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Translational Endocrinology & Metabolism: Posterior Pituitary Update

Translational Endocrinology & Metabolism highlights the intersection of basic science, clinical research,
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ENDOCRINOLOGY
& M E TA B O L I S M

HYPOGLYCEMIA
IN DIABETES
UPDATE

The Endocrine Society


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ISBN: 1-936704-20-0
ISSN (Print): 1948-9536
ISSN (Online): 1948-9544
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VOL. 3, No. 4, 2012

TRANSLATIONAL
ENDOCRINOLOGY
& METABOLISM

HYPOGLYCEMIA
IN DIABETES
UPDATE
Editor-in-Chief
R. Paul Robertson, MD
Pacic Northwest Diabetes Research Center
Seattle, Washington

Guest Editor
Elizabeth R. Seaquist, MD
University of Minnesota
Minneapolis, Minnesota

This activity is supported by an


educational grant from Novo Nordisk Inc.

VOL. 3, No. 4, 2012

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Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update was developed by


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ISBN: 1-936704-20-0
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1 2 3 4 5 _ 15 14 13 12 11

Contents

Continuing Medical Education Information

Contributors

Foreword

11

1. Epidemiology and Impact of Hypoglycemia on


Patients with Diabetes

15

Brian M. Frier, BSc (Hons), MD, FRCPE, FRCPG, and


Simon R. Heller, DM, FRCP
2. Hypoglycemia Detection

47

Vanessa H. Routh, PhD, Casey M. Donovan, PhD, and


Sue Ritter, PhD
3. Cerebral Adaptation to Recurrent Hypoglycemia

89

Rory J. McCrimmon, MD, MBChB, FRCP, and Glin z, PhD


4. Prevention and Management of Hypoglycemia
in the Active Patient with Diabetes

115

Stephen N. Davis, MBBS, FRCP, FACP, and


Mark L. Evans, MBBS, MD, FRCP
5. The Impact of Hypoglycemia on the Developing Brain 137
Raghavendra Rao, MD, and Tamara Hershey, PhD
CME Post Test

161

Patient Resources from the Hormone Health Network

163

Continuing Medical
Education Information
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Learning Objectives
Upon completion of this educational activity, learners will be able to:
Chapter 1: Epidemiology and Impact of Hypoglycemia on Patients With Diabetes
Identify the predictive factors of hypoglycemic risk.
Examine impaired awareness of hypoglycemia and alterations in counterregulatory defenses
associated with hypoglycemia.
Analyze the clinical and socioeconomic consequences of hypoglycemia.
Chapter 4: Prevention and Management of Hypoglycemia in the Active Patient With
Diabetes
Analyze how exercise affects blood glucose in patients with diabetes mellitus.
Help patients with diabetes mellitus plan for exercise to reduce the risk of hypoglycemia.
Compare different approaches to insulin therapy in the context of exercise in patients with
diabetes mellitus.

Target Audience
This continuing medical education activity should be of substantial interest to endocrinologists
and other physicians and allied healthcare providers treating hypoglycemia.

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scientically rigorous. The scientic content of this activity was developed under the supervision of Editor-in-Chief, Dr. Paul Robertson, and Guest Editor, Dr. Elizabeth R. Seaquist.

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The Endocrine Society has reviewed all disclosures and resolved or managed all identied
conicts of interest, as applicable.
The following faculty reported no relevant nancial relationships: Stephen N. Davis, MBBS,
FRCP, FACP, and Brian M. Frier, BSc (Hons), MD, FRCPE, FRCPG.
The following authors reported relevant nancial relationships: Mark L. Evans, MBBS, MD,
FRCP has sat on advisory boards for and has received travel support from Medtronic, Roche and
CellNovo and received speakers fees from Animas, Abbot Diabetes Care and AstraZeneca.
Simon R. Heller, DM, FRCP has sat on a speaker advisory board and has received a consulting fee from Novo Nordisk; has received consulting fees from Eli Lilly and Sano Aventis and
has sat on an advisory board for Lifescan.
Editor-in-Chief R. Paul Robertson, MD, who planned and reviewed content for this activity,
reported no relevant nancial relationship. Elizabeth R. Seaquist, MD, the guest editor, has
reported relevant nancial relationships with AMG Medical, Sano Adventis and SkyePharma
as a consultant and has received Grant/Research Support from Eli Lilly.
Endocrine Society staff associated with the development of content for this activity reported
no relevant nancial relationships.

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The Endocrine Society has determined that disclosure of unlabeled/off-label or investigational
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contraindications, warnings, precautions, and adverse events.

|7

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For questions about content or obtaining CME credit, please contact The Endocrine Society at
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Contributors

Editor-in-Chief
R. Paul Robertson, MD
Pacific Northwest Diabetes
Research Center
Seattle, Washington
Guest Editor
Elizabeth R. Seaquist, MD
University of Minnesota
Minneapolis, Minnesota
Contributing Authors
Stephen N. Davis, MBBS, FRCP, FACP
University of Maryland School
of Medicine
Baltimore, Maryland

Simon R. Heller, DM, FRCP


University of Sheffield
Sheffield, United Kingdom
Tamara Hershey, PhD
Washington University School
of Medicine
St. Louis, Missouri
Rory J. McCrimmon, MD,
MBChB, FRCP
University of Dundee
Dundee, United Kingdom
Glin z, PhD
University of Minnesota
Minneapolis, Minnesota

Casey M. Donovan, PhD


Dornsife College of Letters,
Arts and Sciences
University of Southern California
Los Angeles, California

Raghavendra Rao, MD
University of Minnesota School
of Medicine
Minneapolis, Minnesota

Mark L. Evans, MBBS, MD, FRCP


University of Cambridge
Cambridge, United Kingdom

Sue Ritter, PhD


Washington State University
Pullman, Washington

Brian M. Frier, BSc (Hons), MD,


FRCPE, FRCPG
University of Edinburgh
Edinburgh, United Kingdom

Vanessa H. Routh, PhD


UMDNJ - New Jersey
Medical School
Newark, New Jersey

|9

Foreword

Hypoglycemia is a major concern for patients with diabetes who are treated with insulin or
insulin secretagogues. Its effects can range from inconveniencing symptoms brought on by
counterregulatory hormones to more serious effects such as seizures, tachycardia, and even
death. Repeated episodes may lead to hypoglycemia associated autonomic failure, where the
body fails to mount an appropriate counterregulatory response before profound neuroglycopenia occurs. It is important for clinicians to give their patients up-to-date information to help
prevent hypoglycemia.
This issue of Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update
is a comprehensive review of the latest research and knowledge on this condition, opening with
an examination of the impact of hypoglycemia on the lives of patients with diabetes by Brian
Frier and Simon Heller. Vanessa Routh, Casey Donovan, and Sue Ritter explore the role of glucose
sensors in detecting hypoglycemia and hypoglycemia-associated autonomic failure. Rory
McCrimmon and Gulin Oz discuss how the brain responds to repeated hypoglycemia and
how these adaptations may contribute to reduced counterregulatory responses in some diabetic
patients. Stephen N. Davis and Mark L. Evans consider the challenges in balancing exercise
with the risk of hypoglycemia. Finally, Raghavendra Rao and Tamara Hershey examine the
effects of severe hypoglycemic episodes on the brain development in children.
We are certain you will nd the research presented here both interesting to read and useful
to your practice. This issue contains the most current science as well as ideas for working with
your patients. We hope you will enjoy this research and put the ideas here to good use.

R. Paul Robertson, MD
Editor-in-Chief
Translational Endocrinology &
Metabolism

Elizabeth R. Seaquist, MD
Guest Editor
Translational Endocrinology &
Metabolism: Hypoglycemia
in Diabetes

| 11

Abstract

Hypoglycemia is a major concern for patients with diabetes who are


treated with insulin or insulin secretagogues. Its effects can range from
inconveniencing symptoms brought on by counterregulatory hormones
to more serious effects such as seizures, tachycardia, and even death.
Repeated episodes may lead to hypoglycemia associated autonomic
failure, where the body fails to mount an appropriate counterregulatory
response before profound neuroglycopenia occurs. It is important for
clinicians to give their patients up-to-date information to help prevent
hypoglycemia. This issue addresses these topics by examining the impact of
hypoglycemia on the lives of patients with diabetes; exploring the role of
glucose sensors in detecting hypoglycemia and hypoglycemia-associated
autonomic failure; reviewing how the brain responds to repeated hypoglycemia and how these adaptations may contribute to reduced counterregulatory responses in some diabetic patients; considering the challenges
in balancing exercise with the risk of hypoglycemia; and considering
the effects of severe hypoglycemic episodes on the brain development in
children.

| 13

1. Epidemiology and Impact of


Hypoglycemia on Patients
with Diabetes
Brian M. Frier, BSc (Hons), MD, FRCPE, FRCPG
Simon R. Heller, DM, FRCP

Epidemiology
The significance of hypoglycemia as an adverse effect of treatment became
apparent within a few years of the introduction of insulin (1). As the
importance of maintaining glucose concentrations as close to normal as
possible began to accumulate, the emerging relationship between tight
glucose control with subcutaneous insulin therapy and the risk of severe
hypoglycemia caused some to question the safety of the approach (2).
These doubts were silenced by the publication of the Diabetes Control and
Complications Trial (DCCT), but the epidemiological data that accompanied the DCCT emphasized the risk from hypoglycemia in those undertaking intensive insulin therapy (3). The data also highlighted the need
for a good understanding of the adverse effects of therapy when agreeing
upon clinical approaches with patients or their relatives.
Systematic epidemiological data began to emerge in the 1980s as hypoglycemic adverse effects became more apparent. The evidence was initially obtained from overnight monitoring of individuals with type 1
diabetes (4) and retrospective questioning of those attending hospital clinics, and it was assumed at the time that the risks of hypoglycemia were
generally confined to this group.
These data suggested that therapy (usually with twice daily insulin) in
patients with type 1 diabetes led to severe hypoglycemia in around 10%
to 30% of patients per year (5). The risk of severe hypoglycemia was also
reported as a rate, usually the number of overall number of episodes
experienced by each patient per year, although both methods failed to
highlight that rates of hypoglycemia are not normally distributed. Most
individuals with either type 1 or insulin-treated type 2 diabetes experience few or no episodes at all, while a small proportion experience hypoglycemia, even severe episodes, very frequently (6). This type of distribution

Translational Endocrinology & Metabolism, Volume 3, Number 4, 2012 | 15

requires fairly sophisticated statistical techniques to identify factors that


may predict the likelihood of further episodes
By whatever way hypoglycemic burden is measured, the field has been
hampered by a range of different definitions. This has made comparison
between different studies challenging, and the resulting heterogeneity has
limited the use of meta-analysis in combining data from different studies
to estimate the benefit of new insulins and technologies such as insulin
pumps (7). The American Diabetes Association convened a working group in
an attempt to overcome these difficulties (8). Their work endorsed a definition of severe hypoglycemia as an episode that produces cognitive impairment,
sufficient to require the help of another person to recover. However, the definition of mild or biochemical hypoglycemia continues to be debated (9, 10).
Using the definition of severe hypoglycemia as an episode requiring the
help of another person, a large clinical questionnaire from Denmark completed by 411 patients with type 1 diabetes reported a frequency of mild
symptomatic episodes of 1.8 episodes per patient per week compared to a
frequency of severe episodes of 0.027 episodes per patient per week (11).
The latter equated to around 1.6 severe hypoglycemic attacks per year,
and during their lives around a third of patients had been comatose on at
least 1 occasion. Remarkably, this rate had not changed when examined in
a similar survey 10 years later, despite the introduction of more modern regimens together with the use of insulin analogues (12). In the DCCT, of those
randomized to standard therapy (1 to 2 injections per day with little monitoring), around 10% experienced at least 1 episode over 12 months (13). The
risk was 3 times greater in the group undertaking intensive therapy where
the glucose targets were close to normal. In the DCCT, rates of hypoglycemia rose exponentially as HbA1c approached near normal levels (14).
Clinical trials have generally reported rates of hypoglycemia in subjects
with insulin-treated type 2 diabetes that are lower than in trials of those
with type 1 diabetes with comparable levels of glycemic control. In the
United Kingdom Prospective Diabetes Study (UKPDS) (15) over the first
10 years, the proportion of patients suffering a major hypoglycemic event
per year was 0.4% for chlorpropamide, 0.6% for glibenclamide and 2.3%
for insulin at HbA1c levels comparable to the DCCT.
The overall mean values hide the important observation that rates of
hypoglycemia rose as the duration of insulin therapy increased. Furthermore, in other observational studies involving individuals with type 2
diabetes, if patients are matched for duration of insulin treatment, then
rates are comparable (16). This suggests that increasing duration of type
2 diabetes is associated with an increased risk of severe hypoglycemia,
perhaps due to a progressive failure of endogenous insulin secretion.

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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

This hypothesis is supported by the results of a recent study in which


rates of self-reported and biochemical hypoglycemia were compared over
9 to 12 months in individuals with differing durations of diabetes and
with similar levels of glucose control (HbA1c around 7.5%)(Figure 1-1).
Those with type 2 diabetes within 2 years of starting insulin had rates of
hypoglycemia (both biochemical and symptomatic, including severe) that
were similar to those patients who were taking sulfonylureas (17). However, patients with type 2 diabetes treated with
This suggests that increasing
insulin for over 5 years (and whose endogduration of type 2 diabetes is
enous insulin production as measured by
associated with an increased
stimulated C-peptide secretion was lower),
risk of severe hypoglycemia,
had significantly higher rates of hypoglyceperhaps due to a progressive
mia including severe episodes. This group had
failure of endogenous insulin
a risk of hypoglycemia that was comparasecretion.
ble to individuals with recently diagnosed
type 1 diabetes. Those with a diabetes duration of over 15 years were at greatest risk, with around 50% experiencing
a severe episode over the duration of the study. Other population-based
studies have also indicated that in insulin-treated individuals with type 2
diabetes, severe hypoglycemic episodes occur at rates comparable to those

Proportion Reporting at Least One Severe


Hypo

1.0

0.8

Type 2 DM Sulfonylureas = 103


Type 2 DM <2 years insulin = 85
Type 2 DM >5 years = 75
Type 1 DM <5 years = 46
Type 1 DM >15 years = 54

0.6

0.4

0.2

0.0
Type 2 treated with
Type 2
SU
ins <2 yrs

Type 2 >5
yrs

Type 1 <5
yrs

Type 1
> 15 yrs

FIG 1-1. Proportion of each group experiencing at least one severe self-reported hypoglycaemic episode during 9-12 months of follow-up. Vertical bars, 95% condence intervals (from
UK Hypoglycaemia Study Group: Risk of hypoglycaemia in types 1 and 2 diabetes: effects of
treatment modalities and their duration. Diabetologia 50:1140-1147, 2007, gure 2).

Epidemiology and Impact of Hypoglycemia on Patients with Diabetes

| 17

in type 1 diabetes (18). Thus, as far more people with type 2 diabetes are
treated with insulin, the clinical problem is correspondingly greater.

Predictors of Hypoglycemic Risk


Predictors of Hypoglycemia
Episodes of hypoglycemia do not have a normal distribution. Although the
factors that contribute to a high risk of hypoglycemia are common to many
individuals with diabetes, some people experience very few episodes,
while others are disabled by frequent severe events without any warning.
While epidemiological studies have identified some of the predictive factors, much remains poorly understood, particularly the contribution of
psychological and behavioral factors. Since these determine the ability of
individuals to self-manage their condition, they are probably crucial.
Long Duration of Diabetes
Duration of diabetes is a powerful determinant of hypoglycemic risk.
Those with a duration of diabetes of over 15 years have a 3 times higher
risk of experiencing a severe episode compared to those recently diagnosed (17). The dependence on exogenous insulin and largely absent glucagon response to hypoglycemia in those lacking the ability to secrete
endogenous insulin are clearly relevant factors. This is probably also why
individuals with insulin-treated type 2 diabetes experience a persistent
increase in risk as the duration of insulin treatment increases (19).
Impaired Awareness of Hypoglycemia
Impaired awareness of hypoglycemia is common; around 1 in 5 individuals with type 1 diabetes has difficulty recogImpaired awareness of
nizing hypoglycemia (20), and among patients
hypoglycemia is common;
with insulin-treated type 2 diabetes, around
around 1 in 5 individuals with
1 in 10 complains of some degree of unawaretype 1 diabetes has difculty
ness (21). Unsurprisingly, loss of awareness
recognizing hypoglycemia, and
cosegregates with defective counter-regulatory
among patients with insulinresponses, particularly the hypoglycemic
treated type 2 diabetes, around
activation of the sympathoadrenal system
1 in 10 complains of some
(22). Those with impaired awareness are at
degree of unawareness.
considerable risk of severe hypoglycemia,
with a relative increase in risk of between 5
and 7 times those who can recognize hypoglycemia during standard treatment (23, 24).

18

| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

Renal Impairment
Renal impairment is an important although under-reported contributor
to hypoglycemia. It impairs clearance of insulin and the metabolites of
sulfonylureas. The renal contribution to gluconeogenesis (up to 30%
under some conditions) and glucose reabsorption of filtered glucose are
also relevant. The risk of severe hypoglycemia may be raised by as much
as 2 to 3 times in individuals with type 2 diabetes who have an estimated
glomerular filtration rate (eGFR) less than 60 mL/min (25). Measurement
of renal function is particularly important among patients with type 2 diabetes who experience a severe episode.

Increasing Age and Cognitive Impairment


Individuals who lack the ability to recognize and treat hypoglycemia
are unsurprisingly at greater risk of severe episodes. This may explain
why the elderly, particularly those with cognitive impairment, are particularly vulnerable. However, the association of cognitive impairment with
hypoglycemia (26) may also reflect a reduced ability to treat episodes
appropriately.
Increasing age also leads to impaired sympathoadrenal responses during
hypoglycemia (27), with alterations in the thresholds for both cognitive
impairment and onset of symptoms reducing the margin of safety for selftreatment (28).

Psychosocial Factors
The role of psychosocial factors in determining the risk of hypoglycemia is
increasingly recognized (29). Inappropriate responses of patients to raised
glucose concentrations and their overcorrection with additional doses of
insulin may contribute to loss of hypoglycemia awareness and the risk of
subsequent severe episodes. The potential of anticipating and identifying
these attitudes and developing interventions to address them is currently
the increasing focus of experimental work.

Physiological Defenses to Hypoglycemia


Because individuals with insulin-treated diabetes (and those taking
sulfonylureas) are unable to suppress insulin secretion as glucose levels
fall below 4 mmol/L (72 mg/dL), they lack the major physiological

Epidemiology and Impact of Hypoglycemia on Patients with Diabetes

| 19

defense that prevents hypoglycemia and must rely on other processes


to mitigate the glucose-lowering effects of
Inhibition or prevention of
insulin. However, although these additional
glucagon release impairs
defenses are particularly important to individuglucose recovery by around
als with diabetes, they are already impaired
40%, but if both glucagon and
within just a few months of diagnosis in
epinephrine are blocked, then
individuals with type 1 diabetes and also
glucose recovery is totally
decline (albeit more slowly) with increasinhibited.
ing duration in those with type 2 diabetes.
Counter-regulation
Hypoglycemia stimulates increases in glucagon and epinephrine, leading
to hepatic glucose release, initially from glycogenolysis, with an increasing
proportion due to gluconeogenesis. In addition, peripheral glucose uptake
is progressively inhibited, partly directly, but also secondary to increases in
circulating nonesterified fatty acids following epinephrine-stimulated lipolysis. Inhibition or prevention of glucagon release impairs glucose recovery
by around 40%, but if both glucagon and epinephrine are blocked, then
glucose recovery, at least in the experimental setting, is totally inhibited.
Other hormones including growth hormone and cortisol also raise blood
glucose over time, and during severe hypoglycemia, the liver releases glucose
independent of hormonal control (hepatic autoregulation) (30). The virtual
failure of glucose recovery from experimental hypoglycemia when both
glucagon and sympathoadrenal responses are blocked suggests that other
mechanisms do not play a major physiological role during acute episodes.
Symptoms of Hypoglycemia
Data establishing how patients recognize hypoglycemia have emerged
both from studies in the laboratory where hypoglycemia has been induced
(22, 31) and from questioning larger numbers of patients and using the
statistical technique of factor analysis (32)(Table 1-1).
Adults with type 1 diabetes appear to experience 2 specific groups of
symptoms, autonomic and neuroglycopenic, while other symptoms such
as malaise, nausea, and headache are classified as nonspecific. Importantly, experimental studies have generally corroborated these clinical
observations. Activation of the autonomic nervous system as glucose falls
below normal warns patients of impending hypoglycemia, producing
symptoms of sweating, palpitations, and tremor (hence the term autonomic).
Other symptoms reflect increasing cerebral dysfunction as neuronal glucose
supply falls below a critical level (neuroglycopenia), and include confusion

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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

TABLE 1-1. Classification of symptoms of hypoglycemia using Principal


Components Analysis in patients with insulin-treated diabetes depending
on age group

Children (pre pubertal)

Adults

Elderly

Autonomic/neuroglycopenic

Autonomic

Autonomic

Neuroglycopenic

Neuroglycopenic

Behavioral

Non-specic malaise

Neurological

and loss of concentration. They are caused by cerebral dysfunction due to


reduced glucose availability (neuroglycopenia). The combination of neuroglycopenic and autonomic symptoms,
The combination of
on which individuals learn to rely, varies
neuroglycopenic and autonomic
between and within the same individual,
symptoms, on which individuals
but the symptoms are crucial in alerting
learn to rely, varies between
patients. Most patients rely on a combinaand within the same individual,
tion to help them recognize and treat an
but the symptoms are crucial in
episode before cognitive impairment proalerting patients. Most patients
gresses to a stage where they need the help
rely on a combination to help
of another person. Factor analysis indicates
them recognize and treat an
that while children can perceive autonomic
episode before cognitive
and neuroglycopenic symptoms, they also
impairment progresses to a
experience symptoms related to alterations
stage where they need the help
in emotion and behavior (33).
of another person.
While it is to be expected that parents learn
to recognize hypoglycemia in their children
before the children themselves, it is noteworthy that partners and other
family members often alert adults to impending hypoglycemia (34). Factor
analysis applied to data obtained from elderly patients with type 2 diabetes
showed a greater prominence of less-specific neurological symptoms (incoordination, ataxia, and visual abnormalities) (35), suggesting an increased
susceptibility of other areas of the brain to hypoglycemia in this age group.
How do Patients Recognize a Falling Blood Glucose?
In nondiabetic individuals, activation of the autonomic nervous system,
manifested by an increase in plasma epinephrine (and preceded by release
of glucagon) occurs at around 65 mg/dL (3.6 mmol/L) of glucose.
Symptoms such as tremor or sweating are generated at around 60 mg/dL
(3.3 mmol/L) and this is reflected in laboratory settings at a similar glucose

Epidemiology and Impact of Hypoglycemia on Patients with Diabetes

| 21

level by subjectively rated symptom scores. Experimental studies have generally confirmed clinical observations that cerebral cognitive function (using
sensitive tests such as 4 choice reaction time)
Physiological defenses to
begins to deteriorate at around 55 mg/dL
hypoglycemia are intact at
(3 mmol/L) as blood glucose falls and cerebral
diagnosis but become
glucose delivery diminishes (22) (Figure 1-2).
progressively impaired as
Awareness of hypoglycemia depends upon
diabetes duration increases.
patients recognizing their own peripheral
Other factors may also
autonomic response and taking action before
inuence the rate of decline of
their cognitive dysfunction becomes estabthese defenses, and there
lished in the absence of cerebral glucose
appears to be considerable
delivery. Since both symptom generation
variation in the extent and
(through activation of the autonomic nervous
severity of impaired responses.
system) and cerebral dysfunction reflect neuroglycopenia, it is unsurprising that both
responses occur at comparable low glucose levels. It emphasizes how
important it is for patients to respond to warning symptoms and implies
that a shift in activation of the sympathoadrenal response to a lower blood
glucose could prevent recognition of hypoglycemia.

Impaired Endocrine Defenses and Impaired Hypoglycemia


Awareness
The physiological defenses described previously are intact at diagnosis
(36) but become progressively impaired as diabetes duration increases.
Other factors may also influence the rate of decline of these defenses, and

Glucagon release
Epinephrine release
Sweating, tremor

70

55

35

20

Blood glucose (mM ) mg/dl

Start of brain
dysfunction
Confusion/loss of
concentration

Coma/seizure
brain damage

FIG 1-2. Glucose thresholds for the normal physiological response to hypoglycemia.

22 | Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

there appears to be considerable variation in the extent and severity of


impaired responses. Moreover, those with widespread defects develop a
marked decline in hypoglycemia awareness and a subsequently increased
risk of severe episodes.
Glucagon
The glucagon response to hypoglycemia appears to be intact at diagnosis
but begins to fail within a few months (37). Nearly all patients with type
1 diabetes exhibit absent or reduced responses after 5 years of disease.
The defect is afferent; the -cell fails to recognize hypoglycemia as a stimulus for secretion, since glucagon is secreted normally in response to
other secretagogues such as arginine. There is increasing evidence in people that failing glucagon responses to hypoglycemia represent disruption
of a paracrine mechanism of local insulin inhibition by adjacent -cells as
a result of their autoimmune destruction (38, 39).
Epinephrine and Sympathoadrenal Responses
Impaired epinephrine responses during hypoglycemia occur commonly
among individuals with type 1 diabetes but generally develop after a
longer duration of diabetes compared to impaired glucagon release.
They reflect a more general defective response of sympathoadrenal activation during hypoglycemia, so that in addition to diminished circulating epinephrine levels, symptoms of sweating (sympathetic cholinergic),
palpitations, and tremor are also reduced. The prevalence of impaired
epinephrine or of sympathoadrenal responses to hypoglycemia is more
variable than that of glucagon, although many individuals with type 1
diabetes demonstrate defective responses. A survey of published research
estimated that a diminished epinephrine response was present in around
40% of patients with type 1 diabetes, most of whom had had diabetes
for over 15 years (40). Impaired responses appear to be the result of a
resetting of the glycemic threshold for activation to a lower blood glucose
level.
Patients who are unable to release glucagon and epinephrine during
hypoglycemia have a high risk of severe episodes during subsequent
treatment (41). This reflects not only impaired counter-regulatory mechanisms, but probably a failure of peripheral sympathoadrenal responses,
which alert patients to hypoglycemia by generation of autonomic symptoms.
Defects in the autonomic response to hypoglycemia may not only be
confined to impaired secretion. There is evidence of altered -adrenergic

Epidemiology and Impact of Hypoglycemia on Patients with Diabetes

| 23

sensitivity in some patients with type 1 diabetes although to what extent


these changes contribute to impaired hypoglycemia awareness and susceptibility to severe hypoglycemia in the clinical situation is yet to be
established (42, 43).

Impaired Hypoglycemia Awareness


It has long been realized that a proportion of patients with insulin-treated
diabetes have difficulty identifying impending hypoglycemia (44), but
estimates of its incidence and prevalence are varied. This is a consequence
of differing definitions and because awareness of hypoglycemia is rarely
an all-or-nothing phenomenon. Many patients have experienced a single
or occasional severe hypoglycemic episode without warning, but most of
the time they are alerted by their symptoms and take appropriate action.
Yet clinical surveys of the topic have identified impaired hypoglycemia
awareness as a relatively common problem among individuals with type
1 diabetes, affecting as many as a quarter of adults attending hospital clinics, a proportion which reaches nearly 50% in those with a duration of
diabetes over 20 years (11, 12, 45). Since impaired hypoglycemia awareness reflects diminished autonomic responses, it is unsurprising that
those affected are vulnerable to severe hypoglycemia (Figure 1-3); risks of
severe episodes have been reported in 2 prospective studies as varying
between 3 and 7 times greater compared to those who claimed to recognize hypoglycemia (23, 24).

Strict Glycemic Control, Antecedent Hypoglycemia and


Hypoglycemia-Associated Autonomic Failure
Studies in the 1980s showed that strict glycemic control and intensive
insulin therapy involving individuals with type 1 diabetes resulted in
reduced endocrine and symptomatic responses to hypoglycemia (46),
which were associated with a resetting of the glucose threshold at which
they were activated (47). This was followed by research that established
that just a few hours of mild experimental hypoglycemia reduces sympathoadrenal, endocrine, and symptomatic responses to further episodes of
hypoglycemia. The effect has been demonstrated both in nondiabetic individuals (48, 49) and in adults with both type 1 (50) and type 2 diabetes
(51). Once induced, defective responses appear to be maintained for at least
a week in nondiabetic subjects (52), although the maximum duration of
effect demonstrated in individuals with type 1 diabetes is only 2 days (53).

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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

Percentage of subjects

80

2.36

Normal awareness
of hypoglycaemia
Impaired awareness
of hypoglycaemia

60

2.0

1.5

50.5%

40

20

2.5

1.0
20.1%

0.38

0.5

Number of events per year

100

0.0

0
Percentage

Events

FIG 1-3. Prevalence and incidence of severe hypoglycemia (SH) in the year preceding a
survey of 518 adults with Type 1 diabetes with and without impaired awareness of hypoglycemia (reproduced from Geddes et al, 2008) (20).

The extent to which antecedent hypoglycemia contributes to the widespread impairment in physiological defenses to hypoglycemia demonstrated by patients is still not entirely clear. However, it may largely account
for the failure of counter-regulatory mechanisms and loss of hypoglycemia
awareness after tightening glycemic control, presumably alongside those
associated with long duration of disease.
The term hypoglycemia-associated autonomic failure (HAAF) has
been proposed by Cryer to describe the phenomenon, and he has highlighted how an initial period of hypoglycemia could lead to a downward
vicious spiral of progressively impaired physiological responses, increasing clusters of hypoglycemic episodes and the development of impaired
hypoglycemia awareness (54). However, the extent to which autonomic
dysfunction (a classical complication of diabetes generated by a different
mechanism) may contribute is uncertain. Interestingly, antecedent exercise
results in impaired sympathoadrenal responses to experimental hypoglycemia, and antecedent hypoglycemia impairs subsequent sympathoadrenal
activation during exercise (55). Furthermore, antecedent hypoglycemia has
been demonstrated to impair some cardiac autonomic reflexes, including
baroceptor sensitivity and sympathoadrenal responses, to lower negative

Epidemiology and Impact of Hypoglycemia on Patients with Diabetes

| 25

body pressure in nondiabetic individuals (56). On the other hand, some


patients with clear evidence of classical autonomic neuropathy apparently exhibit normal counter-regulatory responses (57, 58). Some have
speculated that the development of impaired defenses represents an adaptation to stress, which in the context of therapeutic hypoglycemia, increases
the vulnerability of patients to subsequent episodes.

The Mechanism Underlying Impaired Hypoglycemia


Awareness
Impaired hypoglycemia awareness occurs due to a change in the relationship between the physiological responses, which generate symptoms and
the deterioration in cognitive ability, preventing them from being recognized. The precise mechanism has not been established, but one hypothesis
utilizes the clinical and experimental observations, described previously,
that patients with impaired hypoglycemia awareness exhibit diminished
autonomic responses due to a resetting of the threshold for the onset of
autonomic symptoms at a lower glucose concentration (59). Proponents
believe that the weight of evidence indicates that the glycemic threshold
for the onset of cognitive impairment is relatively fixed (60, 61). They suggest that by the time patients with diminished awareness start to generate
peripheral autonomic changes such as sweating and tremor, they have
already become cognitively impaired. This prevents them from responding appropriately, and unless they receive assistance, their blood glucose
will continue to fall, leading to increasing confusion, coma, or seizure.
Not all studies have indicated that the threshold for cognitive dysfunction is fixed; some have reported alteration of glucose thresholds to a
lower level in a similar fashion to autonomic defenses (62, 63). Nevertheless, even this work indicates that the glycemic thresholds for significant cognitive impairment, when measured by sensitive tests of cognitive
function, are set at higher glucose levels than those for sympathoadrenal
activation.

Are Defects in Endocrine Counter-Regulation and Impaired


Hypoglycemia Awareness Reversible?
The observations that a few hours of antecedent hypoglycemia lead to
major alterations in physiological responses to hypoglycemia suggests that
these defects may be functional rather than structural and so amenable to
reversal. Clinical studies have confirmed that impaired hypoglycemia awareness, present in some cases for some years, can be reversed, at least in part

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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

with restoration of symptoms of hypoglycemia, and in some reports, resetting of glycemic thresholds at higher levels for epinephrine release and
for symptoms. In some studies, investigators demonstrated that the effect
of hypoglycemia avoidance was to reset the threshold for release of epinephrine to a glucose concentration above that for cognitive impairment
(64, 65). Not all studies have demonstrated restoration of epinephrine
responses (66), although, interestingly, symptom scores during hypoglycemia improved despite the reversal program having failed to restore epinephrine release.
The potential to reverse some aspects of diminished hypoglycemia awareness by avoiding hypoglycemic episodes offers a practical solution to the
problem of loss of awareness. The work described above suggests that if
patients can completely eliminate hypoglycemia for just a few weeks,
they will obtain useful clinical benefit. The published studies do not
provide detailed descriptions of the clinical techniques that were used
to avoid hypoglycemic episodes in order to restore normal awareness.
Nevertheless, the relevant features appear to include close and continuing communication with specialist medical and nursing staff and discussing blood glucose targets based on intensive monitoring. Patients
need to be prepared to accept occasional high glucose values and not to
overcorrect with extra doses of insulin. It is important to emphasize that
the approach is not designed to run high blood glucose values but to
avoid hypoglycemic episodes, and at least in the published studies, it
was possible to achieve this without a major deterioration in glycemic
control.

Clinical Consequences
Morbidity of Hypoglycemia
Neurological Consequences
Around 25% of all episodes of severe hypoglycemia result in coma (67),
which is the principal neurological consequence of severe hypoglycemia.
Coma and hypoglycemia-induced seizures can result in serious morbidity
such as fracture-dislocations, soft tissue injuries, and head injury. When
electroencephalography (EEG) is performed during hypoglycemia in resting
subjects who are awake, typical changes that occur include a decrease in
alpha waves, an increase in theta waves, and increased bursts of delta waves
over the cerebral cortex, which are more evident over the anterior part of
the brain (68). The EEG abnormalities are more pronounced in people with
type 1 diabetes than in nondiabetic subjects, and epileptiform activity is

Epidemiology and Impact of Hypoglycemia on Patients with Diabetes

| 27

more common. The theta wave changes persist after normoglycemia has
been restored. Hypoglycemia-induced EEG changes may persist for several
days and can become permanent, particularly after recurrent severe hypoglycemia. This may confound interpretation of the EEG when attempting to
exclude idiopathic epilepsy. Epileptiform seizures can also provoke cardiac
arrhythmias (69, 70), which might cause sudden death in association with
a hypoglycemia-induced seizure. Because hypoglycemia often causes dizziness, lightheadedness, confusion, and mental obtundation, accidents causing personal injury are a common sequela (71), and may result in falls with
fractures or joint dislocations, particularly in frail elderly people who may
have other comorbidities such as osteoporosis and coronary heart disease.
Permanent focal neurological lesions following acute hypoglycemia are
rare, whereas transient and reversible neurological deficits are relatively
common; in individual cases, short-lived structural changes have been
demonstrated using sophisticated neuroimaging (72, 73). Functional
changes may therefore occur within the brain without leaving a permanent cerebral abnormality. Based on anecdotal clinical observation, it
is thought that several hours of exposure to profound neuroglycopenia
are required to produce permanent brain damage. Such a catastrophic
outcome is rare and is usually the consequence of attempted suicide
with deliberate massive insulin overdose (74) or associated with excessive
alcohol consumption (75). Structural abnormalities observed in the brains
of survivors of profound hypoglycemia include cortical and hippocampal
atrophy and ventricular dilatation. These severely brain-damaged individuals have evidence of widespread cognitive impairment or exist in a vegetative state. When hypoglycemic coma is prolonged, predicting prognosis
can be difficult. Elevation of serum markers of brain damage, neuronespecific enolase and S-100, within 24 to 48 hours of the onset of coma,
usually indicates a fatal outcome (76).
Total cerebral blood flow is increased during acute hypoglycemia, and
blood flow is altered acutely within different regions of the brain; it
increases in the frontal cortex, presumably as a compensatory mechanism
to preserve the supply of glucose to this part of the brain, which is very
sensitive to glucose deprivation. These regional vascular changes become
permanent in people who are exposed to recurrent severe hypoglycemia
and in those with impaired awareness of hypoglycemia; they are then
observed during normoglycemia (77). This probably represents an adaptive response of the brain to recurrent exposure to neuroglycopenia. However, the permanent hypoglycemia-induced changes in regional cerebral
blood flow may promote localized neuronal ischemia, particularly if the
cerebral circulation is already compromised by the development of

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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

cerebrovascular disease. This risk of cerebral ischemia may then be augmented if the individual is exposed to some other form of hemodynamic
stress that affects the cerebrovascular circulation. Transient ischemic attacks
and hemiplegia are recognized manifestations of hypoglycemia, and in
the elderly they may be misdiagnosed as cerebrovascular disease.
Cognitive function, which includes several forms of mental activity, rapidly becomes impaired when blood glucose declines below 3.0 mmol/L
(54 mg/dL). Complex and attention-demanding cognitive tasks, and those
that require speeded responses are much more affected by hypoglycemia
than simple tasks or those that do not have any time restraint (78, 79).
Although the overall speed of response of the brain to make decisions is
slowed, accuracy is preserved for many tasks (80, 81). Although many
aspects of mental performance become impaired during hypoglycemia,
individual differences exist in the levels at which impairment commences
and in the magnitude of dysfunction that occurs. Recovery of cognitive
function does not occur immediately after the blood glucose returns to
normal, but in some cognitive domains may be delayed for up to 60 minutes (79), which has practical consequences for the performance of tasks
that require complex cognitive functions, such as driving. The profound
and negative effects that hypoglycemia exerts on mood and emotion are
often unrecognized by clinicians (82). Fear of hypoglycemia is common
and is a major obstacle to maintaining strict glycemic control both in type
1 and insulin-treated type 2 diabetes (83).
In adults, the long-term effect of repeated exposure to severe hypoglycemia on cognitive function is less clear. The longitudinal follow-up of the
DCCT showed no differences in cognitive function between the intensive
and standard treatment arms over a period of up to 20 years, despite a
greater frequency of severe hypoglycemia in the intensive arm (84). Similarly, data from a systematic meta-analysis did not show any relationship
between recurrent hypoglycemia and performance in cognitive tests (85).
However, the brain of the very young or elderly person with diabetes may
be much more susceptible to hypoglycemia-induced brain injury (86).
Exposure to hypoglycemia in children with early onset of type 1 diabetes
has been associated with lower verbal IQ (87), and early exposure to
severe hypoglycemia in young children with type 1 diabetes appears to
have adverse long-term effects on cognitive function (88). Cognitive
development may be affected adversely by exposure to hypoglycemia, particularly when accompanied by induced seizures, in very young children
(89). It is possible that repeated exposure to hypoglycemia may accelerate
the onset of dementia in elderly people with type 2 diabetes, but as yet
this remains unproven.

Epidemiology and Impact of Hypoglycemia on Patients with Diabetes

| 29

Mortality
Linking Mortality to Hypoglycemia
It is challenging to calculate accurately the risk of mortality due to hypoglycemia in diabetes. Death certificates are notoriously unreliable in attributing cause of death, with coding often left to hospital clerks who rarely
have appropriate training or access to clinical details (4).
Sustained carbohydrate metabolism continuing postmortem, manifested
by glycogenolysis, raises the blood glucose concentration in major rightsided vessels. Thus, normal or high glucose values on the right side of the
heart do not exclude antemortem hypoglycemia. In contrast, glucose is
also metabolized peripherally; thus low blood glucose is often found after
death in those without diabetes.
The difficulties are reflected in a wide range of published estimates on
hypoglycemic mortality rates. Reports from Scandinavia have estimated
hypoglycemic mortality of between 7% and 10% among young adults,
only slightly lower than mortality rates attributed to diabetic ketoacidosis
(90, 91). Because hypoglycemia is common, however, an individual episode is unlikely to cause death.

Dead in Bed Syndrome


Since glucose is an essential neuronal fuel, as glucose falls below a critical
value, reduced glucose delivery leads to cerebral dysfunction and cognitive impairment and could go on to cause permanent cerebral damage
that has the potential to be fatal. As described previously, death due to
hypoglycemic cerebral damage has been described but is rare. Cases are
identified by prolonged coma and characteristic histological findings (92).
There is increasing evidence that hypoglycemia might contribute to
mortality through its effects on the cardiovascular system. A series of 22
unexpected deaths across the United Kingdom among young patients with
type 1 diabetes highlighted a strong link to nocturnal hypoglycemia (93).
Victims were discovered in an undisturbed bed having gone to bed apparently well, which led to the term, dead in bed, to describe the syndrome in
an accompanying editorial (94). Patients had a variable duration of diabetes, but were under 40 years of age, generally aiming for tight glycemic
control and subject to nocturnal hypoglycemia.
The initial report has since been followed by other observational studies, including more recently, detailed autopsies (95) and genetic analyses
(96). Another recent series involving 2 large registries in the Pittsburgh
area of the United States concluded that this mode of death was increased

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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

tenfold compared with nondiabetic individuals and associated with male


sex, a high HbA1c and insulin dose, and low body mass index (97).
In the nondiabetic population, the most frequent cause of sudden death
is coronary heart disease and associated fatal cardiac arrhythmia. However, in a young age group where coronary disease is rare (even in individuals with diabetes), then additional factors must contribute. Since
there is a link between dead in bed syndrome and hypoglycemia, it is
relevant that there are plausible potential mechanisms by which hypoglycemia might contribute to mortality. Case reports of arrhythmias
provoked by hypoglycemia include atrial arrhythmias and premature
ventricular contractions as well as ventricular tachycardia (98100). Furthermore, hypoglycemia causes abnormal cardiac repolarization, which
itself increases the risk of sudden death. Congenital long QT syndrome
is due to inherited mutations among genes that code voltage gated ion
channels contributing to the cardiac action potential (101). Those affected
exhibit a prolonged QT interval and are prone to arrhythmic death. Medications such as terfenadine and sotalol can cause acquired QT prolongation (102).
Lengthening of the QT interval is induced by both experimental and
clinical hypoglycemic episodes (Figure 1-4), in nondiabetic individuals and

5.0 mM

2.5 mM

FIG 1-4. Typical electrocardiographic changes in response to hypoglycemia (right panel),


compared to euglycemia (left panel) in a non-diabetic volunteer. (From Marques et al, 1997) (103).

Epidemiology and Impact of Hypoglycemia on Patients with Diabetes

| 31

patients with either type 1 or type 2 diabetes (103, 104), and in both adults
(105) and children (106). Reductions in serum potassium and sympathoadrenal activation both contribute to the effect (107). Thus one possible
mechanism accounting for sudden death in type 1 diabetes is acquired
long QT syndrome caused by insulin-induced hypoglycemia (108).
An additional factor that could contribute to arrhythmic risk during
hypoglycemia is the contribution of autonomic activation, particularly if
the parasympathetic and sympathetic components are affected differentially. Parasympathetic activation (or suppression of sympathetic activation) will cause bradycardia, an arrhythmia reported during nocturnal
episodes (109). Studies using heart rate variability to measure cardiac
sympathetic and parasympathetic tone have reported inconsistent changes
during hypoglycemia (110112), and the additional effect of autonomic
neuropathy is also uncertain (113).
A recent case report of a sudden death during hypoglycemia in a
young male patient with type 1 diabetes during coincidental continuous glucose monitoring is strong additional evidence of an arrhythmic
death (114), but the precise mode of death remains unclear. It is likely
that both genetic and environmental affects combine together, but
important areas of uncertainty, including the factors that are most
important and whether it is possible to identify those at greatest risk,
are still to be determined.

Hypoglycemia as a Risk Factor for Increased All-Cause and


Cardiovascular Mortality
Recent trials of intensive glycemic control in individuals with type 2
diabetes have also suggested that hypoglycemia might contribute to
mortality. Severe hypoglycemic events in trial participants appear to be
associated with increased risk of mortality in the months following the
event compared to those with no history of severe episodes. The ACCORD
(Action to Control Cardiovascular Risk in Diabetes), ADVANCE (Action
in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation) and VADT (Veterans Affairs Diabetes Trial) have in
total randomized around 24,000 patients at increased cardiovascular
risk to intensive glucose control (115117). In 2008, the ACCORD trial
was terminated early due to increased mortality in the intensive treatment arm, which equated to 54 excess deaths during the 3 years of the
trial. Hypoglycemia (proportionately greater in those treated intensively) was among several potential causes, including weight gain, the
effect of medication, or even chance. In ACCORD, participants who had

32 | Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

experienced at least 1 severe event had higher mortality ratio than those
with no hypoglycemia in both arms, with a hazard rate of 1.41 (118).
Interestingly, there was also a relationship between a severe hypoglycemic episode and downstream mortality in both VADT and ADVANCE.
However, although all 3 trials have reported a similar association; they
could not establish a causal relationship. In ADVANCE, similar associations were also reported with other outcomes, including microvascular
complications and noncardiac mortality (119). It seems equally possible
that the risk of mortality might be due to residual confounding and be a
marker of ill health and vulnerability.
Indeed the reported data linking hypoglycemia, mortality, and intensive glycemic control are inconsistent and apparently confusing. The
ACCORD trial showed that the relationship between a severe hypoglycemic event and mortality was greater in those randomized to standard
therapy (118). While this observation has been cited to refute a causal
effect of hypoglycemia on mortality, the interpretation does not acknowledge the effect of tight control and repeated hypoglycemia, which is well
known to suppress sympathoadrenal responses to subsequent hypoglycemic episodes. Thus if hypoglycemia has effects on cardiovascular risk
through sympathoadrenal responses, then it might be expected that those
experiencing occasional episodes in the standard group would demonstrate stronger sympathoadrenal activation with a more powerful effect
on the cardiovascular system.
Evidence has also emerged recently of an adverse effect of intensive
glucose control among nondiabetic individuals with critical illness.
Original work in this area suggested that intensive glucose control reduced
mortality in critically ill individuals admitted to a surgical intensive care
unit, but subsequent trials have not been able to reproduce these findings.
Indeed, a recent trial reported increased mortality in those treated intensively (120), and the markedly higher rates of hypoglycemia in this
group have clear potential relevance to the observed outcomes (121).
Subsequent post hoc analyses have confirmed the association between
severe hypoglycemia and mortality, although a causal relationship cannot be established. Furthermore, the fact that the greatest rate of mortality was observed in those who were not taking insulin but who had
experienced hypoglycemia suggests that confounding by vulnerability to
hypoglycemia in those who are the most ill contributes to these findings
(120, 122, 123).
In summary, despite a clear association between hypoglycemia and mortality, it is not yet possible to establish a causal relationship, and important
confounders including increased vulnerability to both hypoglycemia and

Epidemiology and Impact of Hypoglycemia on Patients with Diabetes

| 33

mortality probably contribute to these observations. Nevertheless, there


are plausible mechanisms whereby hypoglycemia could increase cardiovascular risk. It seems appropriate to avoid very strict glucose targets or
approaches more likely to cause hypoglycemia in individuals who are
most vulnerable.

Potential Mechanisms by which Hypoglycemia Might Increase


Vascular Risk
Although it has not been possible to prove a causal link between hypoglycemia and cardiovascular events, several experimental studies have
demonstrated the potentially adverse effects of hypoglycemia on the cardiovascular system. Hypoglycemia leads to activation of the autonomic
nervous system, an increase in circulating catecholamines, and hemodynamic changes. These will affect the heart and could conceivably worsen
microvascular complications. For example, acute changes in peripheral
blood flow could aggravate pre-existing renal disease, and sudden changes
in intraocular pressure might precipitate vitreous hemorrhage in individuals with neovascularization. However, the relationship between hypoglycemia and pathophysiological changes that might worsen macrovascular
disease is more firmly established (124). The pathway for the onset of
acute coronary syndrome and myocardial infarction is well described,
and it is striking how many components of the pathway can be affected
by hypoglycemia.

Hypoglycemia and Macrovascular Complications


Direct precipitation of an acute cardiovascular event (either fatal or nonfatal myocardial infarction or stroke) by hypoglycemia would appear to be
rare, yet experimental studies have demonstrated that hypoglycemia can
stimulate mechanisms that both accelerate atherosclerosis and contribute
to plaque instability. As described previously, hypoglycemia, by contributing to abnormal cardiac repolarization and disturbing autonomic
function, might lower the threshold required to initiate a fatal arrhythmic
event. Furthermore, sympathoadrenal activation will increase myocardial
oxygen demand, which could also aggravate cardiac ischemia and provoke a cardiac event.
Experimental hypoglycemia can impair endothelial function through
increases in von Willebrand factor (125) and endothelin levels (126, 127).
Atherogenic cell adhesion molecules are expressed following hypoglycemia (127). However, the effects on the acute inflammatory response are

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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

less clear, with inconsistent responses following hypoglycemia on interleukin 6 and C-reactive protein (125, 127, 128).
Platelet activation and aggregability are increased following hypoglycemia (125, 127), a mechanism probably mediated by sympathoadrenal
activation (129). Initiation of an acute coronary syndrome may also be
related to the state of the fibrinolytic system, and this also appears to be
activated by hypoglycemia (130). Other work has demonstrated increased
coagulation and reduced fibrinolysis during sustained insulin-induced
episodes (127)
The hemodynamic response following hypoglycemia leads to increases
in heart rate, although this rarely rises above 100 beats per minute, perhaps because of simultaneous parasympathetic activation. Systolic blood
pressure increases, accompanied by a fall in diastolic blood pressure, widening of pulse pressure, an increase in cardiac output, and a fall in peripheral vascular resistance. There is a transient increase in the elasticity of
the arterial system (131), which is diminished in people with type 1 diabetes of longer duration (>15 years), and premature arterial stiffening is
common in diabetes of both types. Accelerating the return of the pressure
wave generated during systole to the heart may diminish diastolic coronary filling. A fall in myocardial blood flow reserve (132) may be of limited clinical significance in a healthy individual but could be critical in a
person with pre-existing coronary heart disease.
There are few reports of clinical hypoglycemic episodes initiating a cardiac ischemic event. Silent ischemia in a diabetic patient with suspected
coronary heart disease has been reported (133), and one study utilizing continuous glucose monitoring reported ischemic electrocardiogram (ECG)
changes during hypoglycemia (some being accompanied by chest pain)
that were not observed when glucose was normal or high (134).

Socioeconomic Consequences
Driving
Because hypoglycemia affects cognitive function and mood, it can affect
many everyday activities that require the interaction of several cognitive
domains. One such important activity is driving; progressive neuroglycopenia interferes with driving performance and can cause road traffic accidents. To investigate the effect on driving performance, hypoglycemia was
induced in adults with type 1 diabetes in a driving simulator, which had
visual, auditory, and kinesthetic feedback to track several performance
variables (135, 136). Driving performance began to deteriorate when

Epidemiology and Impact of Hypoglycemia on Patients with Diabetes

| 35

blood glucose declined below 3.8 mmol/L (68 mg/dL), manifested by


inappropriate speed and braking, poor road positioning, driving off the
road, ignoring road signs and traffic lights, and crashes. Only 1 in 3 drivers self-treated their low blood glucose while driving, and then not until
it had fallen to 2.8 mmol/L (50 mg/dL) or less. These seminal studies also
demonstrated that driving utilized a substantial amount of infused dextrose
and has a significant metabolic demand (137), so that a prophylactic
snack should be eaten before driving when blood glucose is below
5.0 mmol/L (90 mg/dL). Hypoglycemia may impair visual perception
during driving, particularly under conditions of limited perceptual time
and low visual contrast (poor light), as it affects visual information processing and causes a deterioration in contrast sensitivity, inspection time,
visual change detection, and visual movement detection (138, 139).
While hypoglycemia can adversely affect driving performance, all drivers with diabetes do not exhibit a similar degree of risk, and it may be
difficult to identify which individual drivers are most vulnerable. Factors
that have been shown to increase driving risk include previous episodes
of severe hypoglycemia (140, 141), previous hypoglycemia while driving
(140), strict glycemic control (low HbA1c) (141), and a failure to test
blood glucose before driving (142). Surprisingly, impaired awareness of
hypoglycemia has seldom emerged as a major predictor for driving-related
accidents. Affected individuals may be initially resistant to cognitive dysfunction during moderate hypoglycemia (blood glucose 2.5 mmol/L (45
mg/dL)) and recover more quickly than those with intact awareness (63).
Furthermore, accident risk can be minimized by frequent measurement of
blood glucose. Nonetheless, blood glucose awareness training for people
with impaired awareness of hypoglycemia has been reported to reduce
their subsequent rate of motor vehicle accidents (143). The American
Diabetes Association has published a position statement with recommendations about individual evaluation of risks to driving associated with
diabetes (144).
Drivers with type 1 diabetes suffer more motor vehicle accidents than
drivers with type 2 diabetes treated with insulin (142). However, hypoglycemia-related road traffic accidents are not exclusively associated with
insulin therapy. Drivers with type 2 diabetes (aged <65 years) receiving
treatment with medications other than insulin, who had a history of
severe hypoglycemia, recorded a higher rate of motor vehicle accidents
than those with no hypoglycemia (145). Ongoing research is essential to
inform driving licensing authorities how to identify those drivers who are
at greatest risk of having motor vehicle accidents and who should therefore be subject to licensing restrictions. At present, these vary between

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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

countries and continents, and influence employment prospects for people


with insulin-treated diabetes.
Recommended safe driving practices include blood glucose testing before
driving and at regular intervals on longer journeys, and keeping a supply
of both fast-acting and complex carbohydrate in the vehicle. If hypoglycemia occurs while driving, the driver should stop the vehicle and should not
recommence driving for 30 to 45 minutes after the low blood glucose has
been treated, as restoration of normal cognitive function is delayed. Unfortunately, these simple measures are frequently ignored (146), and many health
care professionals remain uninformed about the precautions required for
safe driving (147). Routine education is essential for both groups (Box 1-1).
Employment
Some occupations are not available to people who require insulin therapy
because of the potential risk of developing hypoglycemia. With some jobs,
particularly those involving public transport or jeopardizing the safety of
colleagues, any risk of hypoglycemia is considered unacceptable. In other
situations, employers may impose restrictions on employment, often based
on advice from occupational health physicians. In general, people with
insulin-treated diabetes are not permitted to work in isolated or dangerous
areas or at unprotected heights. They are usually barred from serving in the
armed forces, because the provision of insulin and an appropriate diet may
be impossible during periods of armed conflict. Employment is not usually available as emergency workers, civil aviation (with some exceptions),
the offshore oil industry, and in many forms of commercial driving (148).

Box 1-1. Advice for drivers with insulin-treated diabetes regarding


hypoglycemia
If hypoglycemia occurs while driving, stop the vehicle in a suitable location; leave the
drivers seat.
Always keep an emergency supply of readily accessible fast-acting carbohydrate (e.g.
glucose tablets or sweets) in the vehicle.
Check blood glucose before driving (even on short journeys) and estimate at regular
intervals on long journeys.
Take regular meals and snacks, and rest periods on long journeys; avoid alcohol.
If hypoglycemia is experienced, do not drive until 45 minutes after blood glucose is
restored to normal (delayed recovery of cognitive function).
Carry personal identication indicating diabetes in case of injury in a motor vehicle
accident.

Epidemiology and Impact of Hypoglycemia on Patients with Diabetes

| 37

Severe hypoglycemia does not appear to be a major problem in the workplace among most employees with type 1 diabetes (149). However, many
people with insulin-treated type 2 diabetes have reported problems in
relation to their work following mild hypoglycemia, including not going
to work or arriving late because hypoglycemia (particularly nocturnal)
had occurred outside working hours or it affected work performance to
cause significant loss of productivity (150).
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139. Ewing FM, Deary IJ, McCrimmon RJ, Strachan MW, Frier BM. Effect of acute
hypoglycemia on visual information processing in adults with type 1 diabetes
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Epidemiology and Impact of Hypoglycemia on Patients with Diabetes

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140. Cox DJ, Ford D, Gonder-Frederick L, et al. Driving mishaps among individuals with
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143. Cox DJ, Gonder-Frederick L, Polonsky W, Schlundt D, Kovatchev B, Clarke W.
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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

2. Hypoglycemia Detection
Vanessa H. Routh, PhD
Casey M. Donovan, PhD
Sue Ritter, PhD

Introduction
Insulin-induced hypoglycemia is a life-threatening iatrogenic phenomenon that activates multiple neural and humoral corrective systems. When
blood glucose levels begin to fall below 80 mg/dL, a sequential series of
events occurs. Insulin secretion ceases; secretion of glucagon, epinephrine (E), corticosterone, and growth hormone is initiated, and neurogenic
systems trigger food intake. All of these responses are recruited when
glucose decreases to approximately 60 mg/dL. Together, these corrective
responses (counter-regulatory responses or CRR) rapidly restore euglycemia.
Unfortunately, however, the magnitude of the CRR decreases with recurring hypoglycemic episodes, leading to a syndrome known as hypoglycemiaassociated autonomic failure (HAAF). During HAAF, glucose levels can
fall dangerously low without eliciting the behavioral signs that usually
accompany hypoglycemia. HAAF is the major limiting factor of the intensive insulin therapy needed to control the deleterious effects of diabetic
hyperglycemia (1, 2). In order to understand and develop therapies for
HAAF, it is critical to understand the mechanisms underlying hypoglycemia detection and initiation of the CRR.
For many decades, it has been clear that there are glucose sensors located
throughout the body and the central nervous system (CNS) (38). The
goal of this chapter is to describe glucose sensing by central and peripheral
glucose sensors and evidence that supports their roles in hypoglycemia
detection and HAAF. The authors will focus on 3 glucose-sensing systems
that contribute importantly to glucose counterregulation: the ventromedial hypothalamic nucleus (VMN) (9, 10), the hindbrain catecholamine
neurons (11), and the portal-mesenteric vein (PMV) (12).

Acknowledgements: The authors are grateful to Dr. Z. Song for assistance with data collection
for Figure 2-1. The authors also wish to acknowledge the following grant support: VHR: NIH
DK081358, CA139063 and JDRF 4-2010-433; CMD: NIH DK062471 and JDRF 1-2007605; SR: NIH DK040498, DK081546.

Translational Endocrinology & Metabolism, Volume 3, Number 4, 2012 | 47

Cellular Mechanisms of Glucose Sensing


The idea that discrete glucose sensors detect changes in extracellular glucose and use this information to regulate glucose and/or energy homeostasis is not new. In 1955, John Mayer stated in his glucostatic theory, that
somewhere, possibly in the hypothalamic centers shown to be implicated
in the regulation of food intake, perhaps peripherally as well, there are
glucoreceptors sensitive to blood glucose in the measure that they can
utilize it (13). Less than a decade later, the laboratories of Oomura and
Anand independently discovered hypothalamic neurons whose firing rate
was directly regulated by glucose (5, 14). Using single unit recordings,
Oomura demonstrated that neurons in what were then thought to be the
satiety and feeding centers within the hypothalamus showed reciprocal
responses to changes in extracellular glucose (5). Since that time, glucose
sensors have been found throughout the hypothalamus and numerous
other central sites, including, but not limited to, the amygdala, hippocampus, hindbrain, and recently the subfornical organ (3, 1518). As Mayer
predicted, they are also found peripherally. In addition to the pancreatic beta cell, peripheral glucose sensors are located in the PMV of the
liver, carotid body, oral cavity, and the gut (1921). The VMN, hindbrain,
and PMV glucose sensors appear to be particularly important for the CRR.
There are 2 broad categories of glucose sensing neurons. Glucose-excited
(GE) neurons increase, while glucose-inhibited (GI) neurons decrease their
action potential frequency as glucose increases (22). Both GE and GI neurons are often found together in brain regions containing glucose-sensing
neurons. Glucose sensors can be further divided into those that respond
to changes in glucose metabolism (metabolism-dependent) and those that
respond to the glucose molecule per se (metabolism-independent). The
latter include taste receptors such as those found in the oral cavity and
gut as well as the lateral hypothalamus (LH) orexin neurons. In contrast,
most glucose sensors within the medial hypothalamus and some within
the hindbrain, respond to changes in the adenosine triphosphate (ATP)/
adenosine diphosphate (ADP) (or adenosine monophosphate [AMP]) ratio,
which are secondary to glucose metabolism (23, 24). The mechanisms
underlying glucose sensing are surprisingly diverse, comprising several
different metabolic enzymes and a number of ion channels. These mechanisms will be described for GE and GI neurons.
It is important to consider that although very high glucose concentrations
analogous to those seen in the periphery during severe uncompensated
diabetes were originally used to define glucose sensing neurons, brain glucose levels are now known to be 30% of that in blood. In vivo microdialysis

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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

studies report hypothalamic glucose levels of 1 to 2.5 mM during peripheral euglycemia, ranging from 5 mM during hyperglycemia (blood glucose 20 mM) to 0.2 mM during severe hypoglycemia (blood glucose 2
to 3 mM) (25, 26). Similar glucose concentrations during euglycemia
have been noted in other brain regions (27). Thus, emphasis will be placed
on studies of GE and GI neurons that used physiological glucose concentrations within this range.

GE neurons
GE neurons were first identified in the ventromedial region of the hypothalamus (VMH), a region that contains the VMN and the arcuate (ARC)
nucleus. Thus, there are more data regarding these GE neurons compared
to GE neurons in other locations. In 1990, Ashford et al used the pancreatic beta cell as inspiration for the mechanism by which VMH GE neurons
sense glucose (28). These investigators showed that, like the pancreatic
beta cell, glucose directly depolarizes VMH GE neurons by closing inhibitory ATP-sensitive K+ (KATP) channels (28). Although these early studies used supraphysiological glucose levels, KATP channel-dependent
glucose sensing by VMH GE neurons has stood the test of time (22). However, it is important to note that most neurons, glucose-sensing or not,
possess KATP channels or other ion channels that are regulated by ATP
(29). Thus, the presence of such channels is not sufficient to define a neuron as glucose-sensing.
More recent studies point out further similarities with the pancreatic
beta cell in that both the beta cell and most (but not all) VMH GE neurons
require the low-affinity hexokinase IV isoform glucokinase (GK), which
catalyzes the committed step in glycolysis, to sense glucose (30). The
pancreatic beta cell also uses the low-affinity glucose transporter isoform
2 (GLUT2) to transport glucose into the cell. However, 30% of all VMH
neurons express GLUT2 without regard to glucose sensing capability.
Instead, the insulin-sensitive GLUT4 may play a role, since twice as many
glucose sensing versus nonglucose-sensing neurons express both the
GLUT4 and the insulin receptor (31). The neuronal GLUT3 is expressed
in all VMH neurons (31). Like VMH GE neurons, GE neurons in the
amygdala and dorsal vagal complex (DVC) are GK-dependent. The DVC
GE neurons use the KATP channel to sense glucose, but this has not yet
been demonstrated for amygdalar GE neurons (32, 33). Glucose also
closes an inhibitory ion channel (eg, potassium or chloride) to activate
LH melanocortin-concentrating hormone (MCH) GE neurons. However,
the identity of this inhibitory channel is not known (34).

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The cellular fuel sensor AMP-activated protein kinase (AMPK) may mediate glucose sensing in some GE neurons. A decreased ATP:AMP ratio activates AMPK. AMPK is present in most cells and plays a role in activating
cellular processes that restore intracellular ATP levels. Over the past decade,
much data have emerged regarding a prime role for hypothalamic AMPK in
the regulation of whole-body energy homeostasis (35). AMPK has also been
linked to glucose sensing in several populations of GE neurons. The gonadotropin-releasing hormone (GnRH) neurons in the anterior hypothalamus
are AMPK-dependent GE neurons (36), as are the GnRH-derived immortalized GT1-7 cell line (37). Interestingly, glucose opens a nonselective cation
channel to activate GnRH neurons rather than closing an inhibitory channel such as the KATP channel (36). GT1-7 cells possess the KATP channel
(37). However, whether the KATP channel contributes to glucose sensing
in these cells is not known. Like GnRH neurons, GE neurons found in the
hypothalamic paraventricular nucleus (PVN) and subfornical organ also
use a cation channel rather than the KATP channel to sense glucose (18,
38). Whether glucose sensing in PVN or subfornical organ GE neurons uses
GK or AMPK is not known, although GK is expressed in the PVN (39).
The ARC pro-opiomelanocortin (POMC) neurons may also be AMPKdependent GE neurons, although this is still controversial. Several studies using rats as well as wild-type mice and mice whose POMC neurons
express green fluorescent protein (GFP) suggest that POMC neurons do
not directly sense glucose (4042). On the other hand, other studies using
distinct POMC-GFP and other transgenic mice as well as a POMC-derived
cell line suggest that glucose may directly excite POMC neurons via
AMPK-linked KATP channels. However, several of these studies used
supraphysiological glucose concentrations (4345). In these POMC neurons, AMPK regulation of the hypoxia-sensitive nuclear transcription factor hypoxia-inducible factor 1 alpha may play a role in glucose sensing
(46). In contrast to ARC POMC neurons, glucose sensing by VMN GE neurons is unaffected by AMPK modulators (40).
GE neurons most likely respond to changes in glucose metabolism
(vs the glucose molecule per se), since glycolytic flux through GK, AMPK,
and the KATP channel all depend on intracellular metabolism. Moreover,
inhibition of glucose metabolism also inhibits GE neurons (28). However, it
is also possible that metabolism-independent GE neurons exist. This mechanism may explain glucose sensing in those GE neurons that lack GK (31).
For example, the sodium-glucose cotransporter (SGLT) 1 is also expressed
in about 25% of VMH GE neurons. The SGLT1 couples glucose transport
to an inward (excitatory) sodium current, which could contribute to glucose-induced depolarization (31).

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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

Finally, of the GE neurons described, the ARC POMC and LH MCH


neurons play a clear role in whole body energy homeostasis (47), while
the GnRH GE neurons are likely to coordinate reproductive status with
energy availability (36). On the other hand, VMN GE neurons appear to
play a role in hypoglycemia detection and the development of HAAF (48).
Moreover, VMN GE neurons have been shown to be exquisitely sensitive to decreases in glucose below 2 mM (Km =0.5mM), which would
be associated with peripheral hypoglycemia (49). Because the focus of
this chapter is hypoglycemia detection, only VMN GE neurons will be
discussed.

GI neurons
As mentioned previously, GI neurons are found in many locations that
also contain GE neurons, including the VMN, ARC, PVN, LH, subfornical
organ (SFO), DVC, and amygdala (18, 24, 32, 33, 38). However, GI neurons have not been found in the anterior hypothalamus where GnRH neurons are located. Since these experiments focused only on the GnRH
neurons, it is possible that GI neurons may be found in other cell populations in this region (36). GI neurons exist in both the ARC and the VMN
regions of the VMH (22, 41). In the ARC, about half of the orexigenic
neuropeptide Y (NPY) neurons are GI neurons (41). Because most NPY
neurons coexpress -aminobutyric acid (GABA), it is possible that the
NPY-GI neurons release GABA (47). On the other hand, VMN GI neurons
may be glutamatergic. Tong et al showed that when the vesicular glutamate transporter, vGlut, was deleted in steroidogenic factor 1 (SF-1; marker
for the VMN) neurons, release of adrenal E and glucagon in response to
hypoglycemia was impaired (50). As will be discussed, the atypical neurotransmitter nitric oxide (NO) may also be released from VMH GI neurons when glucose decreases. Finally, LH GI neurons express the peptide
orexin (51). Thus, in terms of transmitter release, GI neurons are phenotypically diverse.
As discussed previously for GE neurons, GK is also necessary for glucose sensing in the majority of VMH GI neurons (30). Moreover, like GE
neurons, about twice as many VMH GI neurons as nonglucose-sensing
neurons express both the insulin receptor and GLUT4 (31). Reduced
expression of the neuronal insulin receptor is associated with a blunted
response of VMH GI neurons to decreased glucose and impaired glucose
counter-regulation (52). However, while many VMH GE neurons do not
appear to use AMPK to sense glucose, this enzyme is critical for glucose
sensing in VMH GI neurons (53). Moreover, a feed-forward relationship

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between AMPK and NO is essential for VMN (but possibly not ARC-NPY)
GI neurons to sense decreased glucose (53, 54). Decreased glucose activates AMPK, which phosphorylates the neuronal NO synthase (nNOS)
leading to NO production. NO then binds to its receptor, soluble guanylyl
cyclase (sGC) and raises cyclic guanosine monophosphate (cGMP) levels.
Increased cGMP causes a further activation of AMPK, which is necessary
for closure of a chloride channel, possibly the cystic fibrosis transmembrane regulator (CFTR). The reduction in chloride conductance depolarizes GI neurons, leading to increased action potential frequency (53).
The mechanism by which cGMP enhances AMPK activity is not known.
However, it may be via activation of an upstream AMPK kinase as has
been shown for endothelial cells (55). What is clear is that the AMPK-NO
pathway is essential. Blocking nNOS or sGC prevents decreased glucose
or AMPK activators from depolarizing GI neurons. Conversely, AMPK
inhibition prevents cGMP-induced activation of GI neurons (53). Thus, in
VMN GI neurons full AMPK activation requires both a glucose decrease
and AMPK-dependent NO production in order to close the chloride channel. Whether NO in VMN GI neurons is only needed for depolarization in
response to decreased glucose or whether NO might diffuse to adjacent
cells and alter their activity is not known.
Similar mechanisms may confer glucose sensitivity to the hindbrain
catecholamine neurons, which increase cfos expression during hypoglycemia or glucoprivation (56). Blockade of AMPK phosphorylation
and administration of the GK inhibitor, glucosamine, in the hindbrain
both reduce glucoprivic feeding (57). In addition, the glucose analog
2 deoxyglucose (2DG), which cannot be metabolized, mimics the effects
of low glucose in a subgroup of hindbrain catecholamine neurons, indicating their responsiveness to glucose deficit and suggesting a GI phenotype
(56). However, strong support of this supposition will require electrophysiological evidence demonstrating their intrinsic responsiveness to glucose,
which is not available at this time. Therefore, to be conservative, the
authors will refer to these neurons simply as hindbrain catecholamine
(or norepinephrine [NE] and E) neurons.
In addition to the VMH GI neurons, GK is expressed in GI neurons in
the amygdala and DVC; however glucose-sensing mechanisms have not
been fully explored in these regions (32, 33). Interestingly, glucose
appears to open a KATP channel and inhibit SFO GI neurons (18). While
VMH GI neurons use KATP channels to respond to changes in extracellular lactate, this KATP channel does not play a role in glucose sensing (49).
In contrast to the metabolically dependent GI neurons, 2DG inhibits LH
orexin neurons (58). This suggests that LH orexin neurons respond to the

52 | Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

glucose molecule per se. While the identity of this glucose receptor is
unknown, as mentioned previously, the sweet taste receptor and the
SGLT are interesting candidates. Various ion channels have been proposed;
however, the exact mechanism has not been established (59, 60).

Nonneuronal Glucose Sensors


In addition to neuronal glucose sensors, glial cells also may play a role in
glucose sensing and hypoglycemia detection. Specialized ependymal cells
known as tanycytes, which line the ventral portion of the third ventricle,
are interesting candidates. These cells are in direct contact with the
cerebrospinal fluid on 1 side and extend processes deeply into the VMN
and arcuate nuclei. While they do not appear to communicate via action
potentials, they are electrically coupled and propagate calcium signals.
Glucose and glucose analogues pulsed onto tanycytes increase intracellular calcium levels (61). Tanycytes also express GLUT2 and KATP channels
(61, 62). The toxin alloxan, which destroys GK-expressing cells, kills tanycytes and impairs the CRR. Interestingly, during HAAF, the tanycytic processes projecting into the VMH retract. However, 2 weeks after the last
hypoglycemic episode when the CRR is restored, tanycytic projections are
once again found within the VMH (62). Astrocytes also possess GLUT2
and may play a role in glucose sensing. Inhibition of carbohydrate metabolism, specifically in astrocytes, blunts insulin secretion in response to
intracarotid glucose injection (63). Glucagon secretion and brainstem
c-fos activation in response to peripheral or central 2DG are blunted in
mice lacking GLUT2. Restoring GLUT2 expression in astrocytes but not
neurons normalizes both the glucagon response and brainstem c-Fos
activation (64). These data suggest that interaction between glial cells and
neurons is necessary for normal hypoglycemia counter-regulation.

Brain Glucose Sensors and Glucose


Counter-regulation
As mentioned previously, glucose-sensing cells of various types are distributed widely in the brain and peripheral tissues. The specific functions
of neuronal glucose-sensing cells depend not only upon their glucosesensing characteristics, but also upon their neural connections. While
it is reasonable to expect that most glucose-sensing neurons contribute to
metabolic homeostasis at some level (cellular, local or systemic), assigning specific roles to the majority of these neurons is limited by incomplete anatomical and physiological information. Historically speaking,

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the hypothalamus and the hindbrain have received the greatest attention
with respect to their glucose-sensing potential, due to their demonstrated
roles in control of food intake and metabolism. Glucose sensors within
both hypothalamic and hindbrain sites contribute importantly to glucose
homeostasis, but their roles in this complex process appear to differ, as
will be discussed. In the hypothalamus, the most complete information
regarding hypoglycemia detection and counter-regulation is available
for VMN GE/GI neurons. Prominent among glucoregulatory neurons in
the hindbrain are NE and E neurons. Therefore, the functional characteristics of the VMN and hindbrain glucose sensors will be covered.

Hypothalamic Glucose Sensing and Counter-regulation


Before proceeding, it is necessary to distinguish between the VMN and the
VMH as referred to in studies highlighted. It is very difficult for in vivo
injection or microdialysis studies to distinguish between the VMN and ARC
due to the close proximity of these nuclei. For accuracy, therefore, these
types of studies will simply refer to the VMH, as will in vitro studies that
dissect the entire VMH. However, it is quite likely that VMN glucosesensing neurons are responsible for observed VMH effects, since the
ARC NPY-GI neurons do not appear to play a clear role in hypoglycemia
detection (65), and glucose sensing by ARC POMC neurons is controversial
(41). On the other hand, genetic deletion studies using the VMN marker,
SF-1, and electrophysiology studies, which visually identify the VMN,
will refer to the VMN directly.
In the late 1980s, counter-regulatory hormone secretion during moderate
or deep hypoglycemia was reported to be independent of hypothalamic
glucose sensors (66). In contrast, others showed that brain glucose sensors were important, especially with regard to glucagon secretion (67).
Since this time, several studies have suggested an important in vivo role
for VMH glucose sensors in the adrenomedullary, as well as glucagon,
response to insulin-induced hypoglycemia both under control conditions
and during HAAF. Specific VMH lesions with ibotenic acid suppressed
adrenal E and NE and glucagon responses to hypoglycemia by 50-80%
each, depending on the degree of hypoglycemia (68). VMH glucoprivation
with 2DG caused hyperglycemia and profoundly augmented these hormonal responses (eg, increasing adrenal E levels 30-fold) (69). Moreover,
VMH glucose perfusion during peripheral hypoglycemia reduced adrenal
E and NE and glucagon release by up to 85% (9). Interestingly, this augmentation of the CRR by VMH glucoprivation was potently reduced following recurrent hypoglycemia (70). Moreover, antecedent hypothalamic

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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

glucoprivation with 2DG reduced adrenal E and glucagon responses to


hypoglycemia by 50% (71). On the other hand, corticosterone secretion
and feeding appear to be unaffected by recurrent hypoglycemia, antecedent glucoprivation, or manipulation of the VMH (7174). These data suggest that the VMH plays an important role in 2 of the major aspects of
the CRR: adrenomedullary activation and glucagon secretion. On the
other hand, the VMH may not influence corticosterone secretion and glucoprivic feeding. Together, these data provide a strong link between
impaired VMH glucose sensing and impaired adrenomedullary hormone and glucagon secretion during HAAF. The role of specific VMN
glucose-sensing neurons will be described.

VMN GE Neurons and Glucose Counter-regulation


A role for KATP-dependent GE neurons in hypoglycemia detection is supported both by in vitro electrophysiological and in vivo studies. During
HAAF, blood glucose levels must fall further before the CRR is initiated.
Similarly, extracellular glucose levels must fall further before VMN GE
neurons are inhibited following recurrent hypoglycemia (10). GE neurons
are absent, and hypoglycemia-induced glucagon release is reduced in
mice lacking the pore-forming unit of the KATP channel, Kir6.2 (75). VMH
injection of the KATP channel opener, diazoxide, amplifies adrenal E and
glucagon release and decreases the glucose infusion rate needed to maintain hypoglycemia during a hyperinsulinemic-hypoglycemic clamp while
blockade of VMH KATP channels with glibenclamide does the converse
(76, 77). Coinjection of the GABA A agonist, muscimol, with diazoxide, or
of the GABA A antagonist, bicucculline, with glibenclamide, blocked the
effects of the KATP channel modulators. Conversely, VMH glibenclamide
increases, while diazoxide decreases local GABA release (78). VMH GABA
levels are reduced by diabetic hypoglycemia, and GABA tone is elevated
during HAAF (57, 79). Reducing VMH GABA tone during HAAF restores
both adrenomedullary E and glucagon responses to hypoglycemia (79).
More importantly, reducing VMH GABA tone restores the glucagon response
to hypoglycemia in diabetic rats in which glucagon secretion is absent
under basal conditions (57). Together, these data suggest that KATPdependent GE neurons may belong to a population of GABA interneurons within the VMH. This is consistent with single-cell reverse transcriptase
polymerase chain reaction (RT-PCR) studies showing that approximately
half of VMH GE neurons express the GABA synthetic enzyme, GAD
(31). Thus during hypoglycemia, reduced glucose would inactivate GE
neurons and reduce VMH GABA release. Decreased inhibitory GABA

Hypoglycemia Detection

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signaling may then play a role in stimulating adrenal E and glucagon


secretion.

VMN GI Neurons and Glucose Counter-regulation


A stronger body of evidence suggests that VMN GI neurons play a role in
the response to hypoglycemia. The glucose sensitivity of VMN GI neurons parallels the ability of the brain to sense and respond to hypoglycemia under a number of conditions (10).
The glucose sensitivity of VMN
As with VMN GE neurons, larger declines
GI neurons parallels the ability
in extracellular glucose are required for the
of the brain to sense and
same degree of activation of VMN GI neurespond to hypoglycemia under
rons following recurrent hypoglycemia (80).
a number of conditions.
VMH injection of lactate or the corticotrophin-releasing factor receptor 2 agonist,
urocortin, impairs adrenal E and glucagon release during acute hypoglycemia by over 55% (74, 81). Similarly, including lactate or urocortin in the
bathing media blunts the response of VMN GI neurons to decreased glucose (49, 74). In contrast, VMH AMPK activation in vivo more than doubled adrenal E and glucagon secretion after recurrent hypoglycemia (82).
Incubating brain slices with an AMPK activator also restores normal glucose sensitivity to VMN GI neurons following recurrent hypoglycemia
(Figure 2-1), while AMPK inhibition blunts their response to glucose
decreases (53, 83). Moreover, altering VMH NO signaling either in vitro
or in vivo results in parallel changes in the glucose sensitivity of VMN GI
neurons or the CRR, respectively (10). These data strongly suggest that VMN
GI neurons play an important role in the CRR, at least in terms of glucagon and adrenal E release. However, other glucose sensors are also
involved. In support of this, while the CRR was significantly blunted, it
was not abolished in nNOS knockout mice, which completely lack VMN
GI neurons (10).

Connections of the VMN that May Mediate


Counter-regulatory Responses
While VMN glucose sensors are clearly important in hypoglycemia detection
and the CRR, efforts to delineate their exact function have been hampered,
because their peptide phenotype is unknown. The VMN contains neurons
expressing peptides relevant to energy and/or glucose homeostasis, including
brain-derived neurotrophic factor (BDNF) and pituitary adenylate cyclaseactivating peptide (PACAP). GABA and glutamate neurons are also found in

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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

the VMN, as are those expressing nNOS (84). As mentioned previously, a role
for VMN amino acid transmitters GABA and glutamate has been suggested in
hypoglycemia detection. For example, deleting vGlut in SF-1 neurons that are
specific for the VMN impairs adrenal E and glucagon secretion (50). Moreover, there is considerable overlap between GI neurons and nNOS/NO
signaling (85), and adrenal E release in response to insulin-hypoglycemia
is impaired in nNOS knockout mice that lack VMN GI neurons (10). The
afferent and efferent connections of the VMN are complex and will only be
covered briefly in this chapter. For a complete discourse on the topic, the
reader is referred to an excellent review by Bruce King (84). This review supports an integrative role for the VMN based on its juxtaposition between
autonomic regulatory and higher limbic sites, especially with regard to stress
circuitry. The VMN receives extensive reciprocal input from limbic regions
such as the amygdala and the bed nucleus of the stria terminalis, the latter a
relay within the hypothalamic-pituiitary-adrenal axis. The VMN receives
input from other hypothalamic areas including the LH and the suprachiasmatic nucleus. VMN axons as well as dendrites project widely throughout the
hypothalamus including to the PVN, dorsomedial nucleus, and LH. The VMN
also projects to the midbrain reticular formation (84). It is this latter connection that enables the VMN to provide input to the sympathetic preganglionic
neurons within the intermediolateral column of the spinal cord. Thus, while
the exact phenotype and neurocircuitry influenced by VMN glucose sensing
neurons is not known, the potential for impacting those neural circuits
involved in hypoglycemia detection and the CRR is clear.

Future Directions: VMN Glucose Sensing


The previous discussion clearly points to an important role for VMN glucose-sensing neurons in hypoglycemia detection and the CRR. However, it
is also clear that there are many unanswered questions that must be
addressed in future studies. Foremost among these is the neurotransmitter
phenotype of both VMN GE and GI neurons. Once this is known, studies with
transgenic animals, in particular conditional gene deletion of these transmitters within VMN neurons, will provide information regarding the relative importance of these neurons to the CRR. In addition, identification of
transmitter phenotype will enable similar tract tracing studies, as those
described for the brainstem, which define the neuroanatomical pathways
by which VMN glucose-sensing neurons impact the CRR. Finally, the
most important unanswered question involves the way that information
provided by the various central and peripheral glucose sensors interacts to
coordinate the CRR under normal and pathological conditions.

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A Control
-54 mV

2.5 mM Glucose
0.1 mM Glucose

-54 mV
10 mV

2.5 mM Glucose
0.5 mM Glucose

1 min

RH
-50 mV

2.5 mM Glucose
0.1 mM Glucose

-50 mV

2.5 mM Glucose
0.5 mM Glucose

RH-AICAR
-52mV

2.5 mM Glucose
0.1 mM Glucose

-52mV

2.5 mM Glucose
0.5 mM Glucose

B
% change in IR

40

30
20

10
0
-10

% change in MP

20
15

a
a

10

5
0

Control
(n=9)

58

RH
(n=6)

RH-AICAR
(n=9)

| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

FIG 2-1. (A) Representative current-clamp recordings of VMN GI neurons in brain slices from
2- to 3-week old male Sprague-Dawley rats. Control and recurrently hypoglycemic (RH) rats were
injected once daily for 3 consecutive days with either saline (control) or insulin (4 U/kg; RH). On
day 4, all rats were sacriced, their brains sliced into 300 m sections, and patch-clamp
recording performed as described previously (80). Brain slices from control and 1 subset of RH
rats were studied in the absence of further treatment. Brain slices from another subset of RH rats
were treated with the AMPK activator, 5-aminoimidazole-4-carboxamide-1-b-4-ribofuranoside
(AICAR, 0.5 mM) in the bathing medium for 15 minutes (RH-AICAR group). AICAR was then
washed out, and glucose sensitivity was evaluated from 1 to 5 hours after treatment. The top trace
in each group represents the neuronal response to a glucose decrease from 2.5 to 0.1 mM and
the bottom trace a glucose decrease from 2.5 to 0.5 mM. Resting membrane potential is given to
the right of each trace. The downward deections represent the membrane response to a constant
hyperpolarizing pulse of -20 pA given for 500 milliseconds every 3 seconds. VMN GI neurons
from control rats were reversibly activated by glucose decreases to both 0.5 and 0.1 mM,
whereas GI neurons from RH rats were only activated by the maximal glucose decrease to 0.1
mM. AMPK activation (RH-AICAR) completely restored the response to 0.5 mM glucose. (B) The
data in (A) were quantied as the percent change in input resistance (IR) and membrane potential
(MP) in 0.5 mM glucose compared to that in 2.5 mM for each group. In GI neurons from
controls, decreasing glucose to 0.5 mM increased IR and MP by 25% and 8%, respectively.
However, in GI neurons from RH rats, the increase in IR and MP was signicantly reduced or
abolished. Treating the brain slices with AICAR completely restored the response to 0.5 mM
glucose. The data were analyzed by 1 way ANOVA followed by post hoc test. Different letters
represent statistically different groups (P<0.05). (Panel A: Control and RH traces and B: IR values
for control and RH reproduced with permission from Song Z, Routh VH. Recurrent hypoglycemia
reduces the glucose sensitivity of glucose-inhibited neurons in the ventromedial hypothalamus
nucleus (VMN). Am J Physiol Regul Integr Comp Physiol. 2006;291(5):R1283.).

Hindbrain Glucose Sensing: NE and E Neurons and Their


Roles in Counter-regulation
Mapping studies using nanoliter injections of 5-thioglucose (5TG) (86), an
antiglycolytic agent similar to 2DG, have revealed hindbrain sites from which
feeding, the adrenal medullary hyperglycemic, glucagon, and corticosterone
responses can be elicited by localized glucose deficit (87, 88). Sites positive for 1 response were nearly always positive for all 4 responses. At tissue sites, there is an approximately fourfold greater sensitivity to 5TG
than at ventricular sites, indicating that the responses are elicited by
mechanisms existing at the injected sites and not by diffusion through the
ventricular system to distant sites. Localized injections of 5TG into hypothalamic tissue sites, including those in VMH nuclei, were not effective in
eliciting any of the counter-regulatory responses, even when higher doses
were administered. These data suggest that hindbrain glucose detection
sites are the elicitation sites for the feeding, adrenal medullary secretion,

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and corticosterone responses to systemic glucoprivation. These findings


are consistent with previous results showing that localized 2DG injections
into hypothalamus and other forebrain sites are ineffective in eliciting
feeding (89, 90), and data showing that feeding and hyperglycemia elicited by lateral ventricular 5TG injection are blocked by occlusion of the
cerebral aqueduct, which prevents the 5TG
from perfusing the hindbrain (91). The disSelective lesion of hindbrain
tribution of hindbrain sites where these
NE and E neurons eliminates
responses can be elicited by localized glucothe feeding, adrenal medullary
privation is similar to the known distriand corticosterone responses to
bution of NE and E cell groups in which
systemic glucoprivation,
systemic glucoprivation increases expresindicating that these neurons
sion of c-Fos (11), a marker of neuronal
are required for glucose CRR.
activation, and induces the genes for
dopamine-beta-hydroxylase (DBH) (92) and
co-expressed NPY (93). Lesion studies, discussed below, also provide
critical data. Selective lesion of hindbrain NE and E neurons eliminates
the feeding, adrenal medullary and corticosterone responses to systemic
glucoprivation, indicating that these neurons are required for glucose
CRR.
Early work demonstrated that NE and E are potent orexigenic agents
(94, 95) that exert control of corticosterone-releasing hormone (CRH) and
thus, of corticosterone secretion (96). Glucoprivation is a potent activator
of NE and E neurons, and increases NE and E release and turnover in the
hypothalamus, where they form dense terminal networks (8, 97100).
Pharmacological blockade of NE and E neurotransmission reduces glucoprivic feeding (101). In accord with these findings, a recent report has
shown that stimulation of the 2 adrenergic receptor by local agonist injections targeting the VMN enhances glucagon and adrenal E release induced
by hypoglycemia (102). Another potentially important role of NE during
glucoprivic conditions is that it stimulates a glycogenolytic response in
astrocytes and stimulates astrocyte glucose uptake, utilization, and glycogen turnover (103, 104), which may provide an immediate neuroprotective action. Together, these findings strongly indicate that NE and
E neurons are activated by glycemic challenge and participate in glucose counter-regulation.
Chemical microdissection using the retrogradely transported immunotoxin, anti-DBH saporin (DSAP), which selectively targets DBH-expressing
(ie, NE and E) neurons (105), has been a useful tool for studying the role
of these neurons in glucose counter-regulation (56, 106). Injection of
DSAP into the PVN, which selectively and retrogradely destroys DBH

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neurons innervating the medial hypothalamus, impairs or abolishes feeding (107), corticosterone (108), and adrenal medullary responses (107) to
both insulin-induced hypoglycemia and 2DG-induced blockade of glycolysis; it also abolishes the suppression of estrous cycles that are normally
induced by chronic glucoprivation (109, 110). DSAP does not impair daily
feeding or feeding stimulated by short-term (overnight) food deprivation
and does not impair feeding in response to mercaptoacetate (107), a drug
that inhibits fatty acid oxidation (111). The feeding deficit caused by the
lesion of hypothalamically projecting catecholamine neurons appears
to be selective for glucoprivic (or counter-regulatory) feeding. The characteristics of glucoprivic responses at the behavioral level provide strong
support for the nonintegrative nature of this control. That is, the hindbrain glucose-sensing neurons, unlike some hypothalamic glucosesensing neurons (42, 49, 112), may not be sensitive to availability of other
metabolic substrates. Glucoprivation stimulates feeding and other CRRs
even in the presence of elevated body adiposity (113), in satiated animals
and during chronic leptin administration (114). Feeding in response to 2DG
is blocked by glucose, but not by coadministration of intravenous fatty
acids (115).
Of the functionally and phenotypically heterogeneous population of
ascending catecholamine neurons, those required for glucoprivic feeding
appear to be those that coexpress NPY. Global deletion of the NPY gene
(Npy) impairs glucoprivic feeding (65, 116), whereas localized lesion of
arcuate neurons coexpressing NPY and agouti gene-related peptide (AgRP)
neurons does not (65, 113). Results using small interfering RNA (siRNA)
technology show that simultaneous (but not separate) silencing of Npy
and Dbh, localized to the area of A1/C1 overlap in the ventrolateral
medulla, reduced the glucoprivic feeding response to only 39% of the
intake of controls injected with nontargeted RNAs and did so without
impairing the feeding response to another metabolic stimulus, mercaptoacetate-induced blockade of fatty acid oxidation (117). These data, combined with the fact that the largest numbers of DBH-NPY coexpressing
neurons are located in the A1 and C1 cell groups in the ventrolateral
medulla, suggest that the latter NE and/or E neurons, rather than those
in the A2/C2 cell group in the dorsomedial medulla (ie, dorsal vagal
complex) are the primary mediators of counter-regulatory feeding. Other
data supporting this localization include the finding that phosphorylation of
AMPK, an energy-sensing mechanism, is increased in response to glucoprivation in A1/C1, but not significantly in the A2 area (23). Phosphorylation
of AMPK is not increased in the A1/C1 area of the hindbrain in rats in
which the catecholamine neurons have been eliminated by PVH injection

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of DSAP. In addition, nearly all NE and E neurons in A1 and C1 area


express c-Fos in response to 2DG or hypoglycemia, whereas only a very
few A2 neurons in the dorsal hindbrain express c-Fos in response to a
glucoprivic stimulus (23). Other work has demonstrated that A2 neurons
may participate in the satiety actions of gut peptides (118120), suggesting a role for these neurons that differs from the catecholamine neurons
in the ventrolateral medulla. Nevertheless, several feeding deficits are produced by lesion of the nucleus of the solitary tract (NTS) and area postrema, and these include impairment of glucoprivic feeding (121123).
Although it is possible, and even likely, that catecholamine neurons
involved in glucose counter-regulation are distributed across several catecholamine cell groups and include both dorsal and ventral sites, the distribution of NE and E neurons that are directly glucose-sensing is not
known. Responsiveness of A1/C1 neurons to glucose and other energyrelated signals has not been examined in electrophysiological experiments. Furthermore, in the NTS, where about 10% of the total population
of neurons are estimated to be GI and 10% GE (33), it is not known
whether any of these glucose-sensing neurons are catecholaminergic. On
the other hand, results from a laser capture microdissection experiment suggest that some NE neurons in the NTS may express GK (33),
which is thought to be present only in glucose-sensing neurons. Electrophysiological characterization of hindbrain catecholamine neuron responsiveness to glucose is an area in need of investigation.

Stimulation of Corticosterone Secretion by Glucose Decit


Retrograde destruction of hindbrain NE and E neurons by PVN injection
of DSAP eliminated 70% of the corticosterone response to both hypoglycemia and 2DG seen in SAP controls (108). The transcriptional response
of CRH neurons to glucose deficit was also reduced. It is noteworthy that
in DSAP-lesioned rats, the corticosterone response to swim stress and the
circadian rhythm of corticosterone secretion did not differ from controls,
and in situ hybridization revealed that the CRH cell population was intact,
indicating that the deficient response to glycemic challenge was not
due to CRH neuron damage. Additional studies have shown that local
NE injections into the PVN also produce transcriptional and secretory
responses, and furthermore, that mitogen-activated protein (MAP) kinase
signaling cascades transduce the effects of NE on CRH cellular activation and secretion (124 , 125 ). Sensitivity of CRH neurons to glucoprivic activation is subject to circadian influences mediated by other
inputs to the PVN neurons (126). Thus, while corticosterone secretion is

62 | Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

elicited by many different stimuli and by multiple pathways, catecholamine neurons appear to elicit the CRH/corticosterone CRR to glucose
deficit.

Stimulation of Adrenal Medullary Secretion by Glucose Decit


Adrenal medullary secretion of E is a crucial response to glucose deficit,
because circulating E rapidly and robustly mobilizes stored glucose and
preserves it for use by the brain by mobilizing and promoting uptake of
lipids as an alternative fuel for glucose in peripheral tissues. It additionally
suppresses insulin secretion, which reduces peripheral glucose uptake.
Adrenal medullary secretion is entirely dependent on neural activation by
sympathetic preganglionic neurons with cell bodies concentrated in the
intermediolateral column (IML) of the spinal cord between spinal levels
T7 and T10. These preganglionic neurons in turn are controlled by spinally projecting neurons from the brain. Evidence has been accumulating
to suggest that preganglionic neurons innervating the adrenal medulla are
directly controlled by and require hindbrain catecholamine neurons that
respond to glucoprivation. In rats, glucoprivation elicits intense activation
of the adrenal medulla in the absence of generalized sympathetic arousal.
Sympathetic preganglionic neurons between T7 and T10, retrogradely
labeled from the adrenal medulla for clear identification, as well as adrenal medullary cells themselves, heavily express c-Fos in response to 2DG
(127). In contrast, preganglionic neurons in other cord levels retrogradely
labeled from celiac or superior cervical ganglia express very little c-Fos in
response to 2DG.
Glucoprivic activation of adrenal medullary preganglionic neurons even
appears to be selective for those neurons that innervate adrenal medullary
E-secreting, as opposed to NE-secreting, chromaffin cells, as demonstrated
recently by in vivo intra-adrenomedullary dialysis of NE and E in freely
moving, unanesthetized rats (128, 129). Differential control of presumed
NE- and E-secreting cells in the adrenal medulla itself by presympathetic
motor neurons with distinct functional and electrophysiological characteristics has also been demonstrated (130). Those controlling E secretion
are strongly activated by glucoprivation but are insensitive to baroreceptor reflex activation, while those presumed to control NE secretion are
strongly stimulated by baroreflex activation, but unaffected by glucoprivation. The 2 types of supraspinal presympathetic neurons in this study
were also shown to have different latencies to respond to electrical stimulation of the rostral ventrolateral medulla. Those responding to baroreceptor
reflex activation responded with short latency, while those responding to

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glucoprivation had long latency responses and were largely unmyelinated. More recent work by has shown that separate populations of neurons respond to systemic glucoprivation and to baroreceptive stimulation
and that each population can be manipulated to produce specific glucose
or blood pressure responses (131). Thus, it appears that the physiological
responses of the adrenal medulla are narrowly tuned and tightly controlled by anatomically and physiologically discrete central neurons
driven by distinct sensory signals.
Hindbrain E neurons with cell bodies in C1-C3 and spinal projections
to sympathetic preganglionic neurons of the IML control the adrenal
medullary response to glucoprivation. Selective retrograde destruction
of these bulbospinal E neurons by intraspinal injection of the targeted
toxin, DSAP, abolishes the elevation of plasma E, as well as the hyperglycemic and adrenal medullary c-Fos responses to glucoprivation (106,
107). In addition, Madden et al (132) reported that injection of DSAP
directly into the C1 cell group severely impaired the adrenal medullary
response to systemic glucoprivation, further suggesting that the effects
of intraspinal DSAP injection were not due to nonspecific spinal damage
(as indicated also by the normal response of the controls injected with
unconjugated saporin). Together, these findings indicate that bulbospinal E neurons are required for the adrenal medullary response to glucoprivation and that the C1 cell group is of particular importance for that
response.
It is important to recall that the hindbrain neurons responsible for glucoprivic stimulation of the adrenal medulla do not require forebrain input
for activation by this stimulus, as indicated by experiments in decerebrate
rats (133). Nevertheless, forebrain neurons may contribute to the function
of these hindbrain neurons in the intact animal. For example, these neurons may be a final common path for adrenal medullary control that can
also be activated by other inputs, such as the VMN.

Afferent and Efferent Connections of Hindbrain


Catecholamine Neurons
A large body of work has provided information regarding the projections
of distinct groups of hindbrain catecholamine neurons (Figure 2-2). Less
is known regarding the afferent input to these neurons. The different clusters
of neurons are named A1, A2, A5, A6, A7 (NE groups) and C1, C2 and C3
(E groups). Importantly, neurons comprising each distinct grouping do
not necessarily innervate the same targets or participate in the same physiological processes. For example, A1 and A2 project only rostrally, A7 only

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A6

C3

C2

A7
A5

Feeding
Corticosterone response
Suppression of estrous cycles

C1

A2
A1

Adrenal medullary
response

Norepinephrine(NE) cell bodies


A1, A2, A5, A6, A7
Epinephrine (E) cell bodies
C1, C2, C3
FIG 2-2. Diagrammatic view of a sagittal section through rat brain showing the approximate locations of the hindbrain catecholamine cell groups and the trajectories of the groups
discussed in this review. Cell groups A1, A2, and C2 project rostrally. Cell group A7
projects spinally. Groups A5, A6, C1, and C3 project both rostrally and spinally. The spinal
projection from C1 arises from cell bodies concentrated in the most rostral portion of the cell
group, while the forebrain-projecting cells are located in the middle and caudal portions of
C1. Cell groups also project locally and innervate sites within the hindbrain and midbrain.
Catecholamine neurons are highly collateralized in their projection and innervation patterns
(134, 135). Black arrows show cell groups damaged by injection of the retrograde
immunotoxin, antidopamine-beta-hydroxylase saporin (DSAP), into the medial hypothalamus.
These include catecholamine neurons that stimulate feeding and secretion of corticotropinreleasing hormone and suppression of estrous cycles in response to glucoprivation (107,
108, 110). The gray arrow indicates neurons in rostral C1 that innervate sympathetic
preganglionic neurons in the intermediolateral column of the thoracolumbar spinal cord and
give rise to the adrenal medullary response to central glucoprivation. Cells in this location (and
other spinally projecting catecholamine cell groups) are damaged by intraspinal injection of
DSAP (107).

caudally; C1-3, A5, and the A6 complex contain subgroups of neurons,


some of which project rostrally and some caudally. As mentioned, neurons making up each group do not necessarily share the same function.
For example, the most rostral portion of cell group C1 contains neurons
that mediate cardiovascular responses to baroreceptor stimulation (131),

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whereas the central and caudal sections of C1 contain neurons that participate in adrenal medullary and feeding responses to glucoprivation.
These features underline the necessity for detailed phenotyping and tracing of anatomical projections of catecholamine neurons for correct assessment of their individual functions.
One common feature of most NE and E neurons is that they are highly
collateralized and distribute their terminals widely throughout the brain
or spinal cord. This makes them well suited for the rapid and highly
orchestrated control of diverse autonomic, behavioral, cognitive, and neuroendocrine responses necessary for survival of glucose deficit. In addition,
catecholamine neurons both innervate orexin cell bodies and coinnervate
many of the same terminal sites as orexin neurons (136). Although the
functional significance of this innervation pattern for glucose counterregulation is uncertain, this pattern is consistent with emerging evidence
suggesting that orexin neurons link homeostatic requirements to appropriate arousal and activity levels (60). Similarly, there is direct interaction
between NPY/AgRP neurons and NE and E neurons, which heavily innervate them. It is accepted that NPY/AgRP neurons play a pivotal role in
integration of metabolic signals and control of daily feeding and energy
homeostasis (137), functions that serve to avert metabolic crisis. Activation of catecholamine neurons by glucoprivation induces expression
of Agrp and Npy (138, 139), an effect one would expect to enhance feeding and other features of these neurons that would be supportive of glucorestoration. The induction of Agrp and Npy by glucoprivation requires
input to AgRP and NPY neurons from hindbrain catecholamine neurons and does not occur in animals in which the catecholamine innervation has been destroyed by DSAP injection. Thus, while NPY/AgRP
neurons are not required for glucoprivic feeding, hyperglycemic or corticosterone responses, activation of their circuitry by hindbrain catecholamine neurons may serve to potentiate feeding or other responses of
importance during acute glucoprivation. In addition, in the PVN DSAPinjected rat, the expression of both Npy and Agrp appears to be chronically
enhanced under basal conditions (139), possibly indicating a role for
these neurons in adaptation to or compensation for the partial loss (ie,
loss of the ascending component) of the catecholamine counter-regulatory
system. This adaptation may confer increased survival potential. These
interconnecting circuits linking NE/E neurons with orexin and NPY/AgRP
neurons provide potential avenues for linking daily feeding and arousal
mechanisms with the circuitry required for hypoglycemia counterregulation.

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Future Directions: Hindbrain Glucose Sensing


Hindbrain catecholamine neurons are required for key glucoregulatory
responses, including glucoprivic feeding, corticosterone secretion, adrenal medullary secretion, and the adaptive physiological response of suppression of estrous cycles. Future work is required to determine which
particular cell bodies are required for each glucoregulatory response.
When this is accomplished, work can then proceed to determine whether
these catecholamine neurons themselves are glucoreceptive or whether
they are activated indirectly by other hindbrain cell types (eg, astrocytes,
epenymocytes, or other neurons) that detect and signal glucose availability. In addition, the cellular mechanisms utilized for glucose detection and
the connections and circuitry of these neurons can then be established,
including those that may enable interaction with VMH and PMV systems
discussed in this review. Given the essential nature of these catecholamine neurons for glucose counter-regulation and homeostasis, it is clear
that a more complete understanding of their mechanisms of glucose sensing and circuitry is crucial for understanding HAAF and its pathogenesis
and prevention.

Unresolved Issues in Brain Glucose Sensing and Glucose


Counter-regulation
Several pieces of data discussed so far in this review appear to be contradictory. First, the data from cannula mapping studies indicate that feeding, adrenal medullary, corticosterone, and glucagon responses can be
elicited from the hindbrain by unilateral injections of nanoliter volumes
and doses of 5TG that are completely ineffective throughout the hypothalamus. In contrast, the authors have also discussed the fact that the VMH has
been studied extensively as an effective site for glucoprivic activation of
glucagon and adrenal medullary secretion and has been shown to contain
glucose-sensing neurons. These discrepant data encapsulate an important, but unresolved issue for which only speculative explanations can be
offered. For example, previous work has shown that restriction of ventricular fluid to the forebrain ventricles severely impairs or blocks the
hyperglycemic and feeding responses to lateral ventricle 5TG. Therefore,
perhaps the larger doses and volumes of the antiglycolytic agent administered into the VMH, compared to those used for hindbrain injections, allow
ventricular diffusion of the glucoprivic agent to hindbrain glucoreceptive
sites. Or, perhaps hindbrain and hypothalamic sites controlling these
responses possess glucose-sensing mechanisms that differ in their sensitivity

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to the magnitude or temporal development of the glucoprivic challenge, as appears to be the case with the PMV system. Specifically with
respect to adrenal medullary secretion, a lesion of descending catecholaminergic projections to the sympathetic preganglionic neurons abolishes the response to systemic glucoprivation. This suggests that VMH
activation of this response may be mediated by projections to hindbrain
catecholamine neurons. However, it is important to note that decerebration studies have shown that the forebrain is not required for the adrenal
medullary response to hypoglycemia. Specifically with respect to glucagon secretion, the authors have not found that DSAP injections reduce
systemic 2DG-induced glucagon secretion (S Ritter, 2012, unpublished
data). Although the direct effects on glucagon secretion of glucose and
insulin within the pancreas itself may obscure a diminished central effect
in an experiment of this type, these data also may indicate that the VMH
plays a predominant role in central control of glucagon secretion. Finally,
perhaps hindbrain and hypothalamic sites are differentially recruited for the
adrenal E response based on the overall energy needs of the body. For
example, the satiety hormones, leptin and insulin, mask the ability of
VMH GI and GE neurons, respectively, to respond to glucose deficit,
whereas fasting enhances activation of GI neurons by decreased glucose,
in part due to decreased leptin levels (40, 140). Thus one might speculate
that under normal energy balance, hindbrain catecholamine neurons
are dominant with regard to the adrenal E response. However, during
energy deficit, the VMH glucose sensors may be recruited to amplify the
response, potentially via projections to hindbrain catecholamine neurons.
This hierarchical activation for distinct central and peripheral glucose
sensors will be considered in more detail in the conclusion section of this
review. It will be important in future work to confront these apparent
discrepancies and to design incisive experiments to resolve them.

Portal-Mesenteric Vein Glucose Sensors


As with the CNS, peripheral glucose sensors are widely distributed throughout the body. These include the oral cavity (141), intestines (142), PMV
(143), and carotid body (144). Most of these are found along the alimentary canal and its associated vasculature, and they are generally associated with sensing elevations in glucose due to ingestion. However, 2
peripheral loci, the PMV and carotid body, have been implicated in
hypoglycemic detection. The carotid body, a polymodal sensor, has been
shown in vitro to respond to glucose, as well as pO2, pCO2, and pH. Its
role in vivo is less clear, with conflicting reports as to the importance

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of the carotid body in detecting insulin-induced hypoglycemia (145, 146).


In contrast, the role of the PMV in detecting hypoglycemia is established
and will be the focus of this discussion.
The concept that the periphery retains glucose sensors capable of
providing the CNS with information regarding the systemic glycemic status dates back to Mayers proposed glucostatic theory (13). Russek (147)
subsequently proposed the existence of hepatic glucoreceptors based on
the anorexic effect of glucose administered intraperitoneal (IP) and its
temporal relationship to portal glucose levels. Shortly thereafter, Niijima
(148) identified afferents in the hepatic branch of the vagus nerve that
were sensitive to portal vein glucose infusion. Additional evidence for
portahepatic glucose sensing would accrue over the next 2 decades,
which, along with the well known glucoregulatory efferent outputs
from the CNS, led to several proposals for the existence of various hepatichypothalamic axes controlling hepatic, pancreatic, and adrenal outputs
(147, 149, 150).

Portal-Mesenteric Glucose Sensors in Hypoglycemic Detection


Initially believed to be primarily involved in sensing the entry of ingested
glucose, evidence has since emerged for a significant role of PMV glucose
sensors in hypoglycemic detection. This was initially demonstrated using
the local irrigation technique in which portahepatic glycemia was selectively normalized via portal glucose infusion during systemic hypoglycemia achieved with a hyperinsulinemic-hypoglycemic clamp. The premise
of this approach is that normalizing glucose across a select region will
blind any critical glucose sensors to the prevailing systemic hypoglycemia
leading to suppression of the CRR. Utilizing this approach, it was shown
that normalizing portahepatic glucose during moderate systemic hypoglycemia (3.25 mM) resulted in a 42% suppression in the adrenal E response
to hypoglycemia (151). At deep hypoglycemia (2.5 mM), the effect of normalizing portal vein glucose concentration was even greater, with a 50%
to 73% suppression in E and 42% to 67% suppression in NE (7, 152).
Lamarche et al (153) confirmed the existence of portahepatic glucose sensors capable of detecting hypoglycemia, using a cross-perfusion technique
that allowed them to establish hypoglycemia across the portahepatis during systemic euglycemia. Despite anesthetic conditions known to blunt
the sympathoadrenal response, they demonstrated 2.5- and 3.5-fold increases
in adrenal E and NE output, respectively, from the adrenal gland during
selective portahepatic hypoglycemia. In addition, denervating just the
portal vein results in a suppressed CRR to insulin-induced hypoglycemia,

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quantitatively comparable to the local irrigation technique described


(154, 155).
PMV glucose sensors are particularly important in detecting slowonset hypoglycemia (ie, 1 mg/dL min-1)
PMV glucose sensors are
(12). When hypoglycemia develops slowly,
particularly important in
the absence of PMV glucose sensory input
detecting slow-onset
results in severely diminished sympathoadhypoglycemia (ie, 1 mg/dL
renal responses, achieving only 5% to 10%
min-1).
of normal. The compromised CRR during
slow-onset hypoglycemia in PMV-denervated
animals is accompanied by a substantial decrease in hindbrain neuronal
activation (156). In contrast, the brain appears fully capable of responding to very rapid decrements in blood glucose (ie, 2 mg/dL min1), in
the absence of portal-mesenteric vein glucose sensors (156). These findings are consistent with earlier studies that demonstrated a greater suppression of the catecholamine response to hypoglycemia when portahepatic
glucose was normalized during a slow-stepped clamp (7) as opposed to a
more rapid induction of hypoglycemia (152). The brains inability to detect
slow-onset hypoglycemia is further supported by studies of cognitive
function demonstrating significantly greater impairment when hypoglycemia develops rapidly versus slowly (157). From a clinical standpoint,
these observations are critical given the prevalence of slow-onset hypoglycemia. Physicians have long been aware that hypoglycemia generally
develops over hours in the clinic as opposed to the very rapid inductions
seen in the research setting. While quantitative data to support these
observations have been scarce, a recent report employing chronically
implanted sensors indicated that over 70% of all hypoglycemic episodes
developed at rates 1 mg/dl min-1[158], ie, rates where PMV glucose
sensors are critical for any significant CRR. Episodes that developed at
rates for which the brain appears independent of PMV glucose sensory
input (ie, 2 mg/dL min1) accounted for less than 10% of all hypoglycemic events.

Identifying the PMV Glucose-Sensing Locus


The precise locus for glucose sensors located in the portahepatic region
was long thought to be the liver itself (159). This is despite the fact that it
has been known for some time that the liver parenchyma of most species,
including the rat and dog, is poorly innervated by comparison with the
surrounding vasculature (160). That the locus for the portahepatic glucose sensors responsible for detecting hypoglycemia was actually in the

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portal vein was first reported by Hevener et al (20). By advancing the tip
of the portal cannula adjacent to the liver, they were able to selectively
elevate liver glycemia while maintaining the portal vein hypoglycemic.
When this occurred, there was no effect on the sympathoadrenal response
to hypoglycemia. Only when both the portal vein and liver were normalized, did they observe suppression of the sympathoadrenal response, as
reported earlier. This observation was confirmed when they demonstrated
that normalizing liver glycemia via the hepatic artery during systemic
hypoglycemia had no impact on the CRR (161). Consistent with a portal vein locus for hypoglycemic detection, several studies have demonstrated that selective denervation of the portal vein results in a suppressed
response to insulin-induced hypoglycemia (12, 154, 155). The findings of
Saberi et al (12) extended the locus to include the superior mesenteric
vein. While denervating the portal vein alone was shown to suppress the
adrenal E response by 61%, extending the denervation to include both the
portal and superior mesenteric vein led to 91% suppression. For adrenal
NE, portal-mesenteric denervation not only led to significantly greater
suppression when compared to portal vein denervation alone, it effectively
eliminated the slow-onset response to hypoglycemia. That the hypoglycemic sensing locus includes both the portal and superior mesenteric vein is
not surprising given that they are only distinguished by a single tributary
(ie, the gastrosplenic vein) and demonstrate similar rich innervation by
calcitonin gene-related peptide (CGRP) reactive nerve fibers (12).

The PMV-CNS Neural Axis


The neural axis by which hypoglycemic sensory information from the
PMV ascends to the brain has been the source of some confusion. Based
on the early and extensive work by Niijima (148, 162, 163), it has generally been assumed that this information is communicated by hepatic vagal
glucose sensitive afferents. This belief has been reinforced by the general
perception that vagal afferents communicate specific chemosensory information, while spinal afferents transmit mechanosensory and noicioceptive inputs. Thus, the concept that all glucose sensory information from
the viscera is mediated by vagal afferents remains firmly entrenched
(164). However, to date there is no evidence to support the role of vagal
afferents in the detection of hypoglycemia in vivo. Jackson et al (165,
166) were the first to address this by examining the effect of acute vagal
blockade upon the CRR. By cooling the vagus nerve to 2C, they effectively eliminated vagal transmission below the neck, but doing so had no
effect upon the CRR. Fugita et al (167) would subsequently show that

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sectioning the hepatic vagus nerve, the purported axis by which portal
vein glucose sensory information reaches the CNS, had no impact on the
sympathoadrenal response to hypoglycemia. Even when all vagal transmission below the diaphragm was eliminated via bilateral subdiaphragmatic vagotomy, the sympathoadrenal response to hypoglycemia remained
fully intact (167). That the glucose sensitive vagal afferents are not
involved in hypoglycemic detection is perhaps not surprising given their
linear response over a wide range of portal vein glucose values (ie, 0
to 28 mM). Increasing portal glucose values from 0 to 28 mM led to a
maximal suppression in hepatic vagal afferent firing rates of 23% to 87%
(148, 162). Extrapolating these findings to glucose concentrations that
define the transition from low euglycemia to deep hypoglycemia (ie, 4.0
to 2.5 mM), the projected increase in firing rate is only 2% to 6% across
the entire range. This modest change in firing rate is inconsistent with the
abrupt and substantial activation of sympathoadrenal output over the
same range of glucose values, leading to a 30-fold increase in plasma E.
While most investigators have focused on vagal glucose sensitive afferents, an earlier report by Schmitt (168) proposed the existence of spinal
glucose-sensitive afferents innervating the portahepatis. Based on the
observed firing rates for LH neurons responding to portal glucose infusion,
Schmitt demonstrated that both spinal transection at T5 and sectioning of
the splanchnic nerve were effective in eliminating the response to portal
glucose infusion, while sectioning both branches of the vagus failed to do
so. The portal vein is richly innervated by spinal afferents as denoted by
CGRP and substance P immunoreactivity (155, 160, 169), which are
largely eliminated by sectioning the celiac-superior mesenteric ganglion
(CSMG) or dorsal root rhizotomy at T8 to T13 (169, 170). Vagotomy, by
contrast, was ineffective in decreasing the content of either CGRP or substance P (SP) in the portal vein (169, 170). Sectioning the CSMG has also
been shown to induce marked blunting of the sympathoadrenal response
to hypoglycemia, indicative of a spinal origin for the portal vein glucose
sensors detecting hypoglycemia (167). Although some vagal afferents
originating from the celiac branch pass through the CSMG, this branching
occurs caudal to the subdiaphragmatic sectioning of the vagus nerve,
which was shown to have no effect on the sympathoadrenal response to
hypoglycemia. Topical application of capsaicin has been shown to substantially reduce CGRP reactivity in the portal vein and with it the ability
for hypoglycemic detection at the portal vein (12, 155). Capsaicin acts
through the transient receptor potential vanilloid receptor 1 (TRPV1)
receptor, which in the abdomen appears to be primarily associated with
spinal afferents, with little expression in vagal afferents (171). Thus,

72 | Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

hypoglycemic detection at the PMV appears to be mediated by spinal


afferents, which likely originate at the thoracic level of the spinal column (ie, T8 to T13).
Evidence has accrued for functional connections between select areas of
the CNS and the portal glucose sensors. Shimizu et al (6) reported that the
majority of identifiable glucose-sensitive neurons in the LH also demonstrated inhibition with portal glucose infusion. Adachi et al (172) reported
similar observations for glucose-sensitive neurons of the NTS, but constrained their observations to afferents arising from the hepatic branch of
the vagus nerve. Alternatively, Schmitt (173) reported the existence of LH
neurons that respond to portal glucose infusion, but appeared to be spinal
in origin. While she did not characterize the innate glucose sensitivity of
those neurons, she did note the existence of neurons demonstrating both
excited and inhibited responses to portal glucose infusion. In all cases,
these observations derive from very high concentrations of glucose infusates
(ie, 280 to 1700 mM) and thus may not be relevant to hypoglycemic detection. However, more recently it has been shown that hypoglycemiainduced Fos activation in the hindbrain (NTS and AP) is largely eliminated
by topical capsaicin treatment of the PMV (156). Suppression of the
sympathoadrenal response to hypoglycemia was also reported, consistent
with that observed with sectioning of the CSMG and distinct from that
observed with total subdiaphragmatic vagotomy (167). While these data
indicate a spinal axis for portal mesenteric glucose sensory input to the
CNS under hypoglycemic conditions, very little is known regarding the
anatomy of these neural connections. Presumably the critical portalmesenteric afferents traverse the CSMG with their cell bodies located
in the dorsal root ganglia at T8 to T13 (168). Berthoud (160) has suggested that the relevant dorsal horn projections may ascend via the spinosolitary and/or spinomesencephalic tracts to reach the NTS and parabrachial
nucleus.

Peripheral Glucose-Sensing Mechanism


In contrast to central glucose sensing neurons, there is little evidence that
peripheral nerves directly sense glucose. While it has recently been shown
that vagal neurons isolated from the nodose ganglia can respond to
changes in glucose concentration (170), all known peripheral glucose
sensory mechanisms involve transduction of the glucose signal by a primary sensory cell. The most extensively studied of these is the taste receptor cell, which translates an oral glucose load into an increased firing rate
of specific glossopharyngeal afferents. The mechanism involves glucose

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binding to the G-protein coupled sweet taste receptor, T1R2+T1R3, to


initiate an intracellular cascade that leads to the intracellular release of
Ca++, membrane depolarization, and release of ATP (141). ATP in turn
activates purinergic receptors located on the afferent nerve terminals that
project to the rostral portion of the NTS, where they synapse with neurons
projecting to higher levels of the CNS, as well as preautonomic neurons
projecting to the pancreas. Within the gut, select enteroendocrine cells
employ several glucose-sensory mechanisms to detect changes in the
luminal glucose concentration leading to the release of various neurotransmitters acting on local vagal afferents (175). The carotid body,
the only other peripheral glucose-sensing loci known to detect hypoglycemia, also utilizes a primary sensory cell (ie, the type 1 cell, a polymodal sensor that detects pO2, pCO2, and pH in addition to glucose
concentration). In the presence of low glucose concentrations, the type 1
cell releases ATP as its primary neurotransmitter that binds with purinergic receptors located on adjacent afferents. While no such primary
sensory cell has been identified for the portal-mesenteric glucose sensors, the patterns of innervation for the portal vein demonstrate similarities to the peripheral sensory loci described. That is, innervation of the
portal vein appears restricted largely to the adventitia surrounding the
vein, with some limited projections to the bilayer of smooth muscle
below (160, 169). There are no reports of any afferents projecting into
the lumen of the portal vein and thus positioned to directly detect portal
glucose concentrations.
While the specific mechanism for hypoglycemic detection at the portal
vein has yet to be elucidated, it is known that it is likely to involve the
catabolism of glucose. Matveyenko et al (176) demonstrated that selectively elevating portal vein lactate or pyruvate levels during insulininduced hypoglycemia led to a suppression in the sympathoadrenal
response comparable to that observed when normalizing glucose across
the portal vein. In contrast, portal infusion of the ketone -hydroxybutyrate
failed to impact upon the sympathoadrenal response under the same conditions. In support of the glucose selectivity of this sensor, GLUT2 knockout mice lack the ability to detect changes in portal vein glucose levels
(177). Even when GLUT2 levels are restored to normal in the liver,
GLUT2/ mice fail to respond to portal glucose infusions, confirming both
the glucose specificity and portal locus of the glucose sensor. Burcelin
(178) further reported that an intact glucagon-like peptide-1 (GLP 1) receptor
was required for portal glucose sensing. The significance of this for the
hypoglycemic condition where GLP-1 levels would be expected to be low
remains to be clarified.

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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

Translational Studies
The existence of portal-mesenteric glucose sensors has been confirmed in
several species (ie, rat, mouse, guinea pig, and dog), but attempts to confirm their existence in people have proven elusive. As with studies of the
brain, investigators are limited by ethical considerations in directly
accessing the portal-mesenteric vein of people. Several investigators have
attempted to circumvent this limitation by providing an oral glucose load
during a hyperinsulinemic-hypoglycemic clamp. Presumably, the oral
glucose load would work as a portal glucose infusion analogous to the
local irrigation approach. However, this oral glucose approach has yielded
inconsistent findings with reports of suppressed, elevated, and unaffected
CRR (179182). In the absence of portal vein glucose measurements,
explaining these differences remains largely speculative. What is clear is
that that most studies using this approach have demonstrated a sensory
response to the portal glucose load (180182). Further support for portalmesenteric glucose sensing in people derives from the work of Perseghin
et al (183), who reported that the CRR is diminished in people with denervated livers (ie, following liver transplantation). While much remains to
be done, the preponderance of evidence suggests that people, like all other
mammalian species studied to date, retain portal-mesenteric glucose sensors critical for hypoglycemic detection.

Future Directions: PMV Glucose Sensors


As the reader will undoubtedly have surmised, there is considerably less
known about the portal-mesenteric glucose sensors when compared with
those of the CNS. Further, much of what is known relates to the vagal
portal glucose sensors, which do not appear to be involved in hypoglycemic detection. Among the areas for future investigation, perhaps the most
obvious is the underlying mechanism for hypoglycemic detection at the
portal-mesenteric vein. If it mimics other peripheral glucose sensors, what
is the primary sensory cell? How is the glucose signal transduced? And
what is the neurotransmitter involved? Alternatively, if these spinal afferents detect glucose directly, is the mechanism similar to those proposed
for either the GE or GI neurons of the CNS? The specific spinal afferents
involved remain to be phenotyped, both chemically and functionally.
Tracing studies are required to ascertain the anatomical path by which
glucose sensory information from the portal-mesenteric vein ascends to
the hindbrain and beyond. Finally, the putative role of portal-mesenteric
glucose sensing in HAAF remains to be fully elucidated.

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Conclusion
In this review, the authors have presented what is known and some
of what is not known about the 3 primary glucose-sensing areas that
contribute to glucose counter-regulation. In doing so, the authors are
confronted with the fact that present data cannot fully explain how these
distinct glucose-sensing regions are activated, how they interact, or how
their functions are integrated to achieve and preserve glucose homeostasis. However, a very significant conclusion one can draw from analysis of
the specific CRRs discussed in this review is
A very signicant conclusion
that there are multiple glucose sensors that
one can draw from analysis of
operate under different physiological conthe specic CRRs discussed in
ditions. For example, both adrenal E and
this review is that there are
glucagon responses to glucoprivation are
multiple glucose sensors that
influenced by all 3 glucose-sensing regions
operate under different
discussed in this review, but it is apparent
physiological conditions.
that these multiple sites of control are not
equivalent. Rather, different sensors appear
to be activated to varying degrees as the threat posed by hypoglycemia to
the brain changes. When glucose levels decline slowly, the PMV is the
dominant system, with the brain playing a modulatory role. On the other
hand, as the rate of glucose decline increases, so may the relative contribution of the brain, such that, as shown by Saberi et al (12), at very
rapid rates of decline, it is the brain that claims the dominant role.
During rapid hypoglycemia, the hindbrain catecholamine neurons may
play a greater role than the VMN in adrenal E secretion, since ablating
these neurons abolishes the adrenal E response to hypoglycemia. In contrast, most studies indicate that while manipulations of the VMH reduce
or enhance adrenal E secretion by 50% or more, it is never completely
abolished. On the other hand, the VMN may be more important than the
hindbrain in the regulation of glucagon secretion. For example, preventing
increased GABA tone during HAAF may restore glucagon release during
hypoglycemia in diabetic rats in which the glucagon response was previously
considered to be irreversibly impaired even in the absence of HAAF (57).
These and other data point to a hierarchical organization of glucosesensing sites. The potential for hierarchical recruitment of different glucose-sensing areas would be energy-conserving, as glucose reserves would
be allocated judiciously as needed, rather than being wasted by premature
mobilization. Evidence has been reviewed that the PMV glucose sensors
are recruited during slow or modest declines in blood glucose. The fact that
the sensitivity of VMN receptors to glucose deficit appears to be dependent

76

| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

on prior metabolic state is also consistent with a hierarchical organization. Contribution of the VMN to hypoglycemia-induced adrenal medullary secretion appears to be enhanced when overall body energy stores are
low. The evidence for this is that the satiety hormones, insulin and leptin,
profoundly reduce the ability of VMN GE and GI neurons, respectively, to
sense decreased glucose in vitro, whereas fasting significantly enhances
the response of VMN GI neurons to decreased glucose (40, 140). This
hierarchical recruitment of glucose sensors could potentially enhance
both glucagon and sympathoadrenal responses as hypoglycemia becomes
a greater threat to the brain. This hypothesis has not been examined thoroughly. However, it would be reasonable to assume that a system with a
higher threshold for activation by glucose deficit than hypothalamic or
peripheral systems, perhaps with selective sensitivity to glucose availability, and with the ability to elicit a multisystem CRR, such as that provided
by hindbrain catecholamine neurons, would be required to avert or
respond to rapidly developing and profound glucoprivation.
Finally, HAAF may be caused by impaired glucose sensing or by impaired
CRR effector mechanisms. There is strong evidence showing that VMN
glucose sensors become impaired during HAAF (48, 80). Manipulations
that enhance glucose-sensitive signaling pathways in the VMH are associated with enhanced sympathoadrenal and glucagon responses to hypoglycemia, both in the control situations and during HAAF (10, 74, 82, 184).
Antecedent hindbrain glucoprivation also impairs adrenal E and glucagon
secretion (S Ritter, 2012, unpublished data). Similarly, antecedent hypoglycemia localized to the PMV impairs the CRR to slow-onset hypoglycemia
(185). Thus, impaired glucose sensing by any of these 3 key glucosesensing systems is implicated in the development of HAAF. This strongly
suggests that as the circuitry and neuronal phenotypes of VMN, hindbrain
catecholamine, and PMV glucose sensors are more fully revealed, they
will become important therapeutic targets for prevention of HAAF during
intensive insulin therapy.
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3. Cerebral Adaptation to
Recurrent Hypoglycemia
Rory J. McCrimmon, MD, MBChB, FRCP
Glin z, PhD

Abstract
Despite significant technological and pharmacological advancements, insulin
replacement therapy fails to adequately replicate -cell function, so achieving
near-normal glucose levels in type 1 diabetes mellitus (T1D) and long-duration
type 2 diabetes mellitus (T2D) is problematic. In particular, intensive insulin
therapy is frequently accompanied by recurrent hypoglycemia, and this leads
in turn to impaired hypoglycemia awareness and a markedly increased risk of
more severe hypoglycemia. In this review, the authors discuss how the brain
responds to repeated hypoglycemia and how these adaptations may explain, at
least in part, the development of impaired glucose counter-regulation in diabetes. The authors will discuss potential mechanisms that may contribute to the
development of reduced counter-regulatory responses in individuals with T1D
and long-duration T2D, including alterations in glucose uptake or metabolism
by the brain, the use of alternate fuels, changes in hypothalamic activated protein kinase (AMPK) activity and neurotransmitter release, as well as the
role of regulators of the stress response such as opiates and urocortin. Finally,
the authors propose that defective counter-regulation may actually result from
the brain adapting to repeated hypoglycemia and that through preconditioning,
recurrent hypoglycemia is inducing hypoglycemia tolerance.

Introduction
Banting et al (1) provided one of the first descriptions of hypoglycemia when
he wrote that the patient, .may first complain of hunger, or more often
of a sense of weakness or fatigue and, especially if it is his first reaction,
he is conscious of some anxiety, or of what he calls nervousness, or he
may even show the signs of a definite neurosis with loss of emotional
Acknowledgements: The authors thank the postdoctoral fellows, postgraduate students, technical staff, and volunteers who contributed greatly to the research that underpins this review.

Translational Endocrinology & Metabolism, Volume 3, Number 4, 2012 | 89

control, such as crying spells... This description of a symptom


complex is characteristic of hypoglycemia and would be recognized by all
endocrinologists in practice today as would the later recognition by physicians such as Lawrence (2) that in some individuals these symptoms may
change over time such that the reactions differ so much from the original that patients are dangerously unaware of their onset.
These classical descriptions of hypoglycemia illustrate two important
points. The first is that individuals with both T1D and T2D dislike the
experience of hypoglycemia. Severe hypoglycemia is feared as much for
its cognitive and emotional consequences as for its potential to result in
long-term physical and psychological morbidity (3). Secondly, symptomatic (and neuroendocrine) responses to hypoglycemia clearly change
over time, frequently leading to the development of impaired awareness
of hypoglycemia, a condition that markedly increases the risk of severe
hypoglycemia (4). This phenomenon is seen in individuals with both
T1D (5) and T2D (6). For instance, rates of severe hypoglycemia (requiring external assistance) in Tayside, Scotland, were 115 events per 100
patient years in individuals with T1D, and 35 events per 100 patient
years in patients with insulin-treated T2D (7). Therefore, in both T1D
and T2D diabetes, severe hypoglycemia is a major adverse consequence
of intensive diabetes management and relates, at least in part to, the
development of defective symptomatic and counter-regulatory responses
to hypoglycemia.

Hypoglycemia in Diabetes
Good glycemic control in both T1D (8) and T2D (9) diabetes reduces both
the incidence and progression of long-term microvascular complications.
However, outside of the clinical trial setting, it has been difficult to achieve
near-normalization of glucose levels in people with diabetes. In the Diabetes Control and Complications Trial for instance, less than 5% of subjects in the intensively treated arm maintained normal hemoglobin A1c
(HbA1c) levels (<6.1%, 43 mmol/mol), and the median HbA1c was
7.2% (55 mmol/mol), which is significantly above the nondiabetic range
(8). Normalizing glucose levels in T1D is challenging, because despite a
number of advances in insulin pharmacology and delivery systems, insulin therapy is still essentially a poor replacement for the healthy islet. At
the same time, even when euglycemia is achieved, it is difficult to do so
safely, because intensive insulin therapy results in a markedly increased
risk of severe hypoglycemia. Subjects who underwent intensive insulin
therapy overall had a threefold increased risk of severe hypoglycemia, and

90

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this risk increased with tighter glycemic control (10). Similarly in the United
Kingdom Prospective Diabetes Study) of individuals with newly diagnosed
T2D, hypoglycemia became limiting in the intensive therapy arm over
time and as a result median HbA1c levels rose to 8.1% (65 mmol/mol),
a point at which microvascular complications are more likely to develop
(9). In both these trials, it became clear that aggressive management of
T1D with insulin or of T2D with sulphonylureas or insulin was associated
with a significantly increased risk of severe hypoglycemia.
It is now recognized that hypoglycemia in diabetes results from more
than just the inadequacies of modern insulin replacement therapy. In fact,
despite the introduction of insulin analogues, continuous glucose sensors,
and structured education programs, the overDespite the introduction of
all rates of severe hypoglycemia remain
insulin analogues, continuous
essentially unchanged over the last 20 years
glucose sensors, and structured
(11). The risk of severe hypoglycemia in
education programs, the overall
T1D and longer-duration T2D results from
rates of severe hypoglycemia
reduced physiological responses (counterremain essentially unchanged
regulatory deficiency) as well as reduced
over the last 20 years.
symptomatic responses to hypoglycemia
(impaired hypoglycemia awareness). Impaired
hypoglycemia awareness affects around 25% of people with T1D (12),
and when present along with significant deficiencies in the counterregulatory response, markedly increases the risk of severe hypoglycemia
and has limited the ability to achieve good glycemic control. Figure 3-1
illustrates the profound disturbance of glucose homeostasis seen in individuals with T1D despite the technological advances in insulin replacement therapy.

Hypoglycemia Counter-regulation in Nondiabetic


Individuals
In nondiabetic individuals, insulin secretion from pancreatic -cells is
inhibited when glucose levels fall below 4.4 mM (80 mg/dL). This results
in loss of the repressive effect of insulin, -aminobutyric acid (GABA),
zinc, and other potential signaling molecules on -cell function (13), rapidly
increasing glucagon secretion (14) and leading to hepatic glycogenolysis
and gluconeogenesis. If glucose levels fall further (<3.8 mM, 70 mg/dl),
epinephrine and norepinephrine are released both from the adrenals and
directly into interstitial fluid from nerve terminals exerting a tonic influence on glucose levels by further suppressing insulin secretion, increasing
glucagon secretion, decreasing peripheral glucose utilization in muscle,

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FIG 3-1. Approximate glucose thresholds for hormonal counter-regulation during insulin-induced
hypoglycemia in nondiabetic individuals (left of axis) and T1D (right of axis) patients who have
undergone intensive insulin therapy. In individuals with T1D, failure to suppress endogenous
insulin secretion, loss of alpha-cell glucagon secretion, and increased threshold (lower glucose)
for counter-regulatory hormone secretion markedly increase their risk of severe hypoglycemia.

increasing lipolysis in fat, and stimulating glycogenolysis and gluconeogenesis (15). Additional responses that are more important as initiators of the
adaptive response to hypoglycemia, but that do not appear to contribute
significantly to the acute response include growth hormone (GH) and
cortisol secretion, which occur below 3.8 mM (70 mg/dL) and 3.2 mM
(60 mg/dL) glucose, respectively (16, 17). These stimulate lipolysis, ketogenesis, and gluconeogenesis. For nondiabetic healthy individuals, the
counter-regulatory response has several fail safes (redundancy), meaning
that hypoglycemia is rarely experienced and only tends to occur during
starvation or ultraendurance sports.
Maintaining glucose homeostasis requires the integration of various
glucose-sensing (GS) systems in both the periphery and central nervous
system (CNS). Fluctuations in peripheral glucose are detected by GS

92 | Translational Endocrinology & Metabolism: Hypoglycemia Update

neurons in the oral cavity, gut, portal/mesenteric vein (PMV), and carotid
body (18). PMV neurons detect changes in blood glucose prior to entry
into the liver from the gut. This information is then relayed through the
vagus nerve and spinal cord to the hindbrain, and from there to higher
brain centers such as the hypothalamus (18). In addition, the hypothalamus, due to its location adjacent to the third ventricle and median eminence, may sample factors from peripheral circulation, including glucose
as well as hormones such as insulin and leptin. It is therefore likely that
within this network glucose and whole-body energy homeostasis are also
integrated, allowing the body to better maintain fuel supplies to essential
organs.

Hypoglycemia Counter-regulation in T1D and T2D


The physiology of abnormal hypoglycemia counter-regulation has been
reviewed extensively (19, 20). Three hallmarks of hypoglycemia counterregulation in T1D are: the inability to reguHallmarks of hypoglycemia
late insulin during hypoglycemia, the loss
counterregulation in type 1
of glucagon secretion in response to hypodiabetes are: the inability to
glycemia in almost all individuals with
regulate insulin during
T1D within a few years of diagnosis, and
hypoglycemia, the loss of
reduced autonomic (catecholaminergic and
glucagon secretion in response
symptom) responses to hypoglycemia in
to hypoglycemia, and reduced
response to repeated exposure to hypoautonomic responses to
glycemia (Figure 3-1). For incompletely
hypoglycemia.
understood reasons, glucagon secretion to
hypoglycemia is markedly diminished with
increasing duration of diabetes, and this occurs in both T1D (21) and
advanced T2D (6). Interestingly, glucagon responses to other stimuli such
as amino acids and exercise persist in T1D, and epinepohrine-induced
glucagon secretion is enhanced, indicating that -cells are still functional
and that this is a defect that is specific to hypoglycemia (21). This defect
is thought to arise primarily from an intraislet abnormality, because loss
of glucagon secretion closely follows decline in c-peptide levels (22). In
this case, -cell loss means that local insulin, zinc or GABA levels are not,
as they would be normally, suppressed (switched off) by hypoglycemia,
allowing for persistent tonic inhibition of the -cell. Other potential contributory factors include a reduced central stimulus to glucagon release as
well as the possibility of a local islet sympathetic neuropathy. More detailed
reviews of this area and the factors affecting -cell glucagon release are available elsewhere (23, 24). The loss of these 2 fundamental mechanisms for

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maintaining glucose, however, does mean that individuals with T1D are
very reliant on protective catecholaminergic responses to hypoglycemia.

Abnormal Catecholamine Secretion


Importantly, during total insulin deficiency, control of hepatic glucose
output during hypoglycemia and exercise is mediated primarily by catecholamines rather than glucagon (25); thus maintenance of this response
is critical. In nondiabetic subjects, when glucose levels fall into the range
of 3.6 to 3.9 mM (65 to 70 mg/dL), epinephrine and norepinephrine are
released from the adrenals and directly into
In the majority of individuals
interstitial fluid from nerve terminals, and
with type 1 diabetes the
this exerts a tonic influence on glucose levels
catecholamine response is
by further suppressing insulin secretion,
reduced in magnitude and
increasing glucagon secretion, and decreasactivated at a lower glucose
ing peripheral glucose utilization in muscle
concentration by 10 years
and increasing lipolysis in fat. In the majordisease duration.
ity of individuals with T1D this response,
when compared with nondiabetic individuals, is reduced in magnitude and activated at a lower glucose concentration by 10 years disease duration (5). A similar finding in individuals with
long-duration T2D has also been reported (6). As for glucagon, epinephrine responses to other stimuli such as exercise persist (25).
A number of factors may contribute to a reduced catecholaminergic
response during hypoglycemia in T1D and T2D. While it is possible, for
instance, that reduced catecholamine synthesis and release (particularly
adrenal) contribute to defective hypoglycemia counter-regulation, the
overwhelming evidence indicates that this defect results primarily from
reduced autonomic stimulation of catecholamine release. Adrenal output
is under the control of the autonomic nervous system, which is, in turn,
regulated by various physiological and pathophysiological stimuli (26). Of
the physiological stimuli, hypoglycemia itself appears to exert a profound
affect on the autonomic nervous system. A single episode of hypoglycemia is sufficient to induce defective epinephrine (and glucagon) secretion
to a subsequent bout of hypoglycemia in healthy people (27). This phenomenon has also been reported in various vertebrate models (rhesus
monkey, dog, rat, and mouse) (2731), indicating that its occurrence is
highly conserved among different species. Moreover, exposing the whole
hypothalamus, but not the hindbrain (32) to recurrent hypoglycemia
induces defective counter-regulation, indicating that this adaptation
results from changes that occur within forebrain regions critical to the

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detection of hypoglycemia and initiation of a counter-regulatory defense


response.

Cerebral Adaptations to Recurrent Hypoglycemia


The landmark study of Heller and Cryer (27) established that a single
episode of antecedent hypoglycemia resulted in reduced symptom and
hormonal counter-regulatory responses during a second, subsequent
episode of experimental hypoglycemia. This phenomenon has now been
demonstrated in individuals with T1D (33), as well as in the rat (30)
and mouse (29), indicating a response to hypoglycemic stress that is
probably evolutionarily conserved. Moreover, both the depth (34), duration (35), and frequency (33, 36) of antecedent hypoglycemia correlate
with the magnitude of the ensuing counter-regulatory deficit, and the defect
resolves over time if the hypoglycemic stimulus is not repeated (37, 38).
Several studies have confirmed that changes in key hypothalamic regions
are central to the development of defective counter-regulation following
repeated hypoglycemia (20). GS mechanisms critical to the detection of
hypoglycemia by specialized neurons in
The depth, duration, and
the brain have been reviewed elsewhere
frequency of antecedent
in this issue (see the article by VH Routh,
hypoglycemia correlate with
CM Donovan and S Ritter [Chapter 2]) and
the magnitude of the ensuing
appear to show many parallels with the
counter-regulatory decit, and
pancreatic -cell, in particular the importhe defect resolves over time if
tant roles for glucokinase (GK), adenothe hypoglycemic stimulus is not
sine triphosphate (ATP)-sensitive potassium
repeated.
channels (KATP), AMPK and the inhibitory
neurotransmitter GABA. Exposing hypothalamic GS regions in rats to recurrent glucoprivation induces a left shift
in the glucose responsiveness of ventromedial hypothalamic (VMH) GS
neurons (ie, not hyperpolarized until glucose levels fall further) (39).
These findings, among others, suggest that altered hypothalamic glucose
sensing may underpin the development of defective counter-regulatory
responses to hypoglycemia in T1D.
Several mechanisms have been suggested to explain the neural malfunctions that develop to mediate defective counter-regulation (summarized in
Figure 3-2). These include an increase in glucose (40, 41) or lactate (42)
uptake, increased glycogen storage (supercompensation) (43), increased
intra-cellular metabolism of glucose through GK (44) or down-regulation
of AMPK activity (45), altered hypothalamic GABA tone (46), and suppression by corticosteroids (47) or urocortin 3 (48). However, the literature in

Cerebral Adaptation to Recurrent Hypoglycemia

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Increased glycogen
content/ lactate
metabolism

Increased glucose
uptake/ utilization

Reduced AMPK
activation

Failure to suppress
GABA

Recurrent Hypoglycemia

Increased opioid
regulation of GS
neurons

Enhanced UCN3/ GC
mediated suppression
of GS neurons

Altered serotonin

FIG 3-2. Potential mechanisms through which recurrent hypoglycemia leads to defective glucose
sensing in key brain regions. Several mechanisms have been proposed that may contribute to the
development of defective glucose sensing following recurrent hypoglycemia. Generally, research
has focused on increased fuel metabolism or uptake, enhanced suppression of the stress
response, or altered neurotransmitter release. This list is not exhaustive, and other mechanisms
have also been proposed. Research has largely been conducted in animal studies, and a clear
picture of the molecular mechanisms that leads to defective glucose sensing has yet to emerge.

this area is at best mixed, and as yet, no clear explanation for this phenomenon has emerged (20).

Role of Glucose Transport/Metabolism


A potential explanation for defective hypoglycemia counter-regulation is
that the local or regional uptake or metabolism of glucose by GS neurons
is enhanced following recurrent hypoglycemia (RH). Evidence from rat
models has shown that prolonged hypoglycemia or RH increases GLUT1 and
GLUT3 expression, raises glucose levels, and enhances glucose uptake in
brain (4951). In addition, RH increases GK mRNA (39) and may enhance
hexokinase activity (52) in the hypothalamus, while direct pharmacological
enhancement of VMH GK activity suppresses the counter-regulatory response
to hypoglycemia (53). Increased glucose uptake and metabolism would
provide better support for intra-cellular energy status, but also reduce the
sensitivity of GS neurons to hypoglycemia if this is an ATP/adenosine
diphosphate (ADP)-dependent mechanism. This is an attractive hypothesis,
but not all studies have observed enhanced brain glucose uptake. Additionally, it is not clear why there should be regional differences (hypothalamic
vs hindbrain) in this adaptation to RH.

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Human studies on glucose transport and metabolism following RH are


inconsistent. Boyle et al (41) examined whether subjects with T1D and
impaired hypoglycemia awareness maintained normal glucose uptake
during insulin-induced hypoglycemia and that this might explain markedly
reduced sympathoadrenal activation. They examined whole-brain glucose
uptake at plasma glucose concentrations of 5.8 mmol/L (105 mg/dL) and
3.0 mmol/L (54 mg/dL) in 24 patients with T1D, stratified into 3 groups
according to their glycosylated hemoglobin values, and compared the values for brain glucose uptake with those measured in 15 nondiabetic subjects at plasma glucose concentrations of 4.2 mmol/L (85 mg/dL) and 3.1
mmol/L (55 mg/dL). They reported that uptake of glucose in the brain
(calculated as the uptake during hypoglycemia minus the uptake during
normoglycemia) did not change in those T1D subjects who had the lowest
glycosylated hemoglobin, whereas glucose uptake fell in the other 2 T1D
cohorts. Moreover, plasma epinephrine and symptom responses were
lowest in the group with the lowest glycosylated hemoglobin values. This
led the investigators to conclude that preservation of normal glucose
uptake in the brain in intensively treated T1D preserves cerebral metabolism, reduces the responses of counter-regulatory hormones, and causes
an unawareness of hypoglycemia.
In contrast, in a subsequent study of nondiabetic subjects using positron emission tomography (PET), 24 hours of interprandial hypoglycemia
(approximately 55 mg/dL, 3.0 mmol/L) were found to significantly reduce
plasma epinephrine, neurogenic symptoms, and other responses to subsequent hypoglycemia, but global rates of blood-to-brain glucose transport,
cerebral glucose metabolism (as assessed by [1-11C]glucose PET) and cerebral blood flow (as assessed by [15O]water PET) were virtually identical
(54). Similarly, a study of diabetic patients with hypoglycemia unawareness
did not reveal any differences in global fludeoxyglucose (FDG) uptake rates
by PET relative to hypoglycemia-aware patients in response to hypoglycemia (2.6 mmol/L) (55). Together, these data did not support the hypothesis that recent antecedent hypoglycemia increases blood-to-brain glucose
transport during subsequent hypoglycemia. In all the previously mentioned
human studies, however, the focus on whole brain blood-to-brain glucose
transport means that regional variations in glucose uptake and metabolism cannot be excluded. A reanalysis of the Cranston et al (55) data uncovered blunted regional responses in FDG uptake to hypoglycemia in
hypoglycemia-unaware patients, particularly in the amygdala and frontal
cortex (56). Differences in regional activation patterns with hypoglycemia
unawareness were further investigated in later neuroimaging studies. For
example, Albelaez et al (57) utilized [15O]water PET to measure cerebral

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blood flow (CBF) as a surrogate of regional synaptic activation in healthy


volunteers subjected to 24 hours of interprandial hypoglycemia (3.0 mmol/L).
This study reported increased thalamic activation associated with impaired
hypoglycemia awareness, which indicated that the thalamus may play an
inhibitory role in reducing counter-regulatory responses to hypoglycemia
following recurrent hypoglycemia. In contrast, a more recent study, which
similarly measured regional CBF, but by arterial spin-labeling magnetic
resonance imaging, reported a blunting of thalamic activation in response
to hypoglycemia in patients with T1D and hypoglycemia unawareness
relative to healthy controls (58). This study further reported a positive
correlation between thalamic activation and epinephrine response to
hypoglycemia, supporting the notion that this brain region is involved in
the coordination of the counter-regulatory response to hypoglycemia.
While some of the findings were contradictory, these studies together
underlined the importance of studying regional brain responses to hypoglycemia when investigating the mechanisms of impaired awareness of
hypoglycemia in the human brain. Also note that the hypoglycemia levels
utilized in all the human studies mentioned ranged from 48 to 65 mg/dL,
and the period of data acquisition for glucose uptake and CBF measurements was somewhat different between different studies. A picture
is slowly emerging where different brain networks are activated sequentially and at different levels of hypoglycemia, which is critical to keep
in mind when comparing findings from different studies with different
designs (58).
Regarding cerebral glucose metabolism, a [11C]-methyl-glucose PET
study of patients with T1D by Bingham et al confirmed the finding of earlier studies regarding a lack of a difference in global glucose transport
with hypoglycemia unawareness. However, a difference in the global cerebral rate for glucose utilization (CMRglc) at hypoglycemia between aware
and unaware patients was detected (59). Namely, CMRglc rose upon induction of hypoglycemia in the aware subjects, while it fell in unaware subjects. More recently, Henry et al (60) used 13C nuclear magnetic resonance
(NMR) spectroscopy to measure cerebral oxidative metabolic rate of
glucose (CMRglc, ox) in the occipital cortex in a small group of individuals
(n=5) with T1D and hypoglycemia unawareness (HbA1c <7.5% and
self-reported hypoglycemia unawareness/biochemical hypoglycemia) and
compared this with nondiabetic control subjects (n=5). All subjects were
infused intravenously with insulin, 13C glucose, and somatostatin in order
to achieve stable glucose plateaus of 200 mg dL1, and CMRglc, ox was
measured from time courses of 13C label incorporation from glucose into
glutamate. In this study, metabolic fluxes between control and diabetic

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patients with hypoglycemia unawareness did not differ, indicating no overall


difference in the rate of glucose oxidation in the brain, which was consistent with the Bingham et al study, where no differences in CMRglc were
detected between aware and unaware patients at euglycemia. A previous
NMR study by the same group (61) had reported higher steady-state glucose levels in a similar population of subjects with T1D, and as such, the
authors interpreted their current findings as indicating an overall increased
rate of glucose transport in the unaware T1D population. Although an
attractive speculation, this study provides limited support of the hypothesis.
Subjects were not studied under hypoglycemic conditions when defective
glucose counter-regulation occurs. Additionally, this study focused on the
occipital cortex, whereas imaging studies (as discussed previously) have
suggested that there are significant regional differences in the brains
response to hypoglycemia. Both issues will be addressable in future NMR
investigations. Namely, a recent study by van de Ven et al demonstrated
the feasibility of obtaining cerebral glucose metabolic rates using similar
13C NMR methods under hypoglycemia (62). In addition, advanced NMR
methods were recently implemented at ultrahigh magnetic fields to assess
neurochemical concentrations with high sensitivity in regions other than
the occipital cortex (63).

Role of Alternate Fuels


It has also been suggested that alternate fuels, particularly a switch from
glucose to lipid metabolism and/or enhanced glycogen stores may contribute to defective counter-regulation (42, 43, 64). In the brain, glycogen
is found in relatively small amounts in astrocytes. It is mobilized during
energy stress and may be released as the transportable lactate, which can
support neuronal activity (65). In animal models, hypoglycemia depletes
brain glycogen content (43, 6668), indicating that glycogen is utilized
and may act as a temporary energy source. Furthermore, in mouse (67)
and rat (49) models of recurrent hypoglycemia, there appears to be an
increase in brain glycogen stores (67) and rate of glycogen resynthesis
after hypoglycemia (49), at least temporarily. A similar increase in the
rate of glycogen synthesis after hypoglycemia has also been observed following a single episode of hypoglycemia in the rat brain using 13C NMR
(43). This suggests the possibility of glycogen supercompensation following one or more bouts of hypoglycemia. An increase in available glycogen
might be expected to provide more energy substrates during subsequent
hypoglycemia. Consistent with this hypothesis, increased brain glycogen
concentration in rats treated with an inhibitor of glycogen phosphorylase

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supports neuronal activity on the initiation of hypoglycemia (65). Such an


outcome might be expected to delay the responses of GS neurons to hypoglycemia and impede initiation of the counter-regulatory response. In support of this notion, Alquier et al (45), using a model of repeated third
ventricle 2-deoxyglucose injection to induce recurrent glucoprivation,
observed elevated hypothalamic glycogen levels, which correlated with
delayed activation of AMPK. This suggests that the mobilization of glycogen on induction of glucoprivation and suppressed local AMPK activity
may be linked to delayed detection of glucoprivation (45). It is important
to note that other studies have failed to find this glycogen supercompensation, and in rodents, brain glycogen represents a small substrate
pool compared with muscle or liver (49). Moreover, elevation of brain
glycogen levels after hypoglycemia was not persistent, and levels returned
to baseline when counter-regulatory responses were still defective in
mice (49).
Human studies on the involvement of brain glycogen in the hypoglycemia response revealed similar findings to those in rodents. Currently 13C
NMR is the only method to detect human brain glycogen and assess its
turnover in vivo (69, 70). Using this methodology, in combination with
long-duration intravenous infusions of [1-13C]glucose (up to 50 hours),
glycogen content in the human brain was found to be similar to that
reported in the rodent brain, at 3 to 5 mol/g, ie, three- to fivefold higher
than free glucose in the brain at euglycemia (71, 72). This glucose stored
in the form of glycogen turns over very slowly, with complete turnover of
bulk human brain glycogen requiring 3 to 5 days (71). As in rodents, the
human brain mobilizes glycogen during moderate hypoglycemia (55 to
60 mg/dL) and increases its glycogen synthesis rate after a single episode
of hypoglycemia compared to that after euglycemia, suggesting glycogen
supercompensation (73). Together with the slow glycogen turnover and
the known 2- to 3-week period of hypoglycemia avoidance necessary
to reverse hypoglycemia unawareness in T1D, these studies support the
hypothesis that supercompensated brain glycogen may contribute to the
development of impaired awareness of hypoglycemia by providing additional fuel to the brain during subsequent hypoglycemic episodes. If so,
one might expect that patients with T1D and hypoglycemia unawareness
have supercompensated brain glycogen levels. However, brain glycogen
content is not higher in patients with T1D and hypoglycemia unawareness relative to healthy controls (72). Note, however, that diabetes itself
might have had confounding effects on the results of this study. Future
studies where hypoglycemia unawareness is induced in healthy volunteers can better elucidate the impact of recurrent hypoglycemia on brain

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glycogen metabolism and its potential involvement in the development of


this unawareness.
Lactate has been proposed as another alternative fuel that may contribute to the development of impaired awareness of hypoglycemia. Lactate
infusions have been shown to diminish symptoms and counter-regulatory
responses and rescue brain function during hypoglycemia (74, 75). Consistently, animal studies have demonstrated increased lactate uptake by
the brain during hypoglycemia (76). Furthermore, lactate perfusion of
the ventromedial hypothalamus suppresses counter-regulation in rodents
in the setting of systemic hypoglycemia (77). These findings led to the
hypothesis that an upregulation of monocarboxylic acid transporters
(MCTs), which transport lactate and other monocarboxylic acids into
the brain, following recurrent hypoglycemia, may provide the brain with
additional substrate during subsequent hypoglycemic episodes, contributing to the development of hypoglycemia unawareness. To test if an upregulation of MCTs contributes alternative substrates to the brain during
hypoglycemia, Mason et al utilized 13C NMR in conjunction with [2-13C]
acetate infusions as a surrogate for other monocarboxylic acids (42). They
observed higher acetate transport in patients with T1D and hypoglycemia
unawareness relative to healthy controls and concluded that upregulated
MCTs may play a major role in maintaining cerebral energy metabolism
during hypoglycemia in these patients. A later rodent study by the same
group supported this conclusion by showing a greater relative contribution by acetate to total oxidative metabolism during hypoglycemia following
recurrent hypoglycemia (78). If recurrent hypoglycemia indeed induces a
shift from glucose to lactate utilization by the brain and if increased lactate uptake contributes to the development of impaired hypoglycemia
awareness remain to be determined. It should also be noted that lactate
administration primarily reduces the epinephrine response to hypoglycemia, rather than the generalized impairment in counter-regulatory hormone secretion seen in hypoglycemia unawareness (75).

Role of AMPK
AMPK is an ancient serine/threonine kinase that plays a critical role in
mediating cellular responses to energy deprivation (79). This makes it an
ideal candidate in any GS system. Certainly, loss of the alpha-2 isoform of
the catalytic subunit of AMPK leads to complete loss of GS capability in
pancreatic beta-cells (80), cultured hypothalamic GS neurons (81), and
hypothalamic proopiomelanocortin/agouti-related peptide POMC/AgRP
neurons (82). Direct pharmacological activation of AMPK, specifically in

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the VMH, augments the counter-regulatory response to hypoglycemia (83),


whereas suppression of VMH AMPK activity attenuates this response (84).
Importantly, recurrent hypothalamic glucoprivation leads to suppressed
AMPK activity (45), while pharmacological activation of VMH AMPK
enhances counter-regulation in rats with defective counter-regulation
(85) and in a rat model of T1D (83). Consequently, direct suppression of
AMPK by enhanced metabolism (such as increased lactate release from
glycogen stores in astrocytes) or an upstream modulator of AMPK activity may contribute to defective counter-regulation. A possible scenario
is that following recurrent hypoglycemia, neuronal AMPK activation is
delayed, which in turn modifies GS neuron responses to hypoglycemia,
resulting in altered synaptic transmission and diminished counter-regulatory
hormone release. However, the phenotype of the neurons associated with
AMPK activation and altered counter-regulation have yet to be determined;
nor has it been shown that prevention of the down-regulation of AMPK
activity in response to recurrent hypoglycemia prevents the development
of defective glucose counter-regulation.

Role of Hypothalamic Neurotransmission


GABA is the major inhibitory neurotransmitter in the CNS and is extremely
important for mediating fast changes in synaptic transmission. In rodent
models, local VMH perfusion of bicuculline to block GABAA receptors amplifies, whereas stimulation of GABAA receptors with muscimol suppresses,
hypoglycemia counter-regulation (86). Moreover, as in the pancreatic betacell, GABA release may be regulated by KATP channels (87), suggesting
that, functionally, KATP channels are upstream of GABAA receptors (ie on
the presynaptic, GABA-secreting neurons). It has been shown that although
acute hypoglycemia decreases VMH GABA levels, repeated hypoglycemia
prevents the fall in GABA (46), and diabetic BB and streptozotocin (STZ)induced diabetic rat models have increased basal GABA levels in the VMH.
This was associated with increased expression of the GABA-synthesizing
enzyme, GAD65, specifically in the VMH. These suggest that KATP-positive
VMH (glucose-excited [GE]) neurons may be GABAergic and that, following recurrent hypoglycemia, these neurons may fail to hyperpolarize in
response to subsequent hypoglycemia. In this model, suppressed counterregulatory responses to hypoglycemia resulting from either diabetes or
recurrent hypoglycemia are a direct result of a relative increase in GABAergic neurotransmission. Interestingly, the VMH GABAergic neurons are
spatially separated from glutamatergic neurons, the main excitatory neurotransmitter in the CNS. Most GABAergic neurons are located in the arcuate

102 | Translational Endocrinology & Metabolism: Hypoglycemia Update

nucleus (ARC) and encapsulating the VMH, where they surround the
glutamatergic neurons (88). Glutamate acts on NMDA, AMPA and kainate
receptors, which are also required for glucose counter-regulation (88), as
ablation of the vesicular glutamate transporter VGLUT2, causes fastinginduced hypoglycemia via defective glucagon secretion (88). This study
induced genetic loss of VGLUT2 in steroidogenic factor-1 (SF-1) neurons.
SF-1 neurons are essential for the development for the mediobasal hypothalamus and are a reasonably specific marker for the VMH. The exact functional
relationship between the GABAergic and glutamatergic neurons and how
this regulates the counter-regulatory response remain to be determined.
These rodent studies raised the possibility that blocking GABA-mediated
inhibition of the counter-regulatory response to hypoglycemia might restore
normal counter-regulatory responses. In a pilot study in healthy, nondiabetic human subjects, Smith and colleagues (89) examined the counterregulatory responses to acute hypoglycemia following the ingestion of
placebo or modafinil, an agent used in narcolepsy that reduces GABA
activity. They reported that autonomic symptom scores and heart rate
were significantly higher with modafinil, while deterioration in performance of 2 cognitive tasks (Stroop and reaction time) was reduced, but
that modafinil had no effect on the counter-regulatory responses to hypoglycemia. The mode of action of modafinil is unclear, however, and it may
act on a number of neurotransmitters. Modafinil also affects monoamine
release and may have been acting directly on sympathetic nerve terminals
and the adrenal gland to enhance catecholamine release. Another recent
study showed that antecedent pharmacologic activation of GABAA receptors with alprazolam blunts neuroendocrine and autonomic nervous system (ANS) responses during next-day hypoglycemia in healthy people
(90), providing support for a role of the GABAergic system in the regulation of the counter-regulatory response. However, the potential for GABA
modulation to amplify counter-regulatory responses to hypoglycemia has
not really been tested in human subjects, although given the importance
of GABA inhibition to many varied neural networks, it seems likely that
selective hypothalamic modulation would be required.
More recent evidence has also suggested that the monoamine neurotransmitter serotonin is involved in counter-regulatory responses. A recent
study in rats has shown that the selective serotonin reuptake inhibitor
(SSRI) sertraline augments epinephrine, norepinephrine, and glucagon
responses to hypoglycemia and prevents blunted epinephrine responses
following RH (91). Furthermore, studies in nondiabetic and T1D patients
have demonstrated a similar amplification of catecholamine responses
following SSRI treatment, although no change in glucagon secretion was

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observed (92). Importantly, these studies demonstrated that muscle


sympathetic nerve activity was enhanced by SSRI treatment, indicating
that enhancement of counter-regulation is mediated, at least in part, by
central mechanisms (92). It should be noted that, contrary to the previously mentioned reports, isolated case studies have demonstrated that
some patients have experienced rapid increases in hypoglycemia frequency
resulting in impaired hypoglycemia awareness on commencement of
SSRIs (93). Thus whether modulation of this neurotransmitter system is a
feasible therapeutic target requires further research.

Role of the Hypothalamic-Pituitary-Adrenal Axis


A series of excellent studies from the Nashville group suggested a major
role for glucocorticoids in the development of defective counter-regulation
following antecedent hypoglycemia (47, 9496). An antecedent rise in
plasma cortisol in human subjects mimicked the effect of antecedent
hypoglycemia to induce defective hormonal counter-regulation (94, 95).
Animal studies suggested this mechanism occurred via central glucocorticoid
receptors in rats (47, 96). However, subsequent studies in human subjects
(97, 98) contradicted these findings, while another groups animal studies
argued instead for a role for corticotrophin-releasing hormone (CRH) (99).
CRH and urocortins 1 to 3 (UCNs 1 to 3) are important regulators of the
neuroendocrine stress response and function through their actions at the
CRH-R1 and CRH-R2 receptor subtypes, respectively. CRH via the CRH-R1
amplifies, whereas UCNs 1 to 3 through the CRH-R2 suppresses the
counter-regulatory response to hypoglycemia (48). Furthermore, the VMH
and tuberal area of the hypothalamus are densely innervated by UCN-3
nerve terminals, which arise from regions such as the medial amygdalar
nucleus (MAN) (100). UCN-3 action in the VMH blunts glucose sensing,
as priming GS neurons with UCN-3 lowered the glucose threshold for
altering their electrical activity, such that glucose levels had to decline
further before any significant change in membrane potential occurred
(48). The MAN expresses GK, although the GK-expressing neurons are
exclusive of UCN-3 mRNA, suggesting that the UCN-3 neurons may not be
directly glucose sensing. Furthermore, local glucoprivation in the MAN
does not elicit a counter-regulatory response, although MAN glucoprivation during mild systemic hypoglycemia amplifies the response, suggesting that the MAN does influence the counter-regulatory response (100).
At present, it is not known whether the MAN is directly involved in the
development of impaired hypoglycemia awareness (IHA) or indeed what
signals activate the UCN-3 neurons that project to the VMH.

104

| Translational Endocrinology & Metabolism: Hypoglycemia Update

Interestingly, both glucocorticoids and CRH/UCN may be important in


the regulation of the counter-regulatory response to hypoglycemia, with
differences between the models indicated previously reflecting redundancy
in the system. For instance, starvation and adrenalectomy decrease, while
corticosterone increases, VMH CRH-R2 levels (101). Similarly, glucocorticoids in a dose-dependent fashion increase UCN-2 mRNA in a mouse neuronal cell line (102) and regulate CRH-R2 expression in hypothalamus
and medial amygdalar (103). Also, in MIN6 insulinoma cells and isolated
mouse islets, glucocorticoids increase CRH-R2 and decrease CRH-R1 expression (104). Thus, antecedent hypoglycemia could potentially still induce
defective counter-regulation in the absence of a rise in endogenous cortisol release in people (98), because a UCN-3/CRH-R2 mechanism remains
intact, while glucocorticoid acting directly or via altering CRH-R2 expression, and possibly CRH-R1, may also influence a subsequent hypoglycemic stress response.

Role of Opioids
Opioids are important mediators of stress and increase during hypoglycemia (105, 106), exercise (107), and psychological stress (108). Studies by
Caprio et al demonstrated that naloxone treatment to block opioid receptors in people amplified the epinephrine and cortisol responses to hypoglycemia (106). More recently naloxone coinfusion in nondiabetic human
subjects during antecedent hypoglycemia was shown to prevent the development defective counter-regulatory responses. The mechanism by which
opioid receptor blockage prevents defects in glucose counter-regulation
are not known and could occur through a hypothalamic, pituitary, or
adrenal effect. In support of the former, naloxone was recently shown
to prevent the induction of mouse hypothalamic Pdk4 and Angptl4
transcripts by RH (109). These genes are thought to induce metabolic
switching from carbohydrate to fat metabolism (110), suggesting opioid
antagonism prevents this adaptation, leading to preserved counter-regulatory
responses for reasons discussed previously. Further research is required to
elucidate the mechanisms by which opioid antagonists prevent the development of defective counter-regulatory responses.

Hypoglycemia Tolerance
In considering the various mechanisms detailed previously (AMPK, glucocorticoids, RCH, UCN, metabolic switching) that may contribute at least
in part to the development of defective hypoglycemia counter-regulation,

Cerebral Adaptation to Recurrent Hypoglycemia

| 105

it becomes apparent that many are critical means by which cells adapt
to physiological stressors. The depth (34), duration (35), and frequency
(33, 36) of antecedent hypoglycemia correlate with the magnitude
of the ensuing counter-regulatory deficit, and the defect resolves over
periods of up to 1 week if the hypoglycemic stimulus is not repeated
(37, 38). This is remarkably similar to the classical description of ischemic tolerance that develops in response to ischemic preconditioning
(111). Preconditioning to induce tolerance happens when a nondamaging stressful stimulus is presented to cells, tissues, or organisms to
promote a transient adaptive response so that injury resulting from
subsequent exposure to the harmful stimulus is reduced. Even without preconditioning, cells respond to stressful stimuli by mobilizing a
host of defense and counter-responses to mitigate injury and prevent
death, but adaptive preconditioning ensures the cell is better able to
survive the stress. The degree of ischemic tolerance is also dependent
on the intensity, duration, and frequency of the preconditioning stimulus (111); additionally, the degree of ischemic tolerance shows crosstolerance with other stressors (eg, exercise [112] and temperature ([113]),
and the effect reduces over time unless the preconditioning stimulus is
repeated (111). Thus, the parallels with the impact on glucose counterregulation of antecedent hypoglycemia are clear and support the
concept that this phenomenon (impaired hypoglycemia awareness)
represents a model of hypoglycemia tolerance (or stress habituation)
(Figure 3-3).
The obvious follow-on question is why should an adaptive response
designed to be neuroprotective increase an individuals susceptibility to
severe hypoglycemia? The likely answer is that it does not, but therapeutic hyperinsulinemia does. Therapeutic hyperinsulinemia suppresses
peripheral lipolysis and delivery of gluconeogenic substrates to the liver
and therefore reduces the supply of alternate substrates to the brain. At
the same time, the combination of unregulated hyperinsulinemia and
a hypoglycemia-specific defect in glucagon secretion ensures a more
rapid and severe hypoglycemia (Figure 3-3). Thus, in T1D, hypoglycemia
tolerance develops in the nonphysiological context of hyperinsulinemia,
which prevents appropriate counter-regulation and induces severe hypoglycemia, where at some point cellular defense mechanisms will be
overwhelmed, and cellular death can ensue. The development of reduced
counter-regulatory responses following repeated hypoglycemia can therefore be considered an adaptive response at a cellular level, but maladaptive for individuals with T1D because of their need for insulin replacement
therapy.

106

| Translational Endocrinology & Metabolism: Hypoglycemia Update

Therapeutic
Hyperinsulinaemia

Glucagon Defect

Hypoglycaemia

Stress

Starvation

Pre -conditioning

Alternate Fuels
Neuroprotective

Hypoglycaemia Tolerance
FIG 3-3. Development of hypoglycemia tolerance in response to repeated hypoglycemia.
Low glucose initiates 2 broad responses at a cellular and whole-systems level, namely stress
and starvation responses. These act to induce preconditioning and metabolic switching, the
net effect of which is to be neuroprotective, enabling cells/neurons to become more resilient
(tolerant) of subsequent hypoglycemia. However, in T1D, this adaptive response may be
viewed as maladaptive, because an absent glucagon counter-regulatory response, combined
with hyperinsulinemia, ensures that hypoglycemia develops rapidly and is much more severe.

Conclusions and Future Perspectives


The mechanisms underpinning the development of defective hypoglycemia counter-regulation remain largely unknown. Data supporting metabolic switching, altered fuel transport and/or use, and stress regulation
are at times inconsistent, and especially in the case of fuel transport and
metabolism, often limited to global measures that may miss important
local changes in key brain regions. Determining the molecular adaptive
mechanisms in neurons and comparing and contrasting this with those in
astrocytes/glial cells within different key GS brain regions will also be
important. However, caution is always required when translating from in
vitro or animal models to human disease. The complex cellular and physiological responses to recurrent hypoglycemia suggest that a number of
adaptive processes may be provoked and that these may show differing
temporal relationships to the initial hypoglycemic stimulus. At least at a
cellular level, current molecular data, drawn largely from animal models
as well as physiological studies of human subjects, suggest recurrent

Cerebral Adaptation to Recurrent Hypoglycemia

| 107

hypoglycemia induces hypoglycemia tolerance through a preconditioning


mechanism. This concept remains hypothetical, and clarifying the nature
of these molecular adaptations will be essential if one is ultimately to
identify potential sites for effective pharmacological intervention.
Grants
The research work of RJM is supported by grants from the Juvenile Diabetes Research Foundation, European Federation for the Study of Diabetes, Diabetes UK, Medical Research Council
and Tenovus Scotland. The preparation of this chapter was in part supported by the National
Institute of Neurological Disorders and Stroke (NINDS) grant R01 NS035192 (ERS, G). The
Center for MR Research is supported by National Center for Research Resources (NCRR) biotechnology research resource grant P41 RR008079, National Institute of Biomedical Imaging
and Bioengineering (NIBIB) grant P41 EB015894, and Institutional Center Cores for Advanced
Neuroimaging award P30 NS076408.

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Goldberg PA, Weiss R, McCrimmon RJ, Hintz EV, Dziura JD, Sherwin RS. Antecedent hypercortisolemia is not primarily responsible for generating hypoglycemia-associated autonomic failure. Diabetes. 2006;55(4):11211126
Flanagan DE, Keshavarz T, Evans ML, et al. Role of corticotrophin-releasing hormone in the impairment of counterregulatory responses to hypoglycemia. Diabetes.
2003;52(3):605613
Zhou L, Podolsky N, Sang Z, et al. The medial amygdalar nucleus: a novel glucosesensing region that modulates the counterregulatory responses to hypoglycemia.
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type 2 CRH receptor mRNA in the VMH by glucocorticoids and starvation. Am J
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Chen A, Perrin M, Brar B, et al. Mouse corticotropin-releasing factor receptor type
2alpha gene: isolation, distribution, pharmacological characterization and regulation by stress and glucocorticoids. Mol Endocrinol. 2005;19(2):441458
Jamieson PM, Li C, Kukura C, Vaughan J, Vale W. Urocortin 3 modulates the neuroendocrine stress response and is regulated in rat amygdala and hypothalamus
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Huising MO, Pilbrow AP, Matsumoto M, et al. Glucocorticoids differentially regulate the expression of CRFR1 and CRFR2alpha in MIN6 insulinoma cells and
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beta-endorphin levels after insulin-induced hypoglycemia in human subjects.
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| Translational Endocrinology & Metabolism: Hypoglycemia Update

4. Prevention and Management


of Hypoglycemia in the Active
Patient with Diabetes
Stephen N. Davis, MBBS, FRCP, FACP
Mark L. Evans, MBBS, MD, FRCP

Introduction
Despite advances with modern therapies and technology, hypoglycemia
remains a common, unwanted and feared consequence of insulin and oral
insulin secretagogue treatment in diabetes (1, 2). In a recent study, nearly
50% of patients with long-standing type 1 diabetes (T1D) self-reported
episodes of severe hypoglycemia (defined as episodes requiring external
assistance (3) during a 9- to 12-month period. Even in those with type 2
diabetes (T2D), 25% with patients treated with insulin reported severe
hypoglycemia during the same period (4). In general, risk factors for hypoglycemia include hypoglycemia unawareness, long duration, type, and
treatment modality of diabetes. Individual episodes of hypoglycemia can
be precipitated by factors which lead to an absolute or relative excess of
insulin. In insulin-treated patients, aside from an imbalance between carbohydrate intake and insulin dosing, injection site anomalies and alcohol,
exercise, and activity are major etiological factors.
There are a number of mechanisms by which exercise may lead to hypoglycemia in the active patient with diabetes. For example, activity may
consume glucose/carbohydrate stores and increase insulin absorption
from injection sites. The effects of certain activities (eg, household chores,
working in the yard, or dog walking) may be underestimated by patients
who may not perceive these tasks as having a significant exercise effect
on glycemia. During higher intensity exercise, symptoms of hypoglycemia may be difficult to distinguish from the effects of exercise. Risk of
hypoglycemia during exercise is particularly heightened for those with
unawareness of hypoglycemia. As will be discussed, exercise and hypoglycemia unawareness may be interlinked.
Despite the presence of successful role models such as the swimmer
Gary Hall Jr, these challenges may make patients reluctant to consider
exercise despite the significant benefits, such as improved metabolic

Translational Endocrinology & Metabolism, Volume 3, Number 4, 2012 | 115

control (glycemia, lipids, weight loss, and blood pressure) and improved
well-being (5, 6). Others may overcompensate, deliberately running blood
glucose levels high in an attempt to avoid hypoglycemia during activity.
However, hyperglycemia may interfere with sports performance and carry
broader implications for overall glycemic control where exercise is frequent. In addition, where this is done in an uncontrolled fashion, the
irony is that erratic glycemia may mean that hypoglycemia during or
after exercise is still problematic. In this chapter are discussed the physiological challenges of exercise in diabetes and also strategies for planning safely for exercise to try to minimize risk of hypoglycemia. The
authors have focused largely on T1D, where the challenges of finding
a balance are usually greater than in those not managed with insulin,
although similar principles may apply to patients with T2D managed with
insulin.

Physiology of Exercise in Health and Diabetes


Counter-regulatory Responses to Hypoglycemia in
Nondiabetics
Hypoglycemia is a rare occurrence in nondiabetics due to the presence
of a coordinated and multilayered defense against a falling plasma glucose. At rest, a drop of plasma glucose from a normal postabsorptive level
of approximately 90 mg/dL (5 mmol/L) to below 80 mg/dL (4.5 mmol/L) is
large enough to activate the first line of defense (counter-regulatory
response), which entails a reduction in endogenous insulin secretion in
those without diabetes. Continuing decreases in plasma glucose (6570
mg/dL) activate neuroendocrine (glucagon, cortisol, growth hormone) and
autonomic nervous system (epinephrine and norepinephrine) counterregulatory hormones (6). Complementing the release of counter-regulatory hormones is the generation of symptom responses that alerts the
individual to hypoglycemia. The mechanisms generating the hypoglycemic symptom responses (usually classified into adrenergic/autonomic
or neuroglycopenic) are complex and are not a simple reflection of the
circulating catecholamine response (7).
The counter-regulatory response is established to
1. Increase glucose production by the body, acutely via the liver (via the
actions of glucagon, epinephrine, norepinephrine, direct autonomic nervous system (ANS) innervation and reductions in insulin. Cortisol and
growth hormone only play a relatively minor role after prolonged hypoglycemia of several hours.

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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

2. Reduce glucose uptake in peripheral tissues (by the previously mentioned hormones and mechanisms), also serving thereby to conserve
plasma glucose levels.
An additional, but important, mechanism in the defense against falling
plasma glucose is the increase in lipolytic substrate (free fatty acids and
glycerol) resultant on the previously mentioned neuroendocrine and ANS
actions. Free fatty acids can provide energy for hepatic glucose production
and reduce glucose uptake in muscle. Glycerol provides an important gluconeogenic substrate for glucose production during prolonged hypoglycemia. Taken together, it is estimated that lipolysis may provide up to 25%
of the defense against hypoglycemia (8).

Counter-regulatory Responses to Exercise in Nondiabetics


Homeostatic physiologic responses to differing stresses in people are
well conserved and have many similarities. Thus the counter-regulatory
mechanisms activated during exercise to
Lipolysis may provide up to
protect plasma glucose are similar to those
25% of the counter-regulatory
described during hypoglycemia. The differdefense against hypoglycemia.
ences in counter-regulatory responses occurring between hypoglycemia and exercise are
quantitative rather than qualitative. The defense against falling plasma
glucose is even more sensitive in exercise than hypoglycemia. A fall in
plasma glucose of only 8 mg/dL (0.4 mmol/L) is enough to activate counter-regulatory responses. The work intensity during exercise is the major
determinant of the counter-regulatory response. During low-to-moderate
work intensity, the hepatic sinusoidal glucagon-to-insulin ratio is the
major regulator of hepatic glucose production, whereas, at higher intensity workloads, the ANS becomes the principal counter-regulatory drive
for hepatic glucose production.
Epinephrine, glucagon, growth hormone, and cortisol responses are less
marked, whereas norepinephrine levels are notably greater during exercise as compared to hypoglycemia. Counter-regulatory responses increase
during exercise depending upon the work intensity. These neuroendocrine and ANS responses are nonlinear, with exaggerated levels occurring
at exercise intensities above the anaerobic threshold (greater than 50%
maximum oxygen consumption [VO2max]).
Circadian differences in counter-regulatory and glycemic responses to
exercise have been described in nondiabetics with a greater blood glucose
lowering seen at midnight compared with earlier in the day (9). Although
it is unclear how this extrapolates to diabetes, clinicians should be aware

Prevention and Management of Hypoglycemia in the Active Patient with Diabetes

| 117

that patients with diabetes might also exhibit circadian differences in


susceptibility to hypoglycemia with exercise.

Counter-regulatory Responses to Hypoglycemia in Diabetes


The defenses against falling plasma glucose in diabetes are altered. In
T1DM, the ability to shut off insulin release during hypoglycemia is
lost, and the release of the powerful counter-regulatory hormone,
glucagon, in response to hypoglycemia is lost after only a few years
disease duration. Whether the 2 defects previously described are mechanistically linked is a topic of considerable debate (7). In T2DM, the
glucagon release in response to hypoglycemia is largely preserved.
However, similar to T1DM, as insulin deficiency becomes critical in
T2DM, the response of glucagon to hypoglycemia also becomes severely
diminished.
With the waning of glucagon release,
Prior hypoglycemia can blunt
an individual with T1DM (or advanced
counter-regulatory responses
T2DM) becomes dependent upon epinephduring subsequent exercise.
rine for the defense against hypoglycemia.
Furthermore, antecedent
If released in appropriate amounts, epinephexercise can also blunt
rine is powerful enough to compensate for
counter-regulatory responses
the loss of glucagon during hypoglycemia.
during subsequent
However, if the mechanism(s) to release
hypoglycemia.
epinephrine is/are also impaired, then the
risk for severe hypoglycemia can increase by up to 25-fold. Unfortunately, this does occur, as epinephrine responses to hypoglycemia can
be acutely and chronically blunted. The latter can occur due to classic diabetic autonomic neuropathy. However, an acute and or chronic
blunting can occur following antecedent repeated episodes of hypoglycemia (10, 11). It is now recognized that antecedent hypoglycemia
can result in syndromes of blunted ANS and neuroendocrine counterregulatory responses that can create a vicious cycle for further hypoglycemia (12).
Work from one of the authors (SND) laboratory and others has demonstrated that prior hypoglycemia can also blunt counter-regulatory responses
(neuroendocrine, ANS, and metabolic) during subsequent exercise. Furthermore, antecedent exercise can also blunt counter-regulatory responses
during subsequent hypoglycemia. Thus a reciprocal, fast-forward vicious
cycle of blunted counter-regulatory responses can be established between
exercise and hypoglycemia (13, 14).

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Counter-regulatory Defenses to Exercise in Diabetes


In T1DM, unlike the response to hypoglycemia, the glucagon response to
exercise is preserved. Epinephrine and norepinephrine responses to submaximal exercise, however, are reduced by 33%, compared to age-, body
mass index (BMI)- and fitness-matched nondiabetic individuals. Furthermore, catecholamine responses during matched relative workloads are
33% to 50% reduced in women (both nondiabetic and T1DM) as compared to men. The reduced ANS drive during exercise would be predicted to contribute to the increased hypoglycemia during exercise. The
pronounced sexual dimorphism in ANS responses during exercise (which
also occurs during hypoglycemia in the resting state) does not appear
to result in increased exercise-related hypoglycemia in women (6).
In T1DM, hypoglycemia can occur both during exercise and for up to
24 hours after exercise. The reasons for this delayed hypoglycemia have
been investigated. Traditionally, it has been proposed that lack of glycogen replacement and an increase in insulin sensitivity, together with an inability
In T1DM, hypoglycemia can
to appropriately reduce insulin replacement,
occur both during exercise
are the major mechanisms for delayed exerand for up to 24 hours after
cise-related hypoglycemia. The authors and
exercise.
others have investigated whether additional
mechanisms exist that contribute to hypoglycemia risk during exercise
in T1DM including deficient counter-regulatory responses.
Unfortunately, antecedent hypoglycemia produces additional blunted
ANS and neuroendocrine responses during subsequent exercise. Antecedent hypoglycemia of 50 mg/dL (2.9 mmol/L) reduces a wide range of
ANS, neuroendocrine, and metabolic counter-regulatory responses (pituitary, ANS, pancreatic, adrenal) by approximately 30% to 90% during nextday submaximal exercise in both T1DM and nondiabetic individuals. Of
particular concern was the dramatic effect of prior hypoglycemia on blunting glucagon release during subsequent exercise in T1DM. The glucagon
counter-regulatory response was nearly suppressed, and, together with
the inability to reduce insulin levels, resulted in a dramatic reduction in
endogenous glucose production and a marked doubling of exogenous glucose to maintain euglycemia during exercise (15).
The depth of antecedent hypoglycemia also determines the magnitude
of subsequent counter-regulatory failure during exercise. Even relatively
mild prior hypoglycemia of 70 or 60 mg/dL (3.9 or 3.3 mmol/L) can
result in blunted neuroendocrine, ANS, and metabolic counter-regulatory
responses during subsequent exercise in T1DM (16).

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Thus the previously described studies demonstrate the reciprocal nature


of the blunting effects of prior hypoglycemia or exercise on subsequent
counter-regulatory responses to either stress. Sandoval et al compared
the effects of prior exercise or hypoglycemia on immediate (2 hours) subsequent hypoglycemia in T1DM (17). Interestingly, prior exercise resulted
in a greater overall counter-regulatory deficit as compared to morning
hypoglycemia. This is due to the fact that prior exercise results in increased
insulin sensitivity, whereas hypoglycemia causes a state of relative insulin
resistance. Thus the hypoglycemia-induced insulin resistance will offer
some protection against a subsequent episode of insulin-induced hypoglycemia. On the other hand, the increased insulin sensitivity following
exercise would combine with the blunted counter-regulatory responses to
provide a stimulus for further hypoglycemia.
The mechanisms responsible for hypoglycemia and exercise-associated
counter-regulatory failure are currently under investigation. Similar to
hypoglycemia, there appear to be complex and multilayered mechanisms
regulating counter-regulatory responses durAntecedent increases of both
ing exercise. To date, antecedent increases
physiologic and pharmacologic
of both physiologic and pharmacologic levlevels of cortisol can blunt
els of cortisol have been demonstrated to
counter-regulatory responses
blunt counter-regulatory responses during
during subsequent exercise in
subsequent submaximal exercise in T1DM
T1DM.
(14). Antecedent activation of neuroinhibitory -aminobutyric acid (GABA)(A) receptors with the benzodiazepine alprazolam has also been reported to blunt
neuroendocrine, ANS, and metabolic counter-regulatory responses during
subsequent exercise.
Much work remains to be performed to determine all the mechanisms
contributing to the deficient counter-regulatory responses occurring during exercise or hypoglycemia following either stress. Treatment strategies
to avoid exercise-related hypoglycemia are emerging and are described
in more depth later in this chapter.

Altered Insulin Kinetics during Exercise in Diabetes


In addition to the changes described previously, there are a number of
other potential differences in the physiological responses to exercise in
diabetes. In T1D, the most obvious contrast is that if therapy is not adjusted,
circulating insulin levels will not fall during exercise. Of note, the portalto-systemic ratio of insulin is abnormal in insulin-treated diabetes where
insulin is delivered subcutaneously rather than being released directly

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into the portal system from the healthy pancreas. Under situations of exercise, this reversed portal-systemic ratio may contribute further to the subnormal hepatic changes in response to exercise. Even where insulin dose
is altered, increased heat and blood flow to skin overlying muscle may
mean that subcutaneous insulin depots are absorbed, paradoxically increasing circulating insulin levels during activity.

Metabolic Effects of Exercise


In addition to the neuroendocrine effects described previously, it may be
helpful to outline briefly the metabolic changes seen with exercise in both
nondiabetics and diabetics. The major physiological effects of exercise are
explained by the increased requirements of skeletal muscle for fuel and
oxygen to maintain increased effort. Oxygen consumption may increase
by 20-fold with increases in heart rate and volume and vasodilation to
increase oxygen supply to muscle. Despite these changes, blood glucose
is usually maintained within tight homeostatic limits during exercise in
nondiabetics, allowing glucose to continue fueling brain metabolism and
function (although there may be small falls in glucose even in healthy
nondiabetic subjects).
With short high-intensity exercise, carbohydrates are the preferred fuel,
but muscle switches to using lipids over a longer duration/lower intensity
of activity (crossover effect) (18). Typically, these protective counterregulatory changes are sustained beyond the end of exercise into recovery.

Clinical Strategies to Minimize Hypoglycemia Risk


Clinical Implications of Altered Responses to Exercise in Diabetes
The most obvious consequence of these differences is that there is an
increased risk of hypoglycemia during exercise in diabetes. However, the
counter-regulatory hormone rise during exercise may mean that blood
glucose levels rise depending on the intensity and nature of activity and
prevailing insulin levels.
Importantly, there is often a predisposition for hypoglycemia to occur
after exercise. The timing of this means that hypoglycemic episodes may
occur during the night following daytime exercise (1921). There may
be a number of mechanisms for this, including increased insulin sensitivity, perhaps related to exercise-induced activation of the cellular energy
sensor, AMP-activated protein kinase (AMPK) (22), waning of the counterregulatory drive, and/or replenishment of depleted glycogen stores.
Nocturnal hypoglycemia carries a particular risk, as counter-regulatory

Prevention and Management of Hypoglycemia in the Active Patient with Diabetes

| 121

responses tend to be lower during the night (23), and sleep interferes with
the ability to perceive hypoglycemia (24).

Different Types of Exercise


Clinicians need to be aware of the effects that different types of exercise
will have on hypoglycemia risk in diabetes. An easy and functional classification is to consider sports as either endurance, where lower-intensity
activity is maintained over a long time period (eg, long distance running or cycling), short/sharp high-intensity/shorter-duration activities
(eg, sprinting or sprint swimming), or combination sports such as soccer
where short/sharp episodes of high intensity are interspersed with more
sustained periods of lower-intensity activity.
During low-intensity endurance activity (aerobic, with heart rate 40%
to 80% of maximal), muscle glycogen stores will be rapidly depleted, with
a switch to fatty acid metabolism but also with muscle uptake of glucose
where available. The effect is that there is a significant risk of hypoglycemia
for T1D patients, both during endurance activity and also afterwards.
With high-intensity (anaerobic, with heart rate more than 80% of maximal) activity, oxygen supply is insufficient to allow mitochondria to oxidize substrate, and blood lactate rises, acting to limit the duration of
activity. This type of activity is typically associated with marked rises in
catecholamines and glucose production. For patients with T1D, this carries the potential for creating hyperglycemia during activity and may even
precipitate ketosis if patients are significantly underinsulinized. However,
as with endurance exercise, there is still a risk of late hypoglycemia.
Combination activity (eg, soccer or basketball) combines episodes of
endurance with short sharp bursts of more intense activity. The implications for T1D are that these sports may carry less risk of hypoglycemia
during activity than for endurance sports. Again, there is still a risk of late
hypoglycemia after activity.
Extreme sports are those where activity is involved with an element
of danger (eg, rock climbing). In addition to the effects of intensity and
type as described previously, particular implications for diabetes are the
danger associated may result in an epinephrine rush, tending to elevate
blood glucose, at least in the short term, and the nature of the activity,
which may carry an extra hazard if participants become hypoglycemic
on a rock face or underwater, for example. High altitude may also affect
blood glucose control, with reports of reduced insulin sensitivity during
the first few days of exposure to high altitude, perhaps mediated by
hypoxia (25).

122 | Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

The intensity of activity can be measured in a number of different ways.


Some patients, particularly if active sportsmen/women, may already use
heart rate monitoring to guide their exercise, aiming to train in a certain
percentage of maximal heart range (220 minus age in years) range. Sports
physiologists and many professional/ semiprofessional teams may measure or at least estimate VO2max, an indicator of the maximal uptake of
oxygen by the body. Like heart rate, exercise intensity can be graded
according to percentage of VO2max. However, a more pragmatic approach
to gauging exercise intensity for clinicians advising their patients might
be to use a perceived effort scale. The Borg scale rates activity on a scale
of 6 to 20, with scores of under 10 representing very light exercise, 10 to
13 light-to-moderate exercise, and over 16 indicating very heavy exertion.
For guidance, Table 4-1 indicates a typical relationship between VO2max,
maximal heart rate, and Borg scores.

Planning for Exercise in Insulin-Treated DiabetesPreparation


Several different strategies have been successfully employed to minimize
risk of hypoglycemia in insulin-treated diabetes. In any individual, there
is inevitably an element of trial and error, and a formula that suits 1 person may not necessarily work for another under apparently similar conditions. Patients should be prepared to start slowly with careful monitoring
of the effects of activity. As ever, support from experienced nurse educators and or dieticians may be invaluable. Importantly, patients undertaking a new exercise program should try to avoid hypoglycemia, not just
because of the immediate effects, but also because of the dangers of inducing hypoglycemia unawareness and establishing a vicious cycle of glycemic instability. It is critical to check that patients know how to self-manage
hypoglycemia rapidly and effectively, that they will have access to hypoglycemia treatment and blood glucose testing equipment. Common sense

TABLE 4-1. Classification of Physical Work IntensityRelative Intensity


of Activity

Intensity

VO2max (%)

Maximal Heart Rate (%)

Borg Scale

Light

2039

3554

1011

Moderate

4059

5569

1213

Hard

6084

7089

1416

Very hard

>85

>90

>17

Prevention and Management of Hypoglycemia in the Active Patient with Diabetes

| 123

safety precautions should be employed, particularly where a new activity


or management strategy is being tried (not running alone in a remote rural
location and/or carrying a cellphone for example).
It is also worth reminding that when evaluating a new exercise program
for their patients with diabetes, clinicians should give consideration to
factors other than glycemic stability/ hypoglycemia avoidance. Patients
should be assessed for the presence of complications such as macrovascular disease (affecting coronary and peripheral arteries for example) and
microvascular complications (eg, feet at risk from sensory neuropathy,
autonomic neuropathy causing blood pressure lability, and proliferative
retinopathy with risk of bleeding with twisting/jarring). This may mean
that certain patients need further investigation or treatment before exercise can be recommended. Patients with established or suspected coronary artery disease may need an evaluation of the ischemic response to
exercise for example.
Clinicians should also be aware that some legislative bodies ban or limit
patients with diabetes from access to certain sports or activities (eg, boxing and scuba diving). The World Anti-doping Agency (WADA) lists insulin as a banned substance, largely because of the illicit use by certain
athletes (particularly weight lifters and wrestlers), although athletes are
able to request medical exemption with appropriate documentation to use
insulin for therapeutic reasons in diabetes.

Targeting Starting Blood Glucose with Exercise


One approach not uncommonly taken by patients might be to run blood
glucose levels high at the start of exercise on the assumption that this will
allow circulating glucose to fuel activity. Although this may make intuitive sense, a simple calculation reveals the limitations of this. For example,
assuming a glucose-free space of 20%, for an 80 kg man, this equates to
an additional 1.6 g of glucose for every 10 mg/dL of glucose. Thus if a
patient deliberately raised blood glucose from 120 to 220 mg/dL, the additional circulating glucose would amount to 16 g, enough to fuel only 5 to
10 minutes of activity.
However, it is prudent to make certain that blood glucose values are in
the normal-to-high target range prior to exercising, for example aiming for
120 to 200 mg/dL depending on the nature of the activity. If values are
lower, patients should be advised to consume a rapid-acting carbohydrate
snack (perhaps 15g initially) to bring into this range prior to commencing activity. If there has been significant hypoglycemia in the preceding
24 hours, then ideally exercise should be avoided if possible. Similarly,

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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

if blood glucose values are higher than the range listed, patients should be
advised to bring down into target before starting exercise because of the
risk of the counter-regulatory hormonal responses to exercise exacerbating hyperglycemia. For similar reasons, patients should not exercise when
ketotic.
Regular blood glucose self-testing during activity, especially where a
new exercise regimen is being performed, is also prudent, perhaps every
30 minutes as a starting guide.

Reducing Insulin Doses for Activity


Where activity is planned in T1D and a fall in blood glucose anticipated,
hypoglycemia risk can be reduced by reducing rapid-acting insulin taken
with the preceding meal. Clearly this is only effective where activity
occurs during the time that insulin is active following injection, typically
up to 4 hours after an insulin bolus. This also requires an a priori knowledge, not only that activity will occur, but also of the likely intensity,
duration, and effects of activity. Nevertheless, this is often a useful strategy, particularly for sports where these factors can be predicted (eg, a
soccer game with a scheduled kick-off time and match duration). RabasaLhoret et al examined the effects of different reductions of insulin prior to
30 to 60 minutes of exercise using a cycle ergometer in patients with T1D,
an endurance activity likely to result in a fall in blood glucose in most
patients with T1D. Under the most intense conditions (75% VO2max for
30 minutes), reductions in premeal insulin of up to 75% were needed to
prevent a fall in blood glucose (26).
Clearly, there will be a learning curve for any individual patient using
this approach. Potential pitfalls include hyperglycemia before and perhaps after exercise if dose adjustment is miscalculated. As already emphasized, a pragmatic approach to insulin dose reduction would be to start
with small reductions, perhaps 20% to 30% initially, and to be prepared
to perform intensive monitoring to identify the best approach. Insulin
dose reduction may also allow those patients who are trying to lose weight
to minimize carbohydrate intake that might otherwise be needed to prevent or treat hypoglycemia.
An alternate or complementary approach to reduce a tendency for hypoglycemia during or immediately after activity might be to reduce preactivity background insulin (for those on injections) or basal infusion rates
for those using insulin pump therapy. As for changes in bolus insulin, the
major drawback of this approach is needing to anticipate in advance the
timing and likely effects of activity. Pump therapy allows more flexibility

Prevention and Management of Hypoglycemia in the Active Patient with Diabetes

| 125

with this, although delays will remain between changing infusion rates and
alterations in circulating/tissue insulin, so that changes probably need to
be made 45 to 60 minutes in advance of activity.
Where there is a significant possibility of activity resulting in late hypoglycemia, background insulin and/or basal infusion rates for pump users
may need to be adjusted accordingly. With all of these approaches, the
drawbacks include making too little or great an adaptation, resulting in
hypoglycemia or hyperglycemia.

Increased Carbohydrate Intake to Prevent Hypoglycemia


Another approach to limiting hypoglycemia risk is to increase carbohydrate
intake to prevent hypoglycemia (27). This may not always be possible
depending on the nature of the activity and may not be desirable (eg, where
exercise is being performed as part of a weight-loss strategy). Sports drinks
such as Gatorade contain 6% to 8% rapid-acting carbohydrate, or drinks
can be self-formulated from powder. Concentrations much above 10% are
generally less well tolerated because of gastrointestinal symptoms, and
the fluid intake may be useful to help maintain hydration during activity.
In general, elite athletes, especially those participating in endurance
sports, may need as much as 8 to 10 g/kg/d carbohydrates, although usually less than this needed for most. Intake of low glycemic index (starchy)
carbohydrates 3 to 4 hours before exercise with insulin may aid boost
glycogen stores, especially prior to endurance or interval sports. Intake
of rapidly absorbed carbohydrate at 1 g/kg/h may help avoid hypoglycemia with endurance activity, perhaps best taken in divided doses at 15- to
20-minute intervals. Following activity, particularly where prolonged aerobic exercise may have depleted glycogen stores, patients should be
encouraged to eat carbohydrates (60120 g) with insulin as needed to
ensure glucose uptake and glycogen storage. This is particularly important if further exercise or activity is planned within a few hours.

Maximal Sprints before Exercise


Another option to try to minimize the fall in glucose induced by endurance exercise is to perform a short sharp burst of anaerobic exercise,
presumably by stimulating counter-regulatory mechanisms. The effects
seem to be affected by relatively brief episodes of high-intensity effort. For
example, a 10-second maximal sprint before exercise limited the fall in
blood glucose following 20-minute cycle ergometer exercise in 7 subjects
with T1D (28). As an alternative where this might be impractical, a

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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

10-second sprint performed at the end of the exercise period also minimized the postexercise fall in blood glucose (29).
Drawbacks of this as an approach are that it may not always be practical, and patients still need to address late hypoglycemia occurring after
exercise rather than in the immediate postexercise period.

An Integrated Approach
Combining the described approaches may offer a pragmatic solution, at
least for starting advice for clinicians guiding their patients with T1D. For
example, low-intensity (510 on Borg scale) or moderate-intensity (1113
on Borg scale) activity for up to 20 minutes is best managed by ensuring
that starting glucose is in the high normal range and reducing quickacting insulin prior to exercise (if planned) or carbohydrate intake if
unplanned. More intense activity and/or combination activity and/or
prolonged low-intensity activity for longer than 60 minutes will probably
need a more intensive approach, potentially combining strategies detailed.

Different Insulin Therapies and Activity in T1D


Adjusting insulin injections is likely to be more difficult, although not
necessarily impossible for patients with T1D or non-T1D on twice-daily
mixed insulin preparations depending on the nature of their activity.
However, most active patients with insulin-treated diabetes will find it
easier to adjust insulin when using either a basal bolus regimen or insulin pump therapy. Where background insulin needs to be aggressively
adjusted to cover activity, this may be easier to manage when patients are
using twice-daily isophane insulin rather than longer-acting insulin analogues, although clearly this needs to be a carefully balanced clinical
decision weighing up other potential advantages and disadvantages of
background analogue insulin. This may be a particular issue with at least
1 ultralong-acting background insulin analogue likely to become commercially available in the near future.
Because of the importance of activity-induced hypoglycemia, structured
training programs in self-management of T1D often include training in dose
adjustment for activity. For example, the DAFNE (Dose Adjustment For
Normal Eating) education program, which includes both skills training and
a practical session on insulin dose adjustment for activity, has demonstrated
reduced rates of hypoglycemia in 2 different health care systems (United
Kingdom and Australia), although it is impossible to dissect out how much
of this is directly attributable to activity-related hypoglycemia (30, 31).

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Insulin Pump Therapy


For many active sportsmen and women with T1D, the flexibility offered
with insulin pump therapy means that this is likely to be the easiest way
of adjusting insulin delivery. For example, basal infusion rates can be
reduced 45 to 60 minutes prior to endurance activity to prevent hypoglycemia during exercise. Similarly, when glucose tends to rise, rates can be
increased as needed but then reduced to cover the postexercise period.
Lower temporary basal rates can be set to cover the potential for late
hypoglycemia, particularly during the night. A typical starting paradigm
might be a 20% reduction but adjusted as needed (32). Pumps are also
easily downloadable, if need be, using remote care management systems
to allow clinicians and educators to give further feedback.
The disadvantages of pump use are largely practical ones. They are
more costly than injection therapy, may be impractical for certain sports
(eg, contact sports such as soccer or rugby or for watersports if pumps are
not waterproof). There is also a danger that infusion sets could be displaced during exercise without detection, resulting in underinsulinization, hyperglycemia, ketosis, and risk of ketoacidosis. Importantly, they
also require the patient to know how to use the technology appropriately.
For those who choose or are obliged to remove their pump for sport,
the practicalities of how to manage this depend on the individual patient
and duration of the sport. For example, soccer players may wear the pump
for a match warm-up aiming to minimize the time disconnected from the
pump. Blood glucose can also be monitored at halftime. Extended periods disconnected from a pump, for example a 6-hour sailing regatta will
likely mean that patients have to use subcutaneous insulin injections(s)
temporarily to cover the hiatus. As emphasized earlier, the strategy for
establishing the most appropriate regimen for an individual will likely
require a forensic approach, building up duration and intensity of sport if
possible combined with much blood glucose monitoring.
Of interest, an insulin pump recently approved in Europe has an intrinsic activity monitor (Cellnovo System, Cellnovo, United Kingdom), theoretically allowing the user to capture and compare patterns of activity
with insulin, carbohydrate, and blood glucose data.

Continuous Glucose Monitoring


In general, data examining the utility of continuous glucose monitoring
(CGM) in diabetes have failed to show a reduction in hypoglycemia, largely
because studies to date have tended to avoid those with a significant

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baseline burden of hypoglycemia (33). Conceptually, there is obvious


potential for using CGM in a targeted fashion to detect and manage hypoglycemia either during or after activity. There are some additional technical challenges with CGM during exercise, however. Typically, interstitial
glucose lags 15 minutes behind changes in blood glucose, which may
mean that detection of a fall in glucose during activity (where the fall may
be rapid) will be delayed (34). One option to overcome this is to set alarms
for a glucose threshold well above the hypoglycemic range (eg, 100 mg/dL),
and to use this as a level at which to take carbohydrate (35). Riddell et al
used both the absolute glucose levels and the indicator of rate of change
of CGM glucose to successfully guide carbohydrate therapy to minimize
hypoglycemia during a 2-week sports camp in adolescents with T1D (36).
The study was observational without a control group, however, and significant numbers reported loss of CGM recording during activity.
In summary, CGM has significant potential to help the avoidance of
hypoglycemia during activity in T1D.

Combining CGM with Insulin Pump Therapy


Sensor-augmented pump therapy offers some conceptual advantages by
combining real-time detection of changes in blood glucose with insulin
pump therapy, allowing the patient to adjust therapy accordingly. A low
glucose suspend (LGS) insulin pump (Paradigm Veo, Medtronic Inc.,
Northridge, California) has been available since 2010 outside the United
States. When used with CGM and with the LGS function activated, the
device suspends insulin delivery when hypoglycemia is detected and users
fail to respond to alarms. In general use, the system appears to reduce risk
of hypoglycemia in adults and children (37, 38). Specifically looking at
exercise, although there are currently no data to support reduced risk of
exercise-induced hypoglycemia, the Aspire study looked at recovery from
hypoglycemia after induction by exercise, demonstrating reduced duration
of exercise-induced hypoglycemia with LGS function activated, importantly with no rebound hyperglycemia (39).

The Articial Pancreas and Activity


The ultimate goal of combining CGM with insulin pump therapy is to
develop a closed-loop artificial pancreas system. In children and adolescents, overnight closed-loop insulin pump therapy reduced time spent in
hypoglycemia after a range of interventions, including an exercise arm
(55% VO2max for 45 minutes on a treadmill) (40). An exciting possibility

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is the development of dual hormone closed-loop systems, able to adapt


insulin infusion and deliver glucagon when needed to prevent or correct
hypoglycemia (41, 42).

Type 2 Diabetes
As earlier indicated, although the information provided is aimed at T1D,
the physiological principles of the effects of activity on blood glucose are
similar for those with T2D. Insulin-treated T2D patients can follow the
same approaches as detailed for T1D. Patients on sulfonylureas may be at
increased risk of hypoglycemia during activity and have no option to alter
therapy, so they will have to rely on carbohydrate intake and/or perhaps
maximal sprints to prevent hypoglycemia. Alternatively, the challenges of
managing diabetes during activity may mean that some patients prefer to
switch to insulin therapy. Although the risk of hypoglycemia is lower in
those using glucagon-like peptide 1 (GLP-1) analogues and dipeptidyl peptidase IV (DPPIV) inhibitors compared with sulfonylureas and insulin, these
patients are not necessarily immune from activity-induced hypoglycemia.

Summary
In summary, several clinical strategies exist to allow patients with insulintreated diabetes to overcome the inherent challenges of undertaking activity. Depending on the nature of activity or exercise, these may require
careful planning and a phased introduction, with monitoring of the effects
on blood glucose to ensure that activity is performed safely, minimizing
risk of hypoglycemia and/or hyperglycemia.

Specific CME Scenarios


Scenario 1
A 47-year-old woman comes for advice. She has had T1D for 20 years
with no significant microvascular or macrovascular complications and is
physically fit. Her hemoglobin A1c (HbA1c) levels, however, indicate that
she has poor glycemic control, with the most recent value being 9.7%.
She uses insulin detemir (11 U morning and 9 U evening) and a rapidacting analogue (aspart) 1 U for every 10 g carbohydrate.
She has specifically come to ask for advice about playing tennis.
She says that she plays 4 times a week at a reasonable competitive (local
tennis club) level, typically for 90 minutes. On weekends, games are

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midmorning or afternoon, but on weekdays, she plays tennis in the early


evening. She reports that her blood glucose levels rise by 150 to 200 mg/dL
from start to finish of games but that she is prone to suffering from hypoglycemia 2 to 6 hours following matches.
Q. What advice should she receive?
A. Tennis is probably a combination sport with short sharp bursts of
activity superimposed on a sustained lower-intensity background. In her
case, it may also be her competitive nature that is driving a counterregulatory drive to elevate blood glucose levels with sport.
Her overall glycemic control is poor, so it is worth addressing this in addition to looking at the effects of sport (her main focus). Relevant to both is
checking basic skills (ie, carbohydrate counting and insulin injection sites).
It is also worth checking that she has preserved awareness of hypoglycemia; many patients may not perceive problematic hypoglycemia as a
problem and may not volunteer information about hypoglycemia frequency
and awareness unless this is actively searched for. Although not a factor
here, clinicians should also ask about alcohol intake, as this may be linked
socially to certain sports (eg, rugby), adding additional factors for patients
to juggle.
The initial management was to try to optimize all of the previously
described factors and to try small increases in rapid-acting insulin prior
to matches, with changes also to basal insulin. Postexercise snacking was
increased to try to minimize hypoglycemia after tennis and in particular
aiming to be more defensive when she played in the evenings because of
the risk of nocturnal hypoglycemia.
However, it was apparent that MDI therapy was just too inflexible to
achieve the changes needed, and she switched successfully to insulin pump
therapy. She now uses a 25% increase in basal infusion rates for tennis
games starting 90 minutes before playing followed by a 20% reduction
in basal infusion, typically for 2 hours after a game. As indicated earlier
in the chapter, this was arrived at by cautious trial with regular monitoring, and it is possible that others might have needed more aggressive or
prolonged reductions in basal rates.
In addition to helping her manage sport, her overall glycemic control
has improved with her last HbA1c reported at 7.8%.

Scenario 2
A 27-year-old woman with a 12-year history of T1D says that she has been
struggling to manage her diabetes during exercise. She has been established on insulin pump therapy for 6 years. She has no evidence for any

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diabetes complications, but she has reduced hypoglycemia awareness


with occasional self-monitored capillary glucose levels below 35 mg/dL
without being aware. She last needed external assistance to rescue from
hypoglycemia 2 years ago. Her current HbA1c is 7.2%, and she is also
relatively insulin sensitive, needing low total amounts of insulin daily.
She is slim but very weight conscious, with a BMI of 22. She tries to
limit her carbohydrate intake and is not keen to have to cover exercise
with carbohydrates. She goes to a gym 4 times a week during weekdays
and power walks at weekends. In the gym, she does a variety of activities,
both organized classes and other activities including swimming, spinning, treadmill, weight lifting, and pilates.
Q. What advice should she receive?
A. Her reduced hypoglycemia awareness is an issue that needs addressing as part of the overall care. In her case, the frequency and amount of
exercise that she was performing with frequent hypoglycemia during
and after activity meant that trying to smooth out glycemic control with
exercise was intrinsically a part of managing her unawareness. For other
patients, this may mean looking at other factors to try to avoid, both biomedical (absolute or relative overinsulinization, overaggressive corrections, inaccurate carbohydrate counting, incorrect insulin:carbohydrate
ratios) and behavioral (eg, aggressively avoiding high blood glucose values or not perceiving hypoglycemia as important).
This situation is more complex than scenario 1 because of the mix of
different activities. She needed to perform structured blood glucose testing (both capillary and use of continuous glucose sensing) to determine
the effects of her different workouts. For swimming, although she had a
waterproof pump, she removed it before entering the pool and swam for
60 minutes. Many of the other gym activities tended to lower blood glucose. Although she had not been keen on taking fast-acting carbohydrates,
after some negotiation she agreed to take small amounts during exercise
as needed (guided by frequent self-monitoring of blood glucose during
exercise). She was also very interested in the concept of anaerobic exercise, such as the 10-second maximal sprint, to try to maintain glycemia.
She found that altering her workout to do weight lifting before treadmill
or endurance work helped.
Postactivity hypoglycemia was more of a problem than she had perceived, and she was also able to target this better by reducing pump infusion basal rates after activity and moving her main carbohydrate meal of
the day (with bolus insulin cover) to the postexercise period to allow glycogen replenishment.

132 | Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

Scenario 3
A 48-year-old man with a 15-year history of T2D treated over last 5 years
with twice-daily 30/70 biphasic insulin says that he has applied and been
offered a place in a marathon running to raise money for the American
Diabetes Association. He is a novice runner and has not taken part in any
organized sport since leaving high school but is keen to use this as an
opportunity to change permanently his lifestyle.
Q. How should he be managed?
A. Although this sounds, at face value, to be a welcome development,
one should carefully analyze the potential risks for him. Check that he
is not hypertensive and has no established cardiovascular disease or
unstable retinopathy. Additionally, one should ensure that he has good
foot care and reasonable glycemic control and no other significant medical problems.
In this case, there were no other issues, and the patient understood
the potential risks involved and the need to be careful and vigilant in
building up his fitness levels slowly. There are many tapering training
regimes available online and in print, and he should choose a conservative one and follow it carefully.
One should remind him about the need for careful foot care. He is
likely to find his diabetes difficult to manage on twice-daily insulin and
most experts would advise changing at least to a basal bolus regimen
with training in how to harness this for flexible insulin dosing including carbohydrate counting, correction values, and other issues. One
author (MLE) finds isophane insulin more useful than longer-acting background insulin because of the ability to alter more rapidly from training to nontraining days. If his health care coverage allows, some find
insulin pump therapy useful for the greater potential to alter insulin dosing, although this carries advantages and disadvantages as set out previously. For example, some distance runners find wearing an insulin pump
cumbersome.
Importantly, the patient is likely to have to adapt his approach, as running distances and time of exercise build up during the approach to a
marathon. There may be little need to alter a great deal as he starts his
training, but as the program progresses, he should expect to have to start
taking extra carbohydrates before training (with insulin, although not
necessarily a full dose as distances build up); during runs, especially once
these extend to an hour or more (perhaps 30 g per 30 minutes as a starting
guide); and after exercise with insulin to replenish glycogen stores, typically 60 to 120 g by the end of his training. Frequent self-monitoring of

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blood glucose to gauge the effects of exercise and his management strategy is essential.
Assuming all goes well, by the race day he should have established how
he manages his diabetes during significant running, albeit submarathon
distances. A typical regimen for a marathon day might be a low glycemic
index (GI) carbohydrate meal 2 to 3 hours before running, with 25% to
50% of usual rapid insulin, aiming to start the race with a blood glucose
around 200 mg/dL. Maintaining hydration is critical, and regular carbohydrate intake (perhaps 30 g every 30 minutes) should take place through
the race. He will need a large carbohydrate meal after finishing (60 to 120 g)
with insulin and ideally a reduction in background insulin that night and
perhaps for the next 24 hours.
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15. Galassetti P, Tate D, Neill RA, Morrey S, Wasserman DH, Davis SN. Effect of antecedent hypoglycemia on counterregulatory responses to subsequent euglycemic
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32. Taplin CE, Cobry E, Messer L, McFann K, Chase HP, Fiallo-Scharer R. Preventing
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5. The Impact of Hypoglycemia


on the Developing Brain
Raghavendra Rao, MD
Tamara Hershey, PhD

Introduction and Case Report


How does the experience of repeated, severe hypoglycemia affect a developing brain? This seemingly simple question has been remarkably difficult to resolve in human and animal research. This chapter reviews this
complex and sometimes contentious literature, focusing on the impact of
hypoglycemia across a wide range of neurodevelopment, from the newborn period through childhood and adolescence, on both brain structure
and brain function. Despite reports from the Diabetes Control and Complications Trial (DCCT) and Epidemiology of Diabetes Interventions and
Complications (EDIC) studies indicating that severe hypoglycemia in
adults with type 1 diabetes (T1DM) does not provoke clinically significant
cognitive decrements over time, case reports and studies of children with
T1DM suggest that severe hypoglycemia during development can impact
brain function and structure, occasionally in dramatic ways.
The following case illustrates the complexity of the important variables
one must disentangle in research studies. A 24-year-old man presented to
the emergency room after having been found in a disoriented and hypoglycemic state. After intravenous glucose, his neurological examination
normalized, except for continued disorientation, retrograde amnesia for
events over previous weeks, and profound anterograde amnesia. From an
extensive medical work-up and neuropsychological testing, he was diagnosed with amnesia resulting from a hypoglycemic episode. His history
complicated the picture, however. He had been diagnosed with T1DM
at the age of 2 years, and had experienced multiple episodes of severe
hypoglycemia (using DCCT criteria) before the age of 10 years, including
1 episode that resulted in transient right-sided upper extremity paralysis.

Acknowledgements: The authors studies cited in the manuscript were supported by grants
HD47276 (Rao) and the Dana Foundation, DK064832, DK064832-06S1, DK064832-06S2,
P30 DK056341-11 and UL1 RR024992 (Hershey) from the National Institutes of Health.

Translational Endocrinology & Metabolism, Volume 3, Number 4, 2012 | 137

He was scrupulous in avoiding hyperglycemia, even from a very early age.


Academically, he did well throughout his childhood, and at the time of his
emergency room visit, was working, attending community college, and
living independently. After his diagnosis with anterograde amnesia, he
underwent cognitive rehabilitation for his memory deficits, but achieved
only minimal recovery over 2 years and ultimately dropped out of college.
Twenty years later, his anterograde memory deficits were still profound,
and daily functioning was impaired. On examination, there were no signs
or symptoms of retinopathy, nephropathy, or peripheral neuropathy, consistent with his overall well controlled glucose levels (average hemoglobin A1c [HbA1c] from previous 10 years was 7.3%). Clinical readings of
the patients magnetic resonance imaging (MRI) scans (Figure 5-1)
revealed abnormal signals in the periventricular white matter and a significantly abnormal splenium of the corpus callosum, extending into adjacent white matter. In addition, the volume of his hippocampus and
cerebellum was smaller than age-matched controls.
The fundamental questions raised by this case are discussed in this
chapter. For instance, how do repeated episodes of hypoglycemia affect
brain structure and function during development and by what mechanism? Do these effects follow a dose-response pattern? In this chapter, the

FIG 5-1. Diffusion tensor image of healthy age- and gender-matched control (left) and case
(right). Note the difference in microstructural white matter in the splenium of the corpus
callosum (arrows).

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authors provide a synthesis of the human and animal literature that begins
to unravel important aspects of these difficult questions.

Overview of Brain Development and Substrate


Utilization
The topic of brain development and energy metabolism has been reviewed
elsewhere (14). Only an overview is provided here. Mammalian brain
development moves through multiple stages, spanning prenatal and postnatal periods (Figure 5-2). Neuronal proliferation, migration, and differentiation are predominantly prenatal events, while synaptogenesis and
myelination commence prenatally and continue for months and years
after birth in people (1). The brain regions mature at different rates with
more caudal regions, such as the hindbrain, developing earlier than the
forebrain structures (cerebral cortex and hippocampus).
The structural maturation and acquisition of function in a brain region
are paralleled by increased metabolic rate, blood supply, and substrate
utilization in the region. As in the mature brain, glucose is the primary
energy substrate for the developing brain, although it is capable of efficient utilization of nonglucose substrates, such as ketone bodies and lactate (2). Cerebral glucose utilization in 5-week-old infants is 70% to 90%
of the adult levels (5). From 2 to 3 months of age until 4 years of age,
glucose use increases dramatically, until it is double the rate of the adult
brain. It stays relatively stable from ages 4 to 10, and then begins to decline
to adult levels (5). These profound alterations in glucose demand over
brain development could be an important factor in determining any impact
of hypoglycemia on brain structure or function. For example, energydemanding processes, such as synaptogenesis and myelination in cerebral
cortex and hippocampus, may be particularly susceptible to hypoglycemia, similar to other conditions associated with altered cerebral energy
metabolism during development (6, 7). However, it is unlikely to be the
full story. Although optimal brain function depends on a continuous supply
of glucose from the blood, this may not be true in the neonatal and early
postnatal brain, when alternative fuel sources are available (4, 8).

Effects of Hypoglycemia on the Developing Brain:


Animal Data
The effects of hypoglycemia on the developing brain have been studied
using various animal models. The authors and others have used a developing rodent model of insulin-induced hypoglycemia (914). Rats and

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mice between postnatal day (P) 1 and P14 are used to model the neurological effects of neonatal hypoglycemia (9, 10, 12, 14), while P21 to P28
rats are used to model the effects in young children (11, 15). The advantages of the rodent model are that the gross regional development of the
rodent brain is similar to people, and the human-equivalent developmental stages are known (1, 16) (Figure 5-2). Additionally, the rapid rate of
rodent brain development (adult level of maturity is reached at 2 months

FIG 5-2. Timetable of brain development in people (A) and rats (B). Note that energydemanding processes, such as synaptogenesis and myelination, are mostly postnatal events
in both species, making them potentially vulnerable during hypoglycemia.

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of age) makes long-term assessments relatively easy, and the availability


of data from similar models in adult rodents (17, 18) allows comparison
across the ages. The disadvantages of the model are that instrumentation and
frequent blood sampling are difficult because of the small body size and
blood volume. Additionally, assessment of
Developing rodents are often
higher-order cognitive and behavioral is difused to model the neurological
ficult, and the results cannot be directly extraeffects of insulin-induced
polated to people because of interspecies
hypoglycemia in infants and
differences in substrate utilization. Compared
children due to similarities in
with the human newborn infant, ketone
neurodevelopment
bodies account for a larger portion of cerebral energy production in suckling rodents
(19, 20). However, the 2 species are comparable in the postweaning period,
when glucose becomes the predominant energy substrate for both (2).
The following data are from developing rodents subjected to insulin-induced
hypoglycemia. Where available, relevant human data are given.

Compensatory Changes During Acute Hypoglycemia


The brain glucose concentration decreases (neuroglycopenia) soon after
the onset of hypoglycemia (10, 14). However, compensatory mechanisms
maintain cerebral energy production for extended periods (Figure 5-3).
Cerebral blood flow increases (21), presumably to enhance substrate
delivery. Adenosine likely mediates cerebral hyperemia (21) and also
suppresses neuronal activity, potentially to conserve energy. Brain glycogenolysis commences (14) to support energy production by supplying
glucosyl units. Relative to the mature brain,
Energy failure in hypoglycemia
glycogen concentration is higher in the develoccurs only after substantial
oping brain, and unlike hypoxia, the rate of
depletion of all available
glycogenolysis is slower during hypoglycenon-glucose substrates
mia (22). Cerebral transport and utilization
of ketone bodies and lactate are enhanced.
Administration of either substrate delays the onset of cerebral energy failure and preserves neuronal function during hypoglycemia (2325). Free
fatty acids and glycerol produced during lipolysis are other alternative
sources of energy. Nevertheless, the protective role of ketone bodies and
fatty acids is limited in hyperinsulinemic hypoglycemia, since ketogenesis
and lipolysis are suppressed. Conversely, lactate appears to be the preferred
alternative substrate to the developing brain during hypoglycemia (26).
Once alternative substrates are exhausted, cerebral amino acids glutamate
and glutamine become the major energy fuels (10), similar to the mature

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FIG 5-3. Compensatory changes and pathogenesis of neuronal injury in the developing brain
during acute hypoglycemia. (Abbreviations: AIF, apoptosis-inducing factor; CBF, cerebral
blood ow; NAD, nicotinamide adenine dinucleotide; NMDA, N-methyl-D-aspartate; PAR,
poly(ADP)ribose polymers; PARP-1, poly(ADP)polymerase-1; ROS, reactive oxygen species).

brain (17, 27). Aspartate is the byproduct of these anaplerotic reactions.


Energy failure occurs only after substantial (>90%) depletion of glutamate
and glutamine (10). Administration of 10% dextrose rapidly corrects neuroglycopenia and cerebral energy failure (10, 14). However, energy production
remains suboptimal, and glutamate and glutamine concentrations are not
fully restored to prehypoglycemia levels for some time (10). Suppressed neuronal activity and neuronal integrity lasting up to 48 hours despite adequate
treatment have also been described in hypoglycemic infants and children (28,
29). The potential impact of such incomplete recovery on neurodevelopment
is discussed in the context of recurrent hypoglycemia.

Pathogenesis of Brain Injury in Acute Hypoglycemia


Neuronal injury in the mature brain during hypoglycemia is not just due
to cellular energy failure and substrate depletion, but involves a multistep
process (17, 18). A similar mechanism is also likely in the developing

142 | Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

brain, although all the steps have yet to be established. The major factors
initiating neuronal injury during hypoglycemia are cerebral energy failure,
electroencephalogram isoelectricity, and release of glutamate and aspartate into the extracellular space (Figure 5-3) (17, 30, 31). Binding of these
amino acids to N-methyl-D-aspartate (NMDA) and non-NMDA receptors on
the postsynaptic neuron leads to influx of Ca2+ and altered intracellular
Ca2+ levels, production of reactive oxygen species, altered mitochondrial
permeability, membrane lipid peroxidation, poly(adenosine diphosphate
[ADP]-ribose)polymerase-1 overactivation, release of apoptosis-inducing
factor, and cell death (3235). Additionally, activation of adenosine A1
receptor contributes to neuronal injury (12), and this susceptibility
appears to be unique to the developing brain (12). In the mature brain,
glucose reperfusion and release of vesicular zinc are involved in the production of reactive oxygen species (3638). The involvement of these factors in the pathogenesis of neuronal injury in the developing brain has yet
to be established.

Regional Pathology of Hypoglycemia-Induced Brain Injury


The brain regions affected in hypoglycemia depend on the severity of
hypoglycemia and differ among mature and developing brains. Widespread
neuronal injury in the cerebral cortex, hippocampus, and striatum, with
lesser involvement of posterior fossa structures (cerebellum and brain
stem) is seen after an episode of severe hypoglycemia (blood glucose
<1.1 mmol/L [<20 mg/dL]) in adult rats (39). The dentate gyrus of
the hippocampus is particularly affected. A similar distribution of injury
has also been described in autopsy studies of human newborn infants
with prolonged and severe hypoglycemia
(blood glucose <1.1 mmol/L [<20 mg/dL]
Brain regions involved in
for approximately 36 hours) (40, 41). Posattention and memory function
terior parietal and occipital regions were
are particularly vulnerable to
predominantly involved. Conversely, modinjury in hypoglycemia during
erately severe (plasma glucose, approxidevelopment.
mately 2.0 mmol/L [35 mg/dL]) acute and
recurrent hypoglycemia results in selective
neuronal loss in the rostral regions of the cerebral cortex in developing
and adult rats (9, 11, 15, 42, 43). The cingulate and orbital regions, which
are involved in attention function, are particularly affected (9, 1113, 15).
Unlike the mature brain, neuronal injury in dentate gyrus is rare. Nevertheless, abnormal hippocampal function is a sequela of recurrent hypoglycemia in juvenile rats (11).

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Age-Related Vulnerability
Is the developing brain more or less vulnerable than the mature brain? On
the one hand, human neonates are able to tolerate acute hypoglycemia
better than adults. Counter-regulatory hormonal changes and increased
cerebral blood flow occur at lower plasma glucose levels (approximately
1.6 mmol/L [30 mg/dL]) in newborn infants (44), as compared with older
children, where such effects are typically seen at a plasma glucose level of
3.6 to 3.9 mmol/L (65 to 70 mg/dL) (45, 46). Relative to the adult, neuronal injury during acute hypoglycemia is less severe in developing rats and
monkeys (9, 47, 48).
On the other hand, recurrent hypoglycemia may be more detrimental to
the developing brain than the mature brain. In persistent hyperinsulinemic hypoglycemia of infancy, the risk of neurodevelopmental deficits is
greater with neonatal onset of the condition, compared with later onset
(49). Whether this is a reflection of more
The developing brain is more
severe hypoglycemia with the former is not
resistant to injury than the
known. Similarly, early onset of hypoglycemature brain during acute
mia increases the risk of neurological defihypoglycemia. However, an
cits in children with T1DM (50). Recurrent
opposite effect is likely after
hypoglycemia in developing rats causes hiprecurrent hypoglycemia.
pocampal dysfunction during the immediate posthypoglycemia period (11), and
increased anxiety, fear-potentiated startle, stress reactivity, and decreased
social play in the long term (13, 51). Conversely, recurrent hypoglycemia in adult rats does not affect hippocampal function, either immediately or in the long term (52, 53), and may in fact, enhance neuronal
function during euglycemia (53) and protect the brain during subsequent hypoglycemia (54). Whether this is also true in people has yet
to be established.
The developmental stage of the brain (Figure 5-2) at the time of recurrent hypoglycemia may be responsible for the differing results during
development and adulthood. By causing frequent energy failure and glutamate depletion (10), recurrent hypoglycemia may irreversibly alter synaptogenesis and connectivity in the developing hippocampus and cerebral
cortex, similar to other postnatal conditions associated with altered energy
and glutamate metabolism in the brain (6, 7). While alternative substrates
may be able to temporarily support energy production during hypoglycemia, they are unable to support synthetic function. The brain weight, cellularity, and protein and myelin contents are decreased in developing rats
subjected to recurrent severe hypoglycemia (55).

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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

While the animal experiments have improved the understanding of the


neurological effects of hypoglycemia during development, additional research
is needed (56). For example, the biological basis for regional and cellular
vulnerability of the developing brain is not known. The relationship between
the concentration of energy substrates in plasma and the risk of brain injury
is not fully understood. Most of the animal studies are cross-sectional and
provide data at a single time point. Even those studies that have employed a
longitudinal design have used a single severity of hypoglycemia, typically,
severe hypoglycemia (plasma glucose <1.1 mmol/L [<20 mg/dL]). Hence
the role of severity, duration, and threshold effect of hypoglycemia in causing
brain injury during development remains unknown. Similarly, there are
wide variations in the severity and frequency of hypoglycemia, and interhypoglycemia interval among the different recurrent hypoglycemia studies. A controlled study is necessary to evaluate age-related vulnerability.

Effects of Hypoglycemia on the Developing Brain:


Human Data
Clinical Conditions Associated with Hypoglycemia During
Development
The common causes of hypoglycemia during development are given in
Box 5-1. Hyperinsulinism, either congenital or iatrogenic, is the most
common cause. Additionally, defective glucose transporter 1 expression at
the blood-brain barrier may cause neuroglycopenia without concurrent
hypoglycemia (57). There is no consistent or universally agreed upon numerical definition of hypoglycemia during development (45, 56). A plasma
glucose concentration less than 2.6 mmol/L (<45 mg/dL) is commonly used
in newborn infants (58, 59), although there is no evidence that such levels
cause brain injury (60). A plasma glucose value of less than 3.9 mmol/L
(<70 mg/dL), with or without symptoms, is used in the pediatric population beyond the neonatal period (45, 46).

Long-Term Consequences of Hypoglycemia on the Developing


Human Brain
Neuroimaging Changes
Neonatal Period
Cranial ultrasonography, computed tomography (CT) scan, and magnetic resonance imaging (MRI) have been used to evaluate the effects of
hypoglycemia on the neonatal brain. MRI is more sensitive than ultrasound

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Box 5-1. Causes of Hypoglycemia during Development

Transient Hypoglycemia
Developmental delay in gluconeogenesis and ketogenesis
Prematurity, small-for-gestation
Failure of metabolic adaptation at birth
Maternal drugs (eg, -blockers), birth asphyxia
Transient neonatal hyperinsulinism
Maternal diabetes mellitus, excess dextrose administration during labor,
Rh-isoimmunization, large-for-gestation, stress (eg, birth asphyxia, toxemia
of pregnancy, and sepsis)
Increased energy demand
Sepsis, cardiopulmonary disease, seizures, hypothermia
Drug-induced
Maternal drugs during gestation (eg, alcohol, -blockers, selective serotonin inhibitors,
ritodrine, and sulfonylurea)
Infant/child (eg, alcohol, propranolol, salicylates, sulfonylurea, quinine, quinolone, and
purine analogs)
Other conditions
Neonatal polycythemia, organ injury (eg, hepatic failure)

Persistent Hypoglycemia
Hyperinsulinism
Congenital (eg, autosomal-dominant and -recessive mutations in potassium-adenosine
triphosphate (ATP) channel, glucokinase, and glutamate dehydrogenase)
Insulin therapy for hyperglycemia (eg, T1DM and very low birth weight infants)
Syndromes (eg, Beckwith-Wiedemann syndrome)
Counter-regulatory hormone deciencies
Panhypopituitarism, growth hormone deciency, cortisol deciency, glucagon
deciency
Inborn errors of metabolism
Disorders of carbohydrate metabolism (eg, glycogen storage disease, galactosemia,
fructose-1-6-diphosphatase deciency)
Disorders of fatty acid oxidation and ketogenesis (eg, medium- and long-chain fatty acid
oxidation disorders)
Disorders of amino acid metabolism (eg, maple syrup urine disease and propionic
academia)

(61, 62) and avoids the radiation exposure of CT scan. Most published
studies are case reports in full-term infants with underlying risk factors
for hypoglycemia (Box 5-1) (6264). Infants in these studies had severe
hypoglycemia (typically plasma glucose <1.6 mmol/L [<30 mg/dL])
associated with symptoms, including seizures. Large case series that
include a control group report MRI changes in 33% to 94% of infants after

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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

neonatal hypoglycemia (61, 65). Earlier studies reported predominant


involvement of the posterior parietal/occipital regions, similar to the
autopsy studies mentioned previously. Patchy hyperintense lesions on
T1-weighted imaging (6163) and restricted diffusion on diffusion-weighted
imaging (66) during the neonatal period, and gray and white matter atrophy on follow-up (64, 67), were seen in this region in up to 60% of the
infants. It is noteworthy that abnormal MRI changes in the posterior parietal/occipital region have also been described in a neonate with iatrogenic
hyperglycemia (68), suggesting that this region may be particularly vulnerