for glucose level in mM use: eAG(mM) = 1.59 × A1C − 2.59

With new IFCC standard the target range of HbA1c for healthy levels is 48–59mmol/mol.

HbA1c HbA1c/Hb
eAG (mg/dl) eAG (mM)
4% 20 68 3.8
5% 31 97 5.4
6% 42 125 7
7% 53 154 8.5
8% 64 183 10
9% 75 212 11.7
10% 86 240 13.3
11% 97 270 15
12% 108 298 16.5
13% 119 326 18
14% 130 355 19.7

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Genetics of Type 2 Diabetes

Development of type 2 diabetes is the result of multifactorial influences that include lifestyle, environment and genetics. The disease arises when insulin resistance-induced compensatory insulin secretion is exhausted. A high-caloric diet coupled with a sedentary lifestyle are the major contributing factors in the development of the insulin resistance and pancreatic β-cell dysfunction. However, a predisposing genetic background has long been suspected in playing a contributing role in the development of type 2 diabetes. By using whole-genome linkage analysis the entire genome of affected family members can be scanned and the family members monitored over several generations. In addition, large numbers of affected sibling-pairs can also be studied. Using these genome-wide linkage methods the first major susceptibility locus for type 2 diabetes was located on chromosome 2 in 1996. This locus was designated NIDDM1. The first gene identified in the NIDDM1 locus with polymorphisms correlated to type 2 diabetes susceptibility was calpain 10 (CAPN10).

CAPN10 is a calcium-activated neutral protease that is a member of the calpain-like cysteine protease family. The CAPN10 gene is located on chromosome 2q37.3 and spans 31 kb composed of 15 exons encoding a 672 amino acid protein. Variation in the non-coding region of the CAPN10 gene is associated with a threefold increased risk of type 2 diabetes in Mexican Americans. However, in European populations polymorphisms in CAPN10 are less contributory to type 2 diabetes than other recently discovered genes. Genetic variants in CAPN10 may alter insulin secretion or insulin action as well as the production of glucose by the liver. Recent studies indicate that CAPN10 may have a critical role in the survival of pancreatic β-cells.

Another early genetic marker for type 2 diabetes was hepatocyte nuclear factor 4-α (HNF4A). Note that HNF4A is also known to be associated with the development of MODY1 (see above). The hepatocyte nuclear factor family of proteins was first identified as an abundant class of transcription factors in the liver. In addition to the liver, HNF4A is expressed in pancreatic β-cells, kidneys and intestines. As indicated above, mutations in HNF4A can cause MODY1 which is characterized by a normal response to insulin but an impaired insulin secretory response in the presence of glucose. The HNF4A gene maps to a region of chromosome 20 that has been linked to type 2 diabetes. Specifically the HNF4A gene is located at 20q12–q13.1 and is encoded in 12 exons. Single nucleotide polymorphisms (SNPs) in the HNF4A gene have an impact on pancreatic β-cell function leading to altered insulin secretion and result in the development of MODY1. The SNPs in the HNF4A gene that are related to development of type 2 diabetes lie in a promoter element called P2. The P2 promoter is used primarily in pancreatic β-cells, whereas, both the P1 and P2 promoters are used in liver cells. The P2 promoter is a binding site for the transcription factors HNF-1α (HNF1A), HNF-1β (HNF1B), and insulin promoter factor-1 (IPF1). As described above, alteration in the function of each of these latter three transcription factors is associated with various forms of MODY.

Recent evidence has demonstrated a role for a member of the nuclear hormone receptor superfamily of proteins in the etiology of type 2 diabetes. The thiazolidinedione (TZD) class of drugs, used to increase the sensitivity of the body to insulin (see below), bind to and alter the function of the peroxisome proliferator-activated receptor-γ, PPARγ. PPARγ is also a transcription factor and, when activated, binds to another transcription factor known as the retinoid X receptor, RXR. When these two proteins interact they bind to specific PPAR response elements (termed PPREs) in target genes thereby regulating their expression. PPARγ is a key regulator of adipocyte differentiation; it can induce the differentiation of fibroblasts or other undifferentiated cells into mature fat cells. PPARγ is also involved in the synthesis of biologically active compounds from vascular endothelial cells and immune cells. Mutations in the gene for PPARγ (gene symbol = PPARG) have been correlated with insulin resistance.

More recent genome-wide screens for polymorphisms (in particular single nucleotide polymorphisms, SNPs) in type 2 diabetes have identified several new candidate genes. The Table below lists several genes that either, reside within chromosomal loci that are highly correlated to the development of type 2 diabetes, or that have had polymorphisms identified in the gene itself that correlate to development of type 2 diabetes. Included in the Table are PPARG and CAPN10 described above as well as the gene potassium inwardly-rectifying channel, subfamily J, member 11 (KCNJ11) which is described in the Insulin Function page.

The transcription factor TCF7L2 (transcription factor 7-like 2, T-cell specific HMG-box) is one of four TCF proteins involved in the signaling pathways initiated by the Wnt family of secreted growth factors. Two SNPs identified in the TCF7L2 gene are the most highly correlated polymorphisms with type 2 diabetes. Given that evidence is accumulating that Wnt and insulin signaling pathways exhibit cross-talk at the level of both the gut and the pancreas, it is likely that new targets in the treatment of type 2 diabetes will involve the interrelationships between these two factors.

In addition to the genes described in the following Table, and those described for permanent neonatal diabetes mellitus (next section), at least 25 additional genes have been shown by genome wide association studies (GWAS) to be associated with type 2 diabetes and/or elevated fasting plasma glucose levels.

Genes Associated with Type 2 Diabetes Susceptibility
Gene Name Gene Symbol Gene Function, Comments Disease
a disintegrin-like and metalloproteinase (ADAM) with thrombospondin type 1 motif, 9 ADAMTS9 demonstrated to proteolytically cleaved bovine versican (a large extracellular matrix proteoglycan) and aggrecan (large aggregated proteoglycan) unknown
Ca2+/calmodulin-dependent protein kinase 1-δ CAMK1D leads to activation of extracellular signal-regulated protein kinase 1 (ERK1) activity β-cell dysfunction
calpain 10 CAPN10 calcium-activated neutral protease, member of the calpain-like cysteine protease family glucose transport
cell division cycle 123 homolog CDC123 CDC123 is in the same chromosomal region as the CAMK1D gene β-cell dysfunction
cyclin-dependent kinase-5 regulatory subunit associated protein 1-like 1 CDKAL1 inhibitor of cyclin-dependent kinase 5 (CDK5) β-cell dysfunction, impaired insulin secretion
cyclin-dependent kinase inhibitor 2A CDKN2A/B the CDKN2A gene produces 2 major proteins: p16(INK4), which is a cyclin-dependent kinase inhibitor, and p14(ARF), which binds the p53-stabilizing protein MDM2, p14 is also called CDKN2B β-cell dysfunction
fat mass- and obesity-associated gene FTO catalyzes the iron- and 2-oxoglutarate-dependent demethylation of N6-methyladenosine in mRNA; expression upregulated in hypothalamus in response to food intake; increased expression in hypothalamus regulates energy intake but does not affect feeding reward circuits obesity
hematopoietically expressed homeobox HHEX is a transcriptional repressor in liver cells, may be involved in the differentiation and/or maintenance of the differentiated state in hepatocytes, is a target of the Wnt signaling pathway β-cell dysfunction, impaired insulin secretion
hepatocyte nuclear factor-1β: hepatocyte transcription factor-2 HNF1B
also called TCF2
mutations in gene associated with MODY5 unknown
insulin degrading enzyme IDE is an extracellular thiol metalloprotease with preference for insulin, also degrades amyloid-β protein; the IDE gene resides within the same chromosomal locus as HHEX β-cell dysfunction
insulin-like growth factor-2 mRNA binding protein 2 IGF2BP2 binds to the IGF2 mRNA β-cell dysfunction
juxtaposed with another zinc-finger gene 1: TAK1(TGFβ-activated kinase-1)-interacting protein 27 JAZF1
also called TIP27
functions as a transcriptional repressor, exhibits antiapoptotic activity β-cell dysfunction
potassium inwardly-rectifying channel, subfamily J, member 11 KCNJ11 forms the core of the ATP-sensitive potassium (KATP) channel involved in insulin secretion; protein is also called Kir6.2 β-cell dysfunction
potassium channel, voltage-gated, KQT-like subfamily, member 1 KCNQ1 pore-forming α-subunit of a cardiac delayed rectifier potassium channel; also referred to as KvLQT because the gene resides in a critical region for the cardiac long QT syndrome-1 disorder which is a region that is also in the imprinted locus associated with Beckwith-Weidemann syndrome; gene also expressed in epithelial cells of the exocrine and endocrine pancreas β-cell dysfunction
Krüppel-like factor 14 KLF14 Krüppel-like transcription factors all related to Drosophila Krüppel gene; are a family of zinc-finger transcription factors; KLF14 is a master trans regulator of adipose gene expression  
leucine-rich repeat containing G-protein coupled receptor 5 LGR5 gene is expressed exclusively in the cycling crypt base of the columnar cells of the gut and hair follicle, protein is a glycoprotein that associates with integrins, the gene is a marker for intestinal stem cells, expression is regulated by Wnt signaling β-cell dysfunction
melanocortin 4 receptor MC4R is a single exon (intronless) gene, mutations in this gene are the most frequent genetic cause of severe obesity, receptor binds α-melanocyte stimulating hormone (α-MSH) obesity
melatonin receptor 1B MTNR1B high affinity G-protein coupled receptor, expressed primarily in pancreatic β-cells β-cell dysfunction, impaired insulin secretion
Notch homolog 2 NOTCH2 one of three mammalian homologues of the Notch gene of fruit flies which regulates cellular differentiation unknown
peroxisome proliferator-activated receptor-γ (PPARγ) PPARG transcriptional co-activator with retinoid X receptors (RXRs), master regulator of adipogenesis, activation of adipocytes leads to increased fat storage and secretion of insulin-sensitizing adipocytokines such as adiponectin insulin sensitivity
solute carrier family 30 (zinc transporter), member 8 SCL30A8 permits cellular efflux of zinc β-cell dysfunction
transcription factor 7-like 2 (T-cell specific HMG-box) TCF7L2 one of four TCF transcription factor proteins involved in the signaling pathways initiated by the Wnt family of secreted growth factors, polymorphisms in this gene have the highest correlation to type 2 diabetes β-cell dysfunction, impaired insulin secretion
thyroid adenoma-associated gene THADA protein contains an ARM repeat (ARM = armadillo which is a fruit fly gene involved in segment polarity), the ARM repeat is involved in protein-protein interactions unknown
tetraspanin 8 TSPAN8 tetraspanins are proteins that contain 4 transmembrane domains, this gene and LGR5 are found in the same chromosomal region β-cell dysfunction
Wolfram syndrome gene; also called diabetes insipidus, diabetes mellitus, optic atrophy, and deafness (DIDMOAD) WFS1 is an integral ER membrane glycoprotein, associates with the C-terminal domain of the ER-localized Na+/K+ATPase β-1 subunit (ATP1B1) β-cell dysfunction

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Neonatal Diabetes

Neonatal diabetes refers to a circumstance in which hyperglycemia results from dysfunction in insulin action within the first 6 months of life. This form of diabetes is not typical type 1 diabetes (T1D, or juvenile onset diabetes) since T1D involves immune destruction of the pancreatic β-cells and thus, requires several years to fully develop. Neonatal diabetes can be transient or permanent. If an infant suffers from the transient form they are at increased risk for developing full-blown later in life.

The advent of genetic studies to identify HLA haplotypes associated with the risk of development of T1D as well as the description of several T1D-associated autoantibodies provided the foundation for characterization of the clinical features of the disease in newborns. Evidence is clear that the etiology of diabetes in the first year of life is different from that of the autoimmune forms of T1D more classically diagnosed when children are older. As indicated, the presentation of diabetes in infants prior to 6-months of age can be transient or permanent. The permanent form of the disease is termed Permanent Neonatal Diabetes Mellitus (PNDM). PNDM is a rare event occurring with a frequency of approximately 2 cases per 100,000 births.

Definitive determination of PNDM requires early gene screening as soon as symptoms manifest. This allows for a differential diagnosis to be made as to whether or not the symptoms can be expected to be transient or permanent. Very low birth weight is highly correlated to PNDM and is associated with fetal lack of insulin. The most prominent of symptoms is the onset of hyperglycemia within the first 6 months after birth. Affected infants do not secrete insulin in response to glucose or glucagon but will secrete insulin in response to tolbutamide administration. Tolbutamide is a drug of the sulfonylurea class used to treat type 2 diabetes. Many infants will exhibit similar neurologic abnormalities, including developmental delay, muscle weakness, and epilepsy. In patients manifesting with neurologic abnormalities there are often associated dysmorphic features, including prominent metopic suture (persistence of the space between the frontal bones of the skull), a downturned mouth, bilateral ptosis (drooping eyelid), and limb contractures.

Early on it was thought that the underlying defect resulting in neonatal diabetes was pancreatic β-cell dysfunction or a defect in β-cell maturation. However, genetic evidence now indicates that neonatal diabetes, in particular PNDM, is the result of single-gene defects. This make PNDM a monogenic disorder. The disorder can be inherited although it is most often the result of a sporadic mutation in one of the parental gametes. Over the past decade at least 12 genes have been identified as being associated with the development of PNDM. The most commonly mutated genes are the potassium inwardly-rectifying channel, subfamily J, member 11 (KCNJ11), ATP-binding cassette transporter, subfamily C, member 8 (ABCC8), and insulin (INS) genes. The proteins of the KCNJ11 and ABCC8 genes form the ATP-sensitive potassium channel (KATP channel) that is involved in insulin secretion (see the Insulin Function page). Mutations in the KCNJ11 gene are also associated with an increased risk for the development of T2D as described in the Genetics of Type 2 Diabetes section above. The insulin gene is one of the non-HLA genes that is mutated in T1D as indicated above in the Genetics of Type 1 Diabetes section.

Genes Associated with Permanent Neonatal Diabetes Mellitus
Gene Name Gene Symbol Comments
ATP-binding cassette transporter, subfamily C, member 8 ABCC8 along with KCNJ11 encoded proteins ABCC8 forms the ATP-sensitive potassium (KATP) channel involved in insulin secretion; gene is also known as the sulfonylurea receptor: SUR; mutations in the ABCC8 gene found in 13% of PNDM cases
eukaryotic translation initiation factor 2-α kinase 3 EIF2AK3 also associated with skeletal dysplasia, mental retardation, and hepatic failure; gene also known as RNA-dependent protein kinase-like endoplasmic reticulum kinase, PERK; this particular form of PNDM is also known as Wolcott-Rallinson syndrome (WRS)
forkhead box family member P3 FOXP3 is a member of the fork-winged helix family of transcription factors,; plays an important role in development and function of CD4-positive/CD25-positive regulatory T cells (Tregs); Tregs are involved in active suppression of inappropriate immune responses
pancreatic glucokinase GCK same gene found associated with MODY2
Gli similar (GLIS family) Krüppel-like zinc finger transcription 3 GLIS3 also associated with severe congenital hypothyroidism, cholestasis, congenital glaucoma, and polycystic kidneys
insulin INS mutations in the INS gene represent 16% of PNDM cases
potassium inwardly-rectifying channel, subfamily J, member 11 KCNJ11 forms the core of the ATP-sensitive potassium (KATP) channel involved in insulin secretion, protein is also called Kir6.2; mutations in this gene found in 30%–50% of PNDM cases
pancreatic and duodenal homeobox 1 PDX1 regulates transcription of the insulin gene; also is a key regulator of the development of the pancreas, most probably by determining maturation and differentiation of common pancreatic precursor cells in the developing gut
pancreas transcription factor 1A PTF1A gene is essential to normal pancreas formation; mutations in gene also associated with cerebellar hypoplasia/agenesis, and dysmorphism; similar phenotypes to those resulting from PDX1 mutations
regulatory factor x-box binding family transcription factor member 6 RFX6 involved in pancreatic islet cell differentiation; also associated with intestinal atresia and gall bladder hyoplasia
solute carrier family, facilitated glucose (GLUT) transporter subfamily, member 2 SLC2A2 also associated with Fanconi-Bickel syndrome (was once called glycogen storage disease XI, GSD11 but term is no longer valid)
solute carrier family, folate/thiamine transporters subfamily, member 2 SLC19A2 mutations in gene result in thiamine-responsive megaloblastic anemia syndrome (also known as Rogers syndrome), defined by the occurrence of megaloblastic anemia, diabetes mellitus, and sensorineural deafness; thiamine treatment results in varying degrees of positive response

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Diabetes and the Metabolic Syndrome: MetS

Although the metabolic syndrome (also called syndrome X) is not exclusively associated with type 2 diabetes and the associated insulin resistance, the increasing prevalence of obesity and associated development of type 2 diabetes places insulin resistance as a major contributor to the syndrome. The metabolic syndrome is defined as a clustering of atherosclerotic cardiovascular disease risk factors that include visceral adiposity (obesity), insulin resistance, low levels of HDLs and a systemic proinflammatory state. There are key components to the metabolic syndrome which include in addition to insulin resistance (the hallmark feature of the syndrome), hypertension, dyslipidemia, chronic inflammation, impaired fibrinolysis, procoagulation and most telling central obesity. For more information on the biochemical and clinical aspects of MetS visit the Metabolic Syndrome page.

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Mitochondrial Dysfunction in Type 2 Diabetes and Obesity

Well established data demonstrate that mitochondrial dysfunction, particularly as it relates to the processes of oxidative phosphorylation (oxphos), is contributory to the development of encephalomyopathy, mitochondrial myopathy, and several age-related disorders that include neurodegenerative diseases, the metabolic syndrome, and diabetes. Indeed, with respect to diabetes, several mitochondrial diseases manifest with diabetic complications such as mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes (MELAS) and maternally inherited diabetes and deafness (MIDD).

Normal biogenesis of mitochondria is triggered in response to changes in the ATP/ADP ratio and to activation of AMPK which in turn results in increased expression of PPARγ co-activator 1α (PGC-1α) and nuclear respiratory factor-1 (NRF1). PGC-1α is a master transcriptional co-activator of numerous genes involved in mitochondrial biogenesis. NRF1 is a transcription factor that regulates the expression of mitochondrial transcription factor A (TFAM, for transcription factor A, mitochondrial; also designated mtTFA) which is a nuclear transcription factor essential for replication, maintenance, and transcription of mitochondrial DNA. NRF1 also controls the expression of nuclear genes required for mitochondrial respiration and heme biosynthesis. Evidence has shown that both PGC-1α and NRF1 expression levels are lower in diabetic patients as well as in non-diabetic subjects from families with type 2 diabetes. The expression of NRF1 is highest in skeletal muscle which is also the tissue that accounts for the largest percentage of glucose disposal in the body and, therefore, is the tissue that is most responsible for the hyperglycemia resulting from impaired insulin signaling.

Mitochondrial dysfunction results in increased production of ROS which activates stress responses leading to increased activity of MAPK and JNK. Both of these serine/threonine kinases phosphorylate IRS1 and IRS2 resulting in decreased signaling downstream of the insulin receptor. Inhibited IRS1 and IRS2 activity results in decreased activation of PI3K. PI3K activation is involved in the translocation of GLUT4 to the plasma membrane resulting in increased glucose uptake. Therefore, inhibition of PI3K results in reduced glucose uptake in skeletal muscle and adipose tissue. Mitochondrial dysfunction results in a reduction in the level of enzymes involved in β-oxidation leading to increases in intramyocellular lipid content. Indeed, skeletal muscle metabolism of lipids has been shown to be impaired in type 2 diabetics. An increased delivery of fatty acids to skeletal muscle, as well as diminished mitochondrial oxidation, results in increased intracellular content of fatty acid metabolites such as diacylglycerol (DAG), fatty acyl-CoAs, and ceramides. These metabolites of fatty acids are all known to induce the activity of protein kinase C isoforms (PKCβ and PKCδ) that phosphorylate IRS1 and IRS2 on serine residues resulting in impaired insulin signaling downstream of the insulin receptor.

Because skeletal muscle consumes the largest amount of serum glucose, mitochondrial dysfunction in this tissue will have the greatest impact on glucose disposal. However, adipose tissue also plays an important role in glucose homeostasis and mitochondrial dysfunction in this tissue has been shown to result in impaired glucose homeostasis resulting in diabetes. For example, when animals are treated with inhibitors of mitochondrial oxidation insulin-stimulated glucose uptake in adipose tissue is significantly impaired. Adipose tissue secretes a number of proteins classified as adipokines. Adiponectin is an adipokine that promotes insulin-sensitivity in insulin-responsive tissues, such as skeletal muscle. When plasma levels of adiponectin are measured in obese or type 2 diabetic subjects it is found to be significantly lower than in age and sex matched control subjects that are of normal weight or that do not have diabetes. In animal studies, the enhancement of adipocyte mitochondrial biogenesis results in increased adiponectin release from adipose tissue. Conversely, expression of adiponectin expression is decreased in adipocytes with mitochondrial dysfunction.

Given that impaired mitochondrial function is clearly associated with obesity and type 2 diabetes, it is not surprising that there is great interest in the use of pharmacology to augment mitochondrial function in the treatment of these disorders. Of significance is the fact that the thiazolidinedione (TZD) class of drugs used to treat the hyperglycemia of type 2 diabetes (see the next section) activate PPARγ which in turn increases the level of activity of PGC-1α. Although the TZDs were first marketed due to their ability to improve insulin sensitivity, they have since been shown to increase mitochondrial functions both in vitro and in vivo. Antioxidants have also been shown to enhance mitochondrial function by reducing the production of ROS. Resveratrol (found in grape skins and red wine) is a potent antioxidant whose activity is, in part, due to its ability to activate the deacetylase SIRT1 (see below). Activated SIRT1 deacetylates PGC-1α resulting in increased transcriptional activity and thus, enhanced mitochondrial biogenesis.

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Therapeutic Intervention for Hyperglycemia

Many, if not all, of the vascular consequences of insulin resistance are due to the persistent hyperglycemia seen in type 2 diabetes. For this reason a major goal of therapeutic intervention in type 2 diabetes is to reduce circulating glucose levels. There are many pharmacologic strategies to accomplish these goals.

1. The Thiazolidinediones (TZDs): The TZDs, such as rosiglitazone (Avandia®) and pioglitazone (Actos®) have proven useful in treating the hyperglycemia associated with insulin-resistance in both type 2 diabetes and non-diabetic conditions. The TZDs function as agonists for the transcription factor, PPARγ. PPARγ is a member of the superfamily of nuclear receptor transcription factors. In addition to PPARγ there are the closely related members, PPARα and PPARβ/δ. PPARγ exists as a heterodimer with the nuclear retinoid X receptors, RXRs. The heterodimer binds to PPAR response elements (PPREs) in a number of target genes. Without ligand bound the heterodimer is associated with a co-repressor complex that includes a histone deacetylase. Deacetylated histone keeps DNA in a transcriptionally repressed state. When ligand binds to PPARγ the co-repressor complex dissociates and a co-activator complex containing histone acetylase associates resulting in chromatin structural changes and transcriptional activation. The net effect of the TZDs is a potentiation of the actions of insulin in liver, adipose tissue and skeletal muscle, increased peripheral glucose disposal and a decrease in glucose output by the liver. Genes shown to be affected by PPARγ action include those encoding glucokinase, GLUT4, malic enzyme, lipoprotein lipase, fatty acyl-CoA synthase and adipocyte fatty acid binding protein (FABP4). PPARγ is primarily expressed in adipose tissue and thus it was at first difficult to reconcile how a drug that was apparently acting only in adipose tissue could lead to improved insulin sensitivity of other tissues. The answer to this question came when it was discovered that the TZDs stimulated the expression and release of the adipocyte hormone (adipokine), adiponectin. Adiponectin stimulates glucose uptake and fatty acid oxidation in skeletal muscle. In addition, adiponectin stimulates fatty acid oxidation in liver while inhibiting expression of gluconeogenic enzymes in this tissue. These responses to adiponectin are exerted via activation of AMPK. The significance of PPARγ as a diabetes target is apparent not only from the observed effects of drugs that activate the receptor but also from genome wide screens showing that mutations in the PPARγ gene are correlated to familial insulin resistance.

Recent studies have identified a critical role for an enzyme (phosphatidic acid phosphatase, PAP1) involved in overall triacyglyceride and phospholipid homeostasis as a critical target of the PPARγ signaling pathway. In the yeast Saccharomyces cerevisiae, the PAP1 gene was identified as Smp2p and the encoded protein was shown to be the yeast ortholog of the mammalian protein called lipin-1. The lipin-1 gene (symbol: LPIN1) was originally identified in a mutant mouse called the fatty liver dystrophy (fld) mouse. The mutation causing this disorder was found to reside in the LPIN1 gene. There are three lipin genes in humans (LPIN1, LPIN2, and LPIN3) with the LPIN1 gene encoding three isoforms derived through alternative splicing. These three lipin-1 isoforms are identified as lipin-1α, lipin-1β, and lipin-1γ. Mutations in the LPIN2 gene are associated with Majeed syndrome which is characterized by chronic recurrent osteomyelitis, cutaneous inflammation, recurrent fever, and congenital dyserythropoietic anemia.

In addition to the obvious role of lipin-1 in TAG synthesis, evidence indicates that the protein is also required for the development of mature adipocytes, coordination of peripheral tissue glucose and fatty acid storage and utilization, and serves as a transcriptional co-activator. The latter functions of lipin-1 have obvious significance to diabetes as it has been shown that some of the effects of the TZD class of drugs are exerted via the effects of lipin-1. Although the lipin proteins do not contain DNA-binding motifs they have protein-interaction domains that allow them to form complexes with nuclear receptors and function as transcriptional regulators. Lipin-1 has been shown to interact with peroxisome proliferator-activated receptor-γ [PPARγ] co-activator 1α (PGC-1α) and PPARα leading to enhanced gene expression. Lipin-1 also is known to interact with additional members of the nuclear receptor family including the glucocorticoid receptor (GR) and hepatocyte nuclear factor-4α (HNF-4α). Lipin-1 also induces the expression of the adipogenic transcription factors PPARγ and CCAAT-enhancer-binding protein α (C/EBPα). The functions of lipin-1α and lipin-1β appear to be complimentary with respect to adipocyte differentiation. Lipin-1α induces genes that promote adipocyte differentiation while lipin-1β induces the expression of lipid synthesizing genes such as fatty acid synthase (FAS) and diacylglycerol acyltransferase (DGAT). The interactions of lipin-1 with PPARα and PGC-1α leads to increased expression of fatty acid oxidizing genes such as carnitine palmitoyltransferase-1 (CPT-1: encoded by the CPT1A gene), acyl-CoA oxidases (peroxisomal fatty acid oxidation pathway), and medium-chain acyl-CoA dehydrogenase (MCAD: encoded by the ACADM gene).

2. Targeting glucagon-like peptide-1 (GLP-1): The synthesis and activities associated with GLP-1 are described in detail in the Gut-Brain Interactions page. As review, the primary metabolic responses to GLP-1 release from the enteroendocrine L-cells of the gut are inhibition of glucagon secretion and enhancement of glucose-dependent insulin release from the pancreas, both effects lead to decreased glycemic excursion. The hormonal action of GLP-1 is rapidly terminated as a consequence of enzymatic cleavage by dipeptidylpeptidase IV (DPP IV or DPP4). Recent clinical evidence has shown that either infusion of GLP-1 or inhibition of DPP4 can result in dramatic reductions in plasma glucose concentrations, reductions in HbA1c and improvement in pancreatic β-cell function. Thus, both represent potential targets for the prevention of the hyperglycemia associated with diabetes and impaired insulin function. For more information on the activities of DPP4 go to the DPP4 page.

There are advantages and disadvantages with the current therapeutic approaches to targeting GLP-1 action in diabetic patients. Current use of GLP-1 mimetics and/or GLP-1 receptor (GLP-1R) agonists focus on peptides or modified peptides and these must be injected. The need for chronic injection as a means of therapy always runs into the problem of patient compliance. One of the first GLP-1R agonists approved for use was βYETTA® (also written as Byetta) developed by Amylin Pharmaceuticals and Eli Lilly and Co. Byetta is composed of exenatide which is a synthetic version of the lizard salivary peptide called exendin-4. Exenatide is 53% identical to GLP-1 at the level of amino acids and binds to and activates the GLP-1R. The advantage of exenatide as a therapeutic is that it is resistant to cleavage and inactivation by DPP4. In a recent trial in patients with type 2 diabetes, BYETTA was shown not only to lower blood glucose levels and HbA1c, but patients also had an associated weight loss. Another exenatide-related drug is Bydureon® which is a once-a-week injectable form of exenatide.

Another GLP-1R agonist is Victoza® (liraglutide) which was developed by Novo Nordisk. Victoza is a once-a-day injectable recombinant DNA produced modified GLP-1 protein complex. The protein is a fatty acid-linked derivative of human GLP-1 that is resistant to DPP4 cleavage. The 16-carbon fatty acyl-chain (palmitic acid) addition to the protein allows liraglutide to bind to albumin in the blood which prevents its excretion via the kidneys. Liraglutide has been shown to have a half-life of 11-13 hours making it ideal for once-a-day injection. Results of clinical studies demonstrated significant reductions in HbA1c levels in liraglutide treated patients. Victoza was approved for use in the United States in January 2010. One problematic side effect of Victoza treatment is pancreatitis which occurs in patients with a higher frequency than with other diabetes treatments. A more recent addition to the GLP-1 receptor agonist family of diabetes drugs is Trulicity® (dulaglutide) manufactured by Eli Lilly and Co.

Although targeting compounds that can inhibit the enzymatic action of DPP4 would seem like ideal candidates for treating the hyperglycemia of uncontrolled diabetes, there are several unknowns associated with DPP4 inhibition. One of these issues is the fact that GLP-1 and GIP are only two of the many known substrates for DPP4 cleavage. Thus, prolonged inhibition of DPP4 enzymatic activity may have unexpected consequences unrelated to control of hyperglycemia. Despite the potential for as yet unknown effects, the DDP4 inhibitor developed by Merck, Januvia® (sitagliptin), has recently been approved for use alone or in combination with either metformin or the thiazolidinediones. Treatment of patients with Januvia as the only therapeutic agent for 18 weeks produced significant reductions of HbA1c, along with an improvement of β-cell function and no change in body weight.

A second generation DPP4 inhibitor developed by Novartis called Glavus® (vildagliptin) has recently received approvable status from the US FDA. Glavus administration is associated with significantly increased pancreatic β-cell function and reduced HbA1c levels without hypoglycemia or other adverse events. Another drug in the DPP4 inhibitor class to receive US FDA approval is Onglyza® (saxagliptin) made by AstraZeneca and Bristol-Myers Squibb. Onglyza is designed as a once-daily orally administered tablet.

DPP4 was originally identified as the lymphocyte cell surface antigen CD26. In humans CD26 functions in many pathways that are not directly related to its peptidase activity. It harbors adenosine deaminase-binding (ADA-binding) properties and is involved in extracellular matrix binding. Of importance to the immune system, CD26 expression and activity are enhanced upon T-cell activation. CD26 interacts with other lymphocyte cell surface antigens including ADA, CD45 and the chemokine receptor CXCR4 (notable is the fact that CXCR4 is a T-cell attachment site for HIV). Currently available data indicates that the peptidase activity of DPP4 is independent of the T-cell activating and co-stimulatory functions assigned to CD26. Of significance, however, is that in gene knock-out mice lacking CD26 there is enhanced insulin secretion and improved glucose tolerance.

The major clinical advantages to the use of DPP4 inhibitors is that the ones in use or in current trials are orally delivered. Compliance in patients is much higher with orally delivered drugs than with those that require injection.

3. The Biguanides: The biguanides are a class of drug that functions to lower serum glucose levels by enhancing insulin-mediated suppression of hepatic glucose production and enhancing insulin-stimulated glucose uptake by skeletal muscle. Metformin (Glucophage®) is a member of this class and is currently the most widely prescribed insulin-sensitizing drug in current clinical use. Metformin administration does not lead to increased insulin release from the pancreas and as such the risk of hypoglycemia is minimal. Because the major site of action for metformin is the liver its use can be contraindicated in patients with liver dysfunction. The drug is ideal for obese patients and for younger type 2 diabetics.

Evidence on the mode of action of metformin shows that it improves insulin sensitivity by increasing insulin receptor tyrosine kinase activity and enhancing glycogen synthesis in hepatocytes, and by increasing recruitment and transport of GLUT4 transporters to the plasma membrane in adipose tissue. Additionally, it has been shown that metformin affects mitochondrial activities dependent upon the model system studied. Metformin has a mild inhibitory effect on complex I of oxidative phosphorylation, has antioxidant properties, and activates both glucose-6-phosphate dehydrogenase (G6PDH) and AMP-activated protein kinase (AMPK). The importance of AMPK in the actions of metformin stems from the role of AMPK in the regulation of both lipid and carbohydrate metabolism (see AMPK: Master Metabolic Regulator for more details). In adipose tissue, metformin inhibits lipolysis while enhancing re-esterification of fatty acids. The activation of AMPK by metformin occurs, in part, through the inhibitory effects of the drug on complex I of oxidative phosphorylation. This would lead to a reduction in ATP production and, therefore, an increase in the level of AMP and as a result activation of AMPK. In fact, since the cells of the gut will see the highest doses of metformin they will experience the greatest level of inhibited complex I which may explain the gastrointestinal side effects (nausea, diarrhea, anorexia) of the drug that limit its utility in many patients. Recent research has demonstrated that metformin directly activates AMPK in both a dose- and time-dependent manner which in turn inhibits the mTOR complex 1 (mTORC1). The mTORC1 is a key regulator of protein synthesis, cellular responses to energy depletion, and control of autophagy.

In adolescent females with type 2 diabetes, the use of metformin is highly recommended to reduce the incidence as well as the potential for polycystic ovarian syndrome, PCOS. PCOS is brought on by the hyperinsulinemia of type 2 diabetes. Insulin effects on the ovary drive conversion of progesterone to testosterone and a reduction in serum hormone binding globulin (SHBG). Taken together, the effects of hyperinsulinemia lead to a hyperandrogenic state in the ovary resulting in follicular atresis and ovulatory dysfunction.

In addition to its effects on hepatic glucose and lipid homeostasis and adipose tissue lipid homeostasis, metformin exerts effects in the pancreas, vascular endothelial cells, and in cancer cells. The latter effects of metformin were recognized in epidemiological studies of diabetic patients taking metformin versus those who were taking another anti-hyperglycemia drug.

4. The Sulfonylureas: The sulfonylurea and meglitinide classes of oral hypoglycemic drugs are referred to as endogenous insulin secretagogues because they induce the pancreatic release of endogenous insulin.

The sulfonylureas have been used in the US for nearly 50 years. The first generation sulfonylureas (tolbutamide, acetohexamide, chlorpropramide and tolazamide) are not routinely prescribed any longer in the US. The second generation sulfonylureas include glipizide (Glucotrol®), glimepiride (Amaryl®) and glyburide (DiaBeta®, Micronase®, Glynase®). Because all of these drugs can induce pronounced hypoglycemia, treatment is initiated with the lowest possible dose and carefully monitored until the dose is found that results in a FPG of 110-140mg/dL. Sulfonylureas function by binding to and inhibiting the pancreatic ATP-dependent potassium channel that is normally involved in glucose-mediated insulin secretion (see Insulin Functions page for more details). Sulfonylureas have no significant effects on circulating triglycerides, lipoproteins or cholesterol.

5. The Meglitinides: As indicated, the meglitinides repaglinide (Prandin®) and nateglinide (Starlix®) are non-sulfonylurea insulin secretagogues that are both fast acting and of short duration. Like the sulfonylureas, meglitinides therapy results in significant reduction in FPG as well as HbA1c. The mechanism of action of the meglitinides is initiated by binding to a receptor on the pancreatic β-cell that is distinct from the receptors for the sulfonylureas. However, meglitinides do exert effects on potassium conductance. Like the sulfonylureas, the meglitinides have no direct effects on the circulating levels of plasma lipids.

6. The α-Glucosidase inhibitors: α-glucosidase inhibitors such as acarbose (Precose®) and miglitol (Glyset®) function by interfering with the action of the α-glucosidases present in the small intestinal brush border. The consequence of this inhibition is a reduction in digestion and the consequent absorption of glucose into the systemic circulation. The reduction in glucose uptake allows the pancreatic β-cells to more effectively regulate insulin secretion. The advantage to the use of the α-glucosidase inhibitors is that they function locally in the intestine and have no major systemic action. Hypoglycemia does not usually occur with the use of α-glucosidase inhibitors but they are effective at reducing fasting plasma glucose (FPG) levels and levels of glycated hemoglobin (HbA1c). The common adverse side effects of these inhibitors are abdominal bloating and discomfort, diarrhea and flatulence.

6. SGLT2 Antagonists: A new class of orally administered compounds that targets renal glucose transport and inducers of glucosuria are currently being tested for efficacy in type 2 diabetes treatment. In the kidney, glucose is filtered at the glomerulus and then reabsorbed via active transport in the proximal convoluted tubule. Two sodium-glucose co-transporters (SGLT1 and SGLT2) have been identified as responsible for this renal glucose reabsorption. The SGLT proteins are members of the solute carrier 5 family of membrane transporters, and thus, SGLT1 is SLC5A1 and SGLT2 is SLC5A2. SGLT1 is expressed in several tissues, with highest levels of expression in the small intestine where its primary function is in glucose and galactose absorption. SGLT2 is expressed nearly exclusively in the apical membranes of epithelial cells of the proximal tubule of the kidney and has been shown to be responsible for approximately 90% of the renal glucose reabsorption (see Figure below). Therefore, it is postulated that selective inhibition of the renal SGLT2 activity should result in greatly enhanced glucose release in the urine. Several drugs (all of which carry the suffix "-gliflozin": empagliflozin, canagliflozin, dapagliflozin, ipragliflozin) that inhibit SGLT2 are currently under investigation. Canagliflozin (Invokana®), dapagliflozin (Farxiga®), and empagliflozin (Jardiance®) are the only drugs in this class currently approved by the FDA for the treatment of type 2 diabetes. The advantage of these drugs is that they are taken orally so compliance will be higher than injected type 2 diabetes drugs. In addition, these drugs are formulated as once-a-day tablets.

Glucose reabsorption in S1 segment of kidney proximal tubule

Diagrammatic representation of the re-uptake of glucose in the S1 segment of the proximal tubule of the kidney by the Na+-glucose co-transporter SGLT2. Following re-uptake the glucose is transported back into the blood via the action of GLUT2 transporters. The Na+ that is reabsorbed with the glucose is transported into the blood via a Na+,K+-ATPase.

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New Frontiers in Diabetes Therapy

Several new approaches are being taken in the search for treatments for diabetes. These include the development of newer drugs that target the same pathways as described in the sections above including, but not limited to, new classes of DPP4 antagonists and GLP-1 receptor agonists. Additional, potentially exciting targets, include the liver-derived growth factor, fibroblast growth factor 21 (FGF21), the NAD+-dependent deacetylase SIRT1 or sirtuin 1, and the lipid binding G-protein coupled receptor identified as GPR119.

FGF21 Agonists: Hepatic lipid homeostasis is tightly controlled through the influences of insulin, free fatty acids, sterol regulated element-binding protein (SREBP), and nuclear receptors and associated regulatory molecules such as the liver X receptors (LXRs) and peroxisome proliferator-activated receptor α (PPARα), espectively. The LXRs are members of the steroid/thyroid hormone superfamily of cytosolic ligand binding receptors that migrate to the nucleus upon ligand binding and regulate gene expression by binding to specific target sequences. There are two forms of the LXRs, LXRα and LXRβ. The LXRs form heterodimers with the retinoid X receptors (RXRs) and as such can regulate gene expression either upon binding oxysterols (e.g. 22R-hydroxycholesterol) or 9-cis-retinoic acid.

Recent evidence demonstrated that expression of the fibroblast growth factor family member, FGF21, was significantly elevated in mice fed a high-fat, low-carbohydrate ketogenic diet. Additionally, in mice with experimentally induced reduction in FGF21 expression there was an associated lipemia, reduced ketogenesis and a resultant fatty liver. Conversely, administration of FGF21 to diabetic animals resulted in reductions in the levels of fasting glucose and serum lipids. These results indicate that FGF21 plays a key role in regulating the expression of genes involved in hepatic lipid homeostasis and that activation of FGF21 activity could prove to be a significant tool in the treatment of the disrupted metabolic status in diabetic individuals.

SIRT1 Activators: SIRT1 or sirtuin 1 is the homolog of the yeast (S. cerevisiae) Sir2 gene (Sir refers to Silent mating type Information Regulator). SIRT1 is a member of the sirtuin family of proteins (seven members; SIRT1 through SIRT7) that are characterized by a sirtuin core domain and grouped into four classes. The yeast sirtuin proteins are known to regulate life-span extension, epigenetic gene silencing and suppress recombination of ribosomal DNA (rDNA). SIRT1 is an NAD+-dependent deacetylase that modulates the activities of proteins that are in pathways downstream of the beneficial effects of calorie restriction. SIRT1 catalyzes a reaction where hydrolysis of NAD+ is coupled to the deacetylation of acetylated lysines in target proteins. These target proteins include histones, transcription factors and transcription factor co-regulators. The NAD+ is hydrolyzed to nicotinamide (which is a strong inhibitor of SIRT1 activity) and O-acetyl-ADP ribose. Principal pathways involved in glucose homeostasis and insulin sensitivity are affected by SIRT1 activity. In skeletal muscle, a major site of insulin-induced glucose uptake, SIRT1 and AMPK work in concert to increase the rate of fatty acid oxidation in periods of decreased nutrient availability.

The plant-derived compound, resveratrol (a polyphenolic compound), is a known activator of SIRT1 function. The effects of resveratrol have been shown to increase mitochondrial content, ameliorate insulin resistance and prolong survival in laboratory mice fed a high-fat diet. Recent studies on the action of SIRT1 agonists have demonstrated that compounds that activate SIRT1, but that are structurally unrelated to resveratrol, also improve insulin sensitivity in adipose tissue, liver and skeletal muscle resulting in lower plasma glucose. The actions of these compounds in laboratory studies indicate the potential efficacy of a therapeutic approach to type 2 diabetes that includes activators of SIRT1 activity.

GPR119 Agonists: The fatty acid-sensing receptor, GPR119, is a Gs-type G-protein coupled receptor. GPR119 is expressed at the highest levels in the pancreas and fetal liver with expression also seen in the gastrointestinal tract, specifically the ileum and colon. GPR119 is a member of the class A family (rhodopsin-type) of GPCRs. GPR119 binds long-chain fatty acids including oleoylethanolamide (OEA), lysophosphatidylcholine (LPC), various lipid amides, and retinoic acid. OEA is the most potent ligand and likely represents the endogenous ligand for GPR119. The demonstration that OEA is the most active endogenous ligand for GPR119 is of particular interest since previous work has demonstrated that OEA, when administered to laboratory animals, causes a significant reduction in food intake and body weight gain. These effects of OEA are the result of the activation of the nuclear receptor PPARα, increased expression of fatty acid translocase, and modification of feeding behavior and motor activity. In addition, activation of GPR119 in the pancreas is correlated with enhanced glucose-stimulated insulin secretion (GSIS) and activation of the receptor in the gut results in increased secretion of the incretin hormones GLP-1 and GIP. These observations indicate that GPR119 activation is associated with a dual mechanism of reducing blood glucose: acting directly through pancreatic β-cells to promote GSIS and in the gut via the stimulation of the incretins GLP1 and GIP both of which increase insulin release from the pancreas in response to food intake. Currently there are several small molecule agonists of GPR119 in clinical trials being tested for their efficacy in treating the hyperglycemia of type 2 diabetes as well as for their efficacy in treating obesity.

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Last modified: February 12, 2018