207

INTEGRATION OF METABOLISM
Questions:
1. What is normal blood sugar level? Describe the mechanisms and factors
that regulate blood sugar level. Add a note on insulin deficiency. - April
98
2. What is normal blood glucose level? Write in detail about its regulation.March 2002
3. Write in detail about glucose haemostasis in the human organism and
add a note on its biomedical importance. - Oct 2003
4. What are the normal fasting and post prandial blood glucose levels?
Explain how normal blood glucose level is maintained. Add a note on the
disruption of hormonal regulation of Blood glucose. - Aug 2005
5. Short notes: Interpretation of glucose tolerance test. -Oct 1998
1. The human body functions as one community. Communication between tissues is
mediated by the nervous system, by the availability of circulating substrates and by
variation in the levels of plasma hormones.
2. The integration of energy metabolism is controlled primarily by the action of
hormones, including insulin, glucagon and catecholamines (epinephrine and nor
epinephrine).
3. The four major organs important in fuel metabolism are liver, adipose tissue muscle
and brain.
REGULATION OF BLOOD GLUCOSE

1. Normal values:
1. Fasting plasma glucose levels: 70-110 mg/dl
2. Post prandial:
< 140 mg/dl
3. Plasma value is slightly higher than whole blood glucose because of RBCs
with less water
4. Urine contains no glucose up to plasma level of 180 mg/dl; this is called renal
threshold
2. Regulation of blood glucose:
1. Factors maintaining entry of glucose into blood:
1. Absorption from intestines
2. Glycogenolysis
3. Gluconeogenesis
4. Glucagon
5. Steroid
2. Factors causing depletion:
1. Tissue utilization
2. Glycogen synthesis
3. Glucose converted to fat
4. Insulin
3. Post prandial regulation:
1. After a meal blood glucose level increases which stimulates insulin secretion
by beta cells of pancreas
2. Insulin facilitates entry of glucose to cells except brain for utilization
3. Insulin helps conversion of extra glucose to glycogen and fat
4. Regulation of fasting state:
1. Fasting levels are maintained by hepatic glycogenolysis for 3 hrs
2. Gluconeogenesis if fasting continues

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3. Glucagon, epinephrine, glucocorticoids, growth hormone, ACTH, and Thyroxin
act as hyperglycaemic hormones.
5. Hormone regulations:
1. Insulin: hypoglycaemic
1.
lowers blood glucose;
2.
favours glycogenesis;
3.
promotes Glycolysis;
4.
inhibits Gluconeogenesis
2. Glucagon: hyperglycaemic
1.
Increases blood glucose
2.
Increases Gluconeogenesis
3.
Promotes glycogenolysis
4.
decreases glycogenesis
5.
inhibits Glycolysis
6.
releases amino acid form muscles
3. Cortisol: hyperglycaemic
1.
Increases blood glucose
2.
Increases Gluconeogenesis
3.
releases amino acid form muscles
4. Epinephrine (Adrenalin): hyperglycaemic
1.
Increases blood glucose
2.
Increases Gluconeogenesis
3.
Promotes glycogenolysis
4.
releases uptake of aminoacids
5. Growth hormone: hyperglycaemic
1.
Increases blood glucose
2.
inhibits Glycolysis
3.
mobilizes fatty acids from adipose tissue
6. Disruption of hormone control:
Hyperglycaemia (Diabetes mellitus)
1. Metabolic disease due to absolute or relative deficiency of insulin (Type I)
2. Mainly due to decreased biological response to insulin- insulin resistance
(Type II)
3. Maturity onset diabetes of young (MODY) ; this is due to defective
Glucokinase and increase in threshold for glucose induced insulin secretion
4. Endocrine: Some tumours can produce counter-regulatory hormones that
oppose the action of insulin or inhibit insulin secretion. These counterregulatory hormones are glucagon, epinephrine, growth hormone and cortisol.
E.g. Cushings disease; thyrotoxicosis; acromegaly
5. Drug induced: steroids; beta blockers
6. Pancreatic disease:
7. Pancreatic disease: Pancreatectomy leads to the clearest example of
secondary diabetes. Cystic fibrosis and chronic pancreatitis; calculus
pancreas; hemochromatosis; cystic fibrosis can also lead to destruction of the
pancreas.
8. Glucagonomas are pancreatic cancers that secrete glucagon.
9. Pheochromocytomas secrete epinephrine.
10. Cushing syndrome results in excess cortisol secretion.
11. Acromegaly results in excess growth hormone production.
12. Drug-induced diabetes; treatment with glucocorticoids and diuretics can
interfere
with insulin function.
13. Anti-insulin receptor auto antibodies (Type B insulin resistance).
7. Hypoglycaemia: blood glucose less than 45 mg/dl

209
Causes:
1.
2.
3.

Post prandial: due to reactive insulin secretion

Fasting:
Insulin-induced hypoglycaemia
1. Insulin injected for diabetes
2. Factitious insulin injection (Munchausen syndrome)
3. Excessive effects of oral diabetes drugs, beta-blockers, or drug
interactions
4. Insulin-secreting pancreatic tumour
4.
Alcohol induced hypoglycaemia often linked with ketoacidosis
5.
Alimentary (rapid jejunal emptying with exaggerated insulin
response) After gastrectomy dumping syndrome or bowel bypass
surgery or resection
6.
Acquired adrenal insufficiency
7.
Acquired hypopituitarism
8. Determination glucose:
1. Glucose oxidase method:
1.
It converts glucose to gluconic acid and hydrogen peroxide.
Peroxidase converts H2O2 into H2O and nascent O which oxidise the
substrate into coloured substrate. The intensity of colour will give the
concentration of glucose.
2.
The above reagent mixture can also be mounted on a plastic film.
A drop of blood is added. The intensity of dye is measured by
glucometer.
METABOLISM IN THE WELL - FED STATE
1) The absorptive state is the 2 to 4 hours period after ingestion of a normal meal.
During this period transient increase in plasma glucose, amino acid, and
triacylglycerols occur. Islet tissue of the pancreas responds to the elevation level of
glucose and amino acids with an increased of insulin and a drop in the secretion of
glucagons. It is an anabolic period (increased synthesis of glycogen, triacylglycerols
and protein). During this absorptive period all tissues use glucose as fuel.
2) Enzymic changes in the fed state: The flow of intermediates through metabolic
pathways is controlled by four mechanisms:
a. The availability of substrates
b. Allosteric activation and inhibition of enzymes
c. Covalent modification of enzymes and
d. Induction repression of enzyme synthesis.
3) Allosteric effects: The allosteric changes usually affect the rate limiting reactions
e.g. glycolysis in the liver is stimulated following a meal by increase in fructose 2, 6
biphosphate, an allosteric activator of phosphofructokinase. I. Gluconeogenesis is
inhibited by fructose 2, 6-biphosphate, an inhibitor of fructose 1, 6-biphosphate.
Allosteric effects work within minutes.
4) Regulation of enzymes by covalent modification: Many enzymes are regulated
by covalent modification, (phosphorylation and de phosphorylation). In the fed state
most of the enzymes regulated by covalent modification are in dephosphorylated
state and active e.g. Pyruvate kinase, Pyruvate dehydrogenase complex, glycogen
synthase HMG CoA reductase and acetyl CoA carboxylase. Three exceptions

210
(active phosphorylated forms) are glycogen phosphorylase, fructose bisphosphate
phosphatase and hormone-sensitive lipase of adipose tissue. Covalent modification
takes minutes to hours
5) Induction and repression of enzyme synthesis: The key enzymes are usually
regulated by hormones that affect their synthesis e.g. insulin stimulates (induction)
the synthesis of glucokinase, phosphofructokinase I, pyruvate kinase, the key
enzyme of glycolysis, regulation of enzyme synthesis takes hours to days
LIVER: NUTRIENT DISTRIBUTION CENTER
Thus, after a meal, the liver receives portal blood containing absorbed nutrients and
high levels of insulin secreted by the pancreas
A. Carbohydrate metabolism: Hepatic metabolism of glucose is increased by the
following mechanism:
a. Increased phosphorylation of glucose: High levels of intra cellular
glucose in the hepatocyte stimulates glucokinase to phosphorylate glucose to
glucose 6-phosphate .
b. Increased gIycolysis: The conversion of glucose to pyruvate to acetyl CoA
is stimulated by the elevated insulin to glucagon ratio that activates the key
enzymes of glycolysis Acetyl CoA is used as either provides energy by
oxidation by the TCA cycle or as a building block for fatty acid synthesis
c. Increased activity of the hexose monophosphate pathway (HMP): The
increased availability of glucose 6-phosphate in the well-Fed state, combined
with the active utilization of NADPH in hepatic lipogenesis, stimulate the HMP
d. Increased Glycogensis: Increased glucose -6 phosphate and insulin to
glucagon activate glycogen synthase the key enzyme of glycogensis
e. Decreased gluconeogenesis: The high insulin to glucagon ratio inhibits
enzymes of gluconeogenesis, such as fructose 1,6-bisphosphatase
B. Fat metabolism
a. Increased fatty acid synthesis: Liver is the primary tissue for de novo
synthesis of fatty acids: Due to increase acetyl CoA and NADPH the substrates
for de novo synthesis of fatty acids (derived from the metabolism of glucose)
and the activation of acetyl carboxylase , that is rate-limiting a reaction in
fatty acid synthesis).
b. Increased triacyl glycerol synthesis: The increased availability of fatty
acids coming from :
i. Increased de novo synthesis of FA from acetyl CoA and
ii. Increased from hydrolysis of the triacylglycerol component of
chylomicron remnants and increased availability of glycerol 3phosphate
(Glucose
Dihydroxyacetone phosphate
glycerol 3-phosphate)
TG formed by the liver
lipoprotein (VLDL)
extrahepatic especially
adipose and muscle tissue
C. Amino acid metabolism
a. Increased protein synthesis (stimulated by insulin)
b. Increased amino acid degradation
In the absorptive period, more amino acids are present than the liver can use
in the synthesis of proteins and other nitrogen compound. The excess amino
acids are either released into the blood for all tissues to use in protein
synthesis or are deaminated; to produce energy. The body cannot store

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proteins. The liver has limited capacity to degrade the branched-chain amino
acids (leucine, isoleucine, and valine) which are metabolized in the muscle
ADIPOSE TISSUE: ENERGY STORAGE DEPOT
Adipose tissue is second only to the liver in its ability to distribute fuel molecules. In a 70 kg
man adipose tissue weighs about 14 kg or about half as much as the total muscle mass. In
obese individuals adipose tissue can constitute up to 70% of body weight.
1. Carbohydrate Metabolism
1. Increased glucose transport: stimulated by insulin (glucose transport)
2. Increased gIycolysis: to provide glycerol phosphate for triacylglycerol synthesis
3. Increased activity in the HMP: To supply NADPH (essential for fat synthesis).
2. Fat Metabolism
1. Increased synthesis of fatty acids: De novo synthesis of fatty acids from
acetyl CoA in adipose tissue is nearly undetectable in humans, except when
refeeding a previously fasted individual. Most of the fatty acids added to the lipid
stores of adipocytes is provided by dietary fat (in the form of chylomicrons), and
a lesser amount is supplied by VLDL from the liver
2. Increased triacylglycerol synthesis: Adipocytes lack glycerol kinase, so that
glycerol 3-phosphate used in triacylglycerol synthesis must come from the
metabolism of glucose Thus, in the well-fed state, elevated levels of glucose and
insulin favor storage of TG
Fatty acid + glycerol 3-ph
triacylglycerol (TG)
3. Decreased triacylglycerol degradation: Insulin inhibits the hormone-sensitive
lipase (dephosphorylated form) and thus inhibits triacylglycerol degradation is in
the well-fed state.
RESTING SKELETAL MUSCLE:
1. At rest, muscle accounts for about 30% of the oxygen consumption of the body; during
vigorous exercise it is responsible for up to 90% of the total oxygen consumption. Skeletal
muscle despite its potential for transient periods of anaerobic glycolysis is an oxidative
tissue.
2. Heart muscle differs from skeletal muscle in three important ways:
a. The heart is continuously active, wherease skeletal muscle contracts intermittent
on demand
b. The heart has a completely aerobic metabolism
c. The heart contains negligible energy stores such as glycogen or lipid .Thus, any
interruption of the vascular supply, for example, as occurs during a myocardial
infraction, results in rapid death of myocardial cells. Heart muscle uses glucose,
free fatty acid and ketone bodies as fuels.
3. Carbohydrate Metabolism:
1. Increased glucose transport: due to increase insulin (glucose transporter 4).
Glucose is phosphorylated to glucose 6-phosphate and metabolized to produce the
energy needs of the muscle. This contrasts with the postabsorptive state in which
ketone bodies and fatty acids are the major fuels of resting muscle.
2. Increased glycogen synthesis: The increased insulin to glucagon ratio and the
availability of glucose 6-phosphate stimulate glycogenesis, especially if glycogen
stores have been depleted as a result of exercise. .

212

4.

3. Fat Metabolism: Fatty acids are of secondary importance as a fuel for muscle in
the well- fed state in which glucose is the primary source of energy.
Amino Acid Metabolism:
1. Increased protein synthesis: An increase in amino acid uptake and protein
synthesis occurs in the absorptive period after ingestion of a meal containing
protein ( stimulated by insulin).
2. Increased uptake of branched-chain amino acids: Muscle is the principal site
for degradation of branched-chain amino acids. Leucine, isoleucine, and valine are
taken up by muscle, where they are used for protein synthesis and as sources of
energy

BRAIN
Although forming only 2% of the adult weight, the brain accounts for 20% of the basal oxygen
consumption of the body at rest. The brain uses energy at a constant rate. Normally, glucose
its primary fuel to the brain, because in the fed state the concentration of ketone bodies is too
low to be an energy source. If the blood glucose levels fall below approximately 30 mg /dl
(normal blood glucose is 70-90 mg/dl) cerebral function is impaired.
A. Carbohydrate Metabolism: In the well-fed state, the brain uses glucose exclusively as a
fuel, completely oxidizing about 140 g / day glucose to carbon dioxide and water. The
brain contains no stores of glycogen, and is therefore completely dependent on the
availability of blood glucose.
B. Fat Metabolism: The brain has no significant stores of triacylglycerols. Blood fatty acids
do not efficiently cross the blood-brain barrier (The endothelial cells that line the blood
vessels in the brain).Thus, the oxidation of fatty acids is of little importance to the brain
METABOLISM IN FASTING
A. Fasting may result from an inability to obtain food, from the desire to lose weight
rapidly, or in clinical situations in which an individual cannot eat because of trauma,
surgery, neoplasmas and burns. In the absence of food, plasma levels of glucose,
amino acids, and triaclyglycerols fall, stimulating the secretion of glucagon and
inhibiting insulin secretion.
B. Fasting is a catabolic period characterized by degradation of glycogen, triaclyglycerols,
and protein to:
a. Maintain sufficient plasma levels of glucose for energy metabolism of the brain
and other glucose requiring tissues
b. Mobilize fatty acids from adipose tissue and ketone bodies from liver to supply
energy to all other tissues .
C. Fuel Stores: The metabolic fuels available in a normal 70-Kg man at the beginning of
a fast are: (1) 15 Kg fat, (2) 0.2 Kg glycogen, and 6 Kg protein. Only about 1/3 of the
body protein can be used for energy production without affecting the vital functions.
The metabolic changes in fasting are opposite to those in the well fed -state.
D. Liver in Fasting:
a. Carbohydrate Metabolism:
i. The liver first uses glycogen degradation, then gluconeogenesis to
maintain blood glucose levels.
ii. Increased glyconeolysis: several hours after a meal, blood glucose
levels decrease stimulating the secretion of glucagon and inhibiting
insulin secretion. . The increased glucagon to insulin ratio stimulates
glyconeolysis. Liver glycogen is nearly depleted after 10 18 hours of

213
fasting. Thus hepatic glyconeolysis is a transient response to early
fasting. Adult's liver contains 100 g of glycogen in the well -fed state.
iii. Increaased Gluconeogensis: gluconeogensis begins 4 6 hours after
the last meal and becomes fully active as liver glycogen stores are
depleted. Gluconeogenesis plays an essential role in maintaining blood
glucose during both overnight and prolonged fasting. The main sources
for gluconeogenesis are amino acids, glycerol and lactate.
b. Fat Metabolism:
i. Increased fatty acid oxidation: The oxidation of fatty acids derived
from adipose tissue is the major source of energy in hepatic tissue in the
post absorptive state.
ii. Increased Synthesis of Ketone bodies: The availability of circulating
ketone bodies is important in fasting because they can be used as fuel
by most tissues including brain, once their level in blood is sufficiently
high. This reduces the need for gluconeogenesis from amino acids, thus
slowing the loss of essential protein. Ketone body synthesize is favored
when the concentration of acetyl CoA, produced from fatty acid
oxidation exceeds the oxidative capacity of the tricarboxylic acid (TCA)
cycle. Unlike fatty acids Ketone bodies are water soluble, and appear
in the blood and urine by the second day of a fast.
E. Adipose Tissue in Fasting:
a. Carbohydrate Metabolism: Glucose transport into the adipocyte and its
metabolism are depressed due to low levels of blood insulin .This leads to a
decrease in fatty acid and triacyl- glycerol synthesis.
b. Fat Metabolism:
i. Increased degradation of triaclyglycerols: The activation of
hormone sensitive lipase and subsequent hydrolysis of stored
triacylglycerol are stimulated by high levels of catecoholamines
(epinephrine and particularly norepinephrine).
ii. Increased release of fatty acids: Fatty acids resulting from the
hydrolysis of stored triacylglycerol are released into the blood. Bound to
albumin, they are transported to other tissues for use as fuel. Part of the
fatty acids is oxidized in the adipose tissue to produce energy. The
glycerol produced from triacylglycerol degradation is used by the liver
for gluconeogenesis.
iii. Decreased uptake of fatty acid: In fasting, lipoprotein lipase activity
of adipose tissue is low. Thus, circulating triacylglycerol of lipoproteins is
not available for triacylglycerol synthesis in adipose tissue.
F. Resting Skeletal Muscle in Fasting:
a. Resting muscle uses fatty acids as its major fuel source. By contrast, exercising
muscle initially uses its glycogen stores as a source of energy. During intense
exercise, glucose -6-phosphate derived from glycogen is converted to lactate
by anaerobic glycolysis. As these glycogen reserves are depleted, free fatty
acids provided by the mobilization of triacylglycerol from adipose tissue
become the major sources.
b. Carbohydrate Metabolism: Glucose transport and subsequent glucose
metabolism are depressed because of low blood insulin.
c. Fat Metabolism: During the first 2 weeks of fasting, muscle uses fatty acids
from adipose tissue and ketone bodies from the liver as fuels. After about 3
weeks of fasting, muscle decreases its utilization of ketone bodies and oxidize

214
only fatty acids. This leads to a further increase in the already elevated levesl
of blood ketone bodies.
d. Protein Metabolism: During the first few days of starvation there is rapid
breakdown of muscle protein, giving amino acids that are used by the liver for
gluconeogenesis. Alanine and glutamine are quantitatively the most important
glucogenic amino acids released from muscle. After several weeks of fasting,
the rate of muscle proteolysis decreases due to a decline in the need for
glucose as a fuel for brain
G. Brain in Fasting: During the first days of fasting, the brain continues to use only
glucose as a fuel. In prolonged fasting ( greater than 2-3 weeks ) , plasma ketone
bodies reach markedly high levels and are used in addition to glucose as a fuel by
the brain. This decreases the need for protein catabolism for gluconeogenesis.
Diabetes mellitus
Short
1.
2.
3.
4.
5.

notes:
interpretation of glucose tolerance test- Oct 98
Glycoselated haemoglobin- Aug 2007
GTT June 1990
Confirmatory tests for the diagnosis of diabetic mellitus- April 1998
Glucose tolerance test April 1998, April 1999,

Introduction:
a. Metabolic disease due to absolute or relative deficiency of insulin
b. Incidence is 1 per 10 persons of total population
c. Criteria for diagnosis:
d. fasting blood is more than 126 mg/dl on more than one occasion
e. one value of >200 mg/dl after glucose load
Classification:
1. Type I :
a. 5 % of diabetic cases
b. Insulin dependant
c. insulin level is deficient;
i. immune mediated
ii. idiopathic
d. onset below 30 years of age
e. more prone for ketosis
f. circulating antibodies against insulin are seen in 50% cases
g. antibodies against islet cell cytoplasmic proteins are seen in 80% cases
2. Type II:
a. Non insulin dependent (NIDDM)
b. Circulating insulin level is normal, mildly elevated or slightly decreased
c. Further classified as:
i. Obese
ii. Non obese
iii. Maturity onset diabetes of young (MODY) ; this is due to defective
Glucokinase and increase in threshold for glucose induced insulin
secretion
d. Mainly due to decreased biological response to insulin- insulin resistance
e. Usual age is above 40 years
f. Less prone to develop ketosis
g. 60% are obese and may have increase insulin level
3. Diabetic prone states:
a. Gestational

215

4.

5.

6.

7.

8.

b. Impaired glucose tolerance

c. Impaired fasting glycaemia
Secondary to other causes:
a. Endocrine: Cushings disease; thyrotoxicosis; acromegaly
b. Drug induced: steroids; beta blockers
c. Pancreatic disease: chronic pancreatitis; calculus pancreas; hemochromatosis;
cystic fibrosis
Metabolic syndrome or insulin resistance syndrome of diabetes: this is characterised
by:
a. Abdominal obesity
b. Increased blood triglycerides and low HDL cholesterol
c. High BP
d. Due to insulin resistance or decreased glucose tolerance
e. Increased risk of coronary artery disease
f. More common in developing countries
g. Some may have genetic predisposition for this syndrome
h. Physical inactivity is another important factor
i. Criteria for diagnosis:
i. Waist more than 40 in men 35 in women
ii. Triglyceride > 150 mg/dl
iii. HDL < 40 in men and , 50 in women (mg/dl)
iv. BP > 130/85
v. Fasting glucose >100 mg/dl
j. Management:
i. Exercise
ii. Weight reduction
iii. Less fat, trans fatty acid and cholesterol in diet
Metabolic derangement in Diabetes mellitus:
a. Carbohydrate metabolism:
i. Decreased uptake of glucose by cells
ii. Inhibition of Glycolysis
iii. Stimulation of neoglucogenesis
iv. Hyperglycaemia
b. Lipid metabolism:
i. Increase in free fatty acids and fatty liver
ii. Unutilised acetyl CoA is diverted to ketone bodies leading to ketosis
iii. Hyperlipidemia ( increase in NEFE,TAG and cholesterol)
c. Protein metabolism:
i. Increase in protein breakdown
ii. Muscle wasting
Clinical presentations:
i. Glucosuria
ii. Polyuria
iii. Polydipsia
iv. Polyphagia
v. Wasting
vi. Recurrent infections and tuberculosis due to glucose providing
nutrition for microbs and deranged macrophage activity
Complications:
1. Acute:
i. Ketoacidosis: more common in type I; more acetyl CoA converted into
ketones; also metabolic acidosis; acidotic breathing is called Kussmaul
respiration; can lead to coma
ii. Increased blood glucose causes hyperosmolality and lead to nonketotic
coma
2. Chronic:

216
iii. Atherosclerosis and microangiopathy
iv. Cataract and retinopathy
v. Peripheral neuropathy
9. Lab tests:
1. Blood and urinary glucose monitoring
2. Lipid profile
3. Urea and creatinin levels
4. Microalbuminuria (50-300 mg/day) and frank albuminuria
9. Glucose tolerance test:
1. Standardise test
2. Useful in doubtful cases
3. No GTT for confirmed cases
4. It is also diagnostic of renal glycosuria
Procedure for GTT:
1. Good carbohydrate diet 3 days prior to test
2. 30-50 gm of carbohydrate diet in the previous night
3. Avoid drugs that alter glucose level and exercise and smoking
4. Starvation from 8 PM previous night.
5. At 8 am fasting blood and urine samples are collected
6. Glucose loading: 75 gm of glucose in 200 to 300 ml of water to drink in 5
minutes.
7. Blood and urine samples are collected at hr intervals;
8. Mini GTT: only fasting and 2 hour samples are collected.
Results:
1. Normal pattern: blood glucose level reaches a peak after 1 hour and comes
down to fasting level in 2 hours; none of urine sample will show presence of
glucose.
2. Diabetes mellitus:
1. fasting blood is more than 126 mg/dl on more than one occasion
2. one value of >200 mg/dl after glucose load

3. Impaired tolerance: the values lie between normal and diabetic states
4. Gestational diabetes: carbohydrate intolerance for the first time only
during pregnancy
5. Alimentary glycosuria: within 2 hour samples are normal but a peak rise
after 2 hrs occurs due to increased alimentary absorption of glucose e.g.
Gastrectomy and hyperthyroidism
6. Renal glycosuria: normal renal threshold is 175-180 mg/dl; if urine sugar is
positive when blood glucose is normal it is called renal glycosuria; this is
due to impairment of tubular re absorption of glucose; e.g. Pregnancy,
Fanconi syndrome
7. In diabetic nephro sclerosis urine sugar may be absent even in high blood
glucose levels
Factors affecting GTT:

217
a. Starvation, exercise, liver disease, hyperthyroidism and hypothyroidism
the results will be abnormal
b. Crticosteroid stressed test: this could unmask the prediabetic state
Reducing substance in urine: 8 drops of urine in 5 ml of Benedictreagent boiled for 2
minutes;
Interpretation:
0.5% green; 1 % yellow; 1.5% orange; 2 % red
Positive Benedicts test:
1. Sugars:
1. Glucose
2. Fructose
3. Lactose
4. Galactose
5. Pentose
5. Non sugar reductants:
1. Glucuronides
2. Salicylates
3. Ascorbic acid
4. Homogentesic acid
Glycated
1.
2.
3.
4.

Hb: (glycosylated HB):

In hyperglycaemia glucose is added to proteins in body called glycation;
Glycated haemoglobin in RBC is called HBA1;
HbA1c forms 80% of the total HbA1 molecules;
HbA1c estimation gives information about long term glycemic control (10-12
weeks)
5. Normal Value of HbA1c is 4-7%; in diabetes it goes up to 8-15%

Glycated albumin: this is called fructosamino albumin; estimation will give information of
glycemic control for the past 2-3 weeks
Management:
a. Diet
b. Exercise
c. Oral hypoglycaemic agents: sulphonyl urea and biguanides
d. Insulin
Hypoglycaemia: Proves fatal
a. <50 mg/dl is hypoglycaemia
b. Cause:
i. insulin or other drug overdose
ii. post prandial hypoglycaemia
iii. Insulin secreting tumours
iv. Von Gierkes disease
INSULIN
Questions:
1. What is the normal blood sugar level? Describe the mechanisms and
factors that regulate blood sugar level. Add a note on insulin deficiency.
April 1998
2. Short notes: structure and function of human insulin. Sep 2002; Feb
2006;Feb 2007
3. Describe the biochemical actions of insulin in carbohydrate, lipid and
protein metabolism. Name the disorder associated with insulin
deficiency. How do you confirm the diagnosis? April 2001

218
Insulin is a polypeptide hormone produced by the B-cells of the islets of Langerhans of
the pancreas. Insulin is one of the most important hormones coordinating the
utilization of fuels by tissues. Its metabolic effects are anabolic stimulating the
synthesis of glycogen (glycogensis), triacylglycerols (lipogenesis) and protein.
Structure:
1. It is a protein hormone with 2 polypeptide chains; A chain with 21 aminoacids
and B chain with 30 aminoacids
2. Two chains linked by disulphide bonds between A7 to B7 and A20 to B 19
3. There is an intrachain disulphide link in A chain between 6 and 11 aminoacids
4. Species variation is restricted to aminoacids 9,9 and 10 of A chain and C terminal
of B chain
Biosynthesis of Insulin:
1. Insulin is a polypeptide hormone of 51 amino acids that is composed of two
polypeptide chains. It is synthesized as a single polypeptide chain but is cleaved
in three places before secretion to form the C-peptide and the active insulin
molecule containing the A and B chains.
2. Insulin is first synthesized as preproinsulin which is changed to insulin as follows:
Pre pro insulin(109 aminoacids) pro insulin (86 aminoacids) insulin (51
aminoacids; C peptide is removed)

3.
4. Preproinsulin and pro insulin are inactive. Insulin is stored in the cytosol in
granules that are released by exocytosis. Insulin is degraded by the enzyme
insulinase present in the liver and to a lesser extent in the kidneys.
5. Insulin has a plasma half-life of about 6 minutes. This short duration of action
permits rapid changes in circulating levels of the hormone. Normal insulin level is
5-15 micro units / ml of blood
6. Insulin and C-peptide are synthesized and secreted in equimolar quantities.
Therefore, measurement of C-peptide is an index of rate of secretion of insulin.
7. Mutations causing changes in amino acid sequence at the cleavage points can
lead to familial pro-insulinemia.
Regulation of Insulin Secretion
Stimulation of insulin secretion:
1. The relative amounts of insulin and glucagon secreted by the pancreas are
regulated so that the rate of hepatic glucose production is kept equal to the use
of glucose by peripheral tissues.

219
2. Glucose: ingestion of glucose or a carbohydrate rich meal leads to a rise in blood
glucose which stimulates insulin secretion. Glucose is the most important
stimulus for insulin secretion. As blood glucose level increases, the insulin
secretion also correspondingly increases. Glucose induces a biphasic response to
insulin secretion. A discharge of insulin from the beta cell storage pool occurs
during the initial rapid phase of insulin release within first 2 minutes. The second
phase of insulin release lasting for 5-10 minutes is of smaller magnitude and is
due to discharge of newly synthesized hormone. Beta cells have GluT 2 receptors
for glucose absorption; ATP stimulates the receptor protein and calcium channel
is opened. Increased intracellular Ca causes insulin secretion
3. Amino Acids: ingestion of protein leads to a rise in plasma amino acids which
stimulate insulin secretion. Elevated plasma arginine is a particularly potent
stimulus for insulin secretion
4. Gastrointestinal hormones: The intestinal peptide secretin as well as other
gastrointestinal hormones, stimulate insulin secretion after the ingestion of the
food. They cause an anticipatory rise in insulin secretion. The same amount of
glucose given orally stimulates more insulin secretion than if given intravenously.
Inhibition of insulin secretion:
1. The synthesis and release of insulin are decreased during starvation and stress.
These effects are mediated by epinephrine which is secreted by the adrenal
medulla in response to stress, trauma or extreme exercise. Under these
conditions the secretion of epinephrine is controlled by the nervous system.
2. Epinephrine stimulates glycogenolysis, gluconeogenesis and lipolysis.
Epinephrine inhibits insulin secretion by the pancreas. Thus, in emergency
situations, the sympathetic nervous system largely replaces the plasma
glucose concentration as the controlling influence over cell secretion
Insulin degradation:
1. Rapidly degraded by liver
2. Plasma half-life is less than 5 minutes
3. Protease called insulinase is involved for degradation
Mechanism of action of Insulin:
1. Insulin binds to specific, high-affinity receptors in the cell membrane of most
tissues, including liver, muscle and adipose. This is the first step in a cascade of
reactions leading to many biological actions.
2. Insulin receptor: It is a tetramer linked by disulfide bonds. The extracellular subunit contains the insulin binding site. The cytosolic domain of the -subunit is
a tyrosine kinase, which is activated by insulin.
3. Signal transduction: At least four IRSs have been identified that show similar
structures but different tissue distributions. The actions of insulin are terminated
by dephosphorylation of the receptors.
4. Membrane effects of Insulin: Glucose transport in many tissues, such as
skeletal muscle and adipocytes, increases in the presence of insulin. Insulin
stimulates the recruitment of glucose transporters (GLUT-4) from a pool present
in intracellular vesicles. Some tissues have insulin independent systems for
glucose transport e.g. hepatocytes, erythrocytes, cells of the nervous system,
intestinal mucosa, renal tubules and cornea.
5. Receptor regulation:

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a. Elevated levels of insulin increase the degradation of receptors, thus
decreasing the number of surface receptors. This is one type of down
regulation.
b. Time course of insulin actions: After insulin binding to the receptors
the responses will be:
i. Increase glucose transport (seconds).
ii. Change in enzyme activity (change in phosphorylation states)
minutes to hours
iii. Increase in the amount of enzymes e.g glucokinase,
phosphofructokinase, and pyruvate kinase (hours to days) this
means increase protein synthesis
6. Insulin activates enzymes like Glycogen synthase, pyruvate kinase, etc by
covalent modification.
7. DNA synthesis: insulin increases DNA synthesis, cell growth and anabolism.
8. Glucose uptake: Insulin increases the recruitment of GluT4 in cells which
facilitates glucose uptake by tissues.
Physiological Actions of Insulin (Metabolic Effects of Insulin)
1. Glucose metabolism:
a. Uptake of Glucose by Tissues: Insulin facilitates the membrane transport
of glucose. Facilitated diffusion of glucose in muscle is enhanced by
insulin.
b. Utilization of Glucose: Insulin stimulates Glycolysis, glycogenesis as well
as fatty acid synthesis from glucose
c. Insulin reduces blood glucose by:
i. Insulin lowers the blood glucose level by promoting utilization and
storage.
ii. Gluconeogenesis is inhibited by insulin by repressing the key
enzymes, pyruvate carboxylase (PC) phosphoenol pyruvate
carboxykinase (PEPCK) and glucose-6-phosphatase
iii. Insulin inhibits glycogenolysis by favouring the inactivation of
glycogen phosphorylase and inhibiting glucose-6-phosphatase.
2. Lipid metabolism:
1. Lipogenesis:
1. Insulin favours lipogenesis by providing more Acetyl CoA by
pyruvate dehydrogenase reaction
2. By increasing the activity of Acetyl CoA carboxylase insulin
provides glycerol for esterification of fatty acids to TAG
3. Insulin provides NADPH by increasing the GPD activity of HMP
shunt pathway
2. Inhibition of lipolysis: Insulin inhibits lipolysis through inhibition of
hormone sensitive lipase
3. Anti-ketogenic Effect:
1. Insulin depresses HMG CoA synthase and so ketogenesis is
decreased.
2. In presence of insulin, acetyl CoA is completely utilized in the citric
acid cycle
3. Production of ketone bodies reduced
5.

Protein metabolism:
1. Favour protein synthesis; reduces protein degradation
2. Has anabolic effect in general
3. Stimulates cell replication

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1.

2.

3.

4.

5.
6.

7.

8.
9.
10.

c-peptide
Insulin is a polypeptide hormone of 51 amino acids that is composed of two
polypeptide chains. It is synthesized as a single polypeptide chain but is
cleaved in three places before secretion to form the C-peptide and the active
insulin molecule containing the A and B chains. The A chain has 21 amino
acids and B chain has 30 amino acids. These two chains are joined together
by two disulphide bonds.
Insulin is first synthesized as preproinsulin which is changed to insulin as
follows:
a. Pre pro insulin(109 aminoacids) pre-pro-insulin. It is rapidly converted to
pro-insulin in the endoplasmic reticulum by removal of leader sequence of
23 amino acid residues.
b. pro insulin (86 aminoacids)
c. insulin (51 aminoacids;
d. C peptide is removed
The connecting peptide, or C-peptide, is a short 33-amino-acid peptide that
connects insulin's A-chain to its B-chain in the proinsulin molecule. The Cpeptide is essential for proper insulin folding. The number of amino acids in C
peptide may vary according to species. Insulin with 51 amino acids is thus
formed
Equimolar amounts of C-peptide and insulin are then stored in secretory
granules of the pancreatic beta cells and both are eventually released to the
portal circulation
Measuring C-peptide can help to determine how much of own natural insulin a
person is producing as C-peptide is secreted in equimolar amounts to insulin.
C-peptide levels are measured instead of insulin levels because C-peptide
can assess a person's own insulin secretion even if they receive insulin
injections, and because the liver metabolizes a large and variable amount of
insulin secreted into the portal vein but does not metabolise C-peptide,
meaning blood C-peptide may be a better measure of portal insulin secretion
than insulin itself.
A very low C-peptide confirms Type 1 diabetes and insulin dependence and is
associated with high glucose variability, hypoglycaemia and increased
complications.
C-peptide may be used for determining the possibility of gastrinomas
associated with Multiple Endocrine Neoplasm syndromes (MEN 1).
C-peptide levels may be checked in women with Polycystic Ovarian Syndrome
(PCOS) to help determine degree of insulin resistance.
Therapeutics: Recent studies suggests that Several physiological effects have
been observed in patients, who lacked endogenous C-peptide. With C-peptide
asministration, Improvements were seen on diabetic peripheral neuropathy,
nephropathy and other decrements associated with long-term complications
of type I diabetes

GLUCAGON
1. Glucagon is a polypeptide hormone secreted by the -cells of the pancreatic islets of
Langerhans. Glucagon is composed of 29 amino acids arranged in a single
polypeptide chain. The amino acid sequence of glucagon is the same in all
mammalian species. Epinephrine, glucagon, cortisol, and growth hormone are antiinsulin (counter regulatory) hormones.
2. Regulation of Glucagon Secretion:
1. Stimulation of glucagon secretion:

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i. Low blood glucose: hypoglycemia is the primary stimulus for
glucagon secretion.
ii. Amino acids: stimulate the secretion of both glucagon and insulin.
iii. Epinephrine and norepinephrine: stimulate glucagon secretion
(during stress, trauma or severe exercise)
3. Inhibition of glucagon secretion: Glucagon secretion is markedly decreased by
elevated blood sugar and by insulin (carbohydrate-rich meal).
4. Metabolic Effects of Glucagon:
1. Effects on carbohydrate metabolism: The most important action of glucagon
is to maintain blood glucose levels by stimulation of hepatic glycogenolysis
and gluconeogenesis
2. Effects on lipid metabolism: Glucagon stimulates hepatic oxidation of fatty
acids and formation of ketone bodies. The lipolytic effect of glucagon in
adipose tissue is minimal in humans
3. Effects on protein metabolism: Glucagon increases the uptake of amino acids
by the liver for gluconeogenesis
5. Mechanism of action of glucagon :
1. Glucagon binds to high-affinity receptors on the cell membrane of the
hepatocyte activation of adenylate cyclase in the plasma membrane
increase cAMP (second messenger).
2. cAMP activates protein kinase and increases the phosphorylation of specific
enzymes or other proteins. The phosphorylation activates or inhibits the key
regulatory enzymes of carbohydrate and lipid metabolism.
HYPOGLYCEMIA
1.

Hypoglycemia is characterized by:

a. Central nervous system symptoms, including confusion, aberrant behavior, or
coma;
b. A simultaneous blood glucose level equal to or less than 40 mg/dl; and
c. Symptoms being corrected within minutes following the administration of
glucose. Hypoglycemia is a medical emergency
2. The central nervous system has an absolute need for a continuous supply of blood
glucose as a fuel for energy metabolism. Transient hypoglycemia can causes
cerebral dysfunction, but severe, prolonged hypoglycemia causes brain death. The
most important hormonal changes to correct hypoglycemia are elevated glucagon
and epinephrine combined with decrease insulin secretion.
3. Symptoms of hypoglycemia: The symptoms of hypoglycemia can be divided to
two groups,
a. Adrenergic symptoms: Anxiety, palpitation, tremor, and sweat. These
symptoms are due to increased epinephrine secretion regulated by the
hypothalamus due to hypoglycemia. These symptoms occur when the blood
glucose levels fall rapidly.
b. Neuroglypenic Symptoms: The decrease glucose supply to the brain leads to
brain dysfunction causing headache, confusion, slurred speech, seizures,
coma and death. These symptoms result from a gradual decrease in blood
glucose.
4. Glucoregulatory Systems: Humans have two overlapping glucose-regulating
systems that are activated by hypoglycemia:
a. The islets of Langerhans, which secrete glucagon

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b. The glucoreceptors in the hypothalamus stimulate the secretion of both
epinephrine (through the autonomic nervous system) and ACTH and growth
hormone (GH) by the anterior pituitary gland. Glucagon, epinephrine, cortisol
and GH are called the counterregulatory hormones because they antagonize
the action of insulin on glucose utilization.
c. Glucagon and Epinephrine: Hypoglycemia is corrected by decreased
secretion of insulin and increased secretion of glucagon, epinephrine, cortisol,
and growth hormone. Glucagon and epinephrine are most important in the
acute, short- term regulation of blood glucose levels. Glucagon stimulates
hepatic glycogenolysis and gluconeogenesis. Epinephrine stimulates
glycogenolysis and lipolysis, inhibits insulin secretion, and inhibits insulin
dependent uptake of glucose by tissues.
d. Cortisol and Growth hormone: These hormones are less important in the
short term regulation of blood glucose levels, but they are important in the
long term regulation of glucose metabolism. They stimulate gluconeogenesis.
5. Types of hypoglycemia: Hypoglycemia may be divided into three groups
a. Insulin induced hypoglycemia: Hypoglycemia occurs frequently in patients
with diabetes receiving insulin treatment. Mild hypoglycemia in fully
conscious patients is treated by oral administration of carbohydrate. More
commonly, patients with hypoglycemia are unconscious or have lost the
ability to coordinate swallowing. In these cases, glucagon, administered
subcutaneously or intramuscularly, is the treatment of choice
b. Postprandial hypoglycemia: This is the second most common of the form
of hypoglycemia It is caused by an exaggerated insulin release following a
meal, causing a transient hypoglycemia with mild adrenergic symptoms. The
blood glucose level returns to normal even if the patient is not fed. The only
treatment usually needed is that the patient eat frequent small meals instead
of the usual three large meals.
c. Fasting hypoglycemia: It is rare and produces neuroglycopenic symptoms.
It may be due to:
a) Reduction in the rate of glucose production by the liver as in patients
with hepatocellular damage or adrenal insufficiency or in fasting
persons who have consumed large quantities of ethanol which inhibits
gluconeogenesis. Alcohol consumption can also increase the risk for
hypoglycemia in patients using insulin
b) An increased rate of glucose utilization by the peripheral tissues, most
commonly due to elevated insulin resulting from a pancreatic b-cell
tumor. If untreated, a patient with fasting hypoglycemia may lose
consciousness and develop convulsions and coma.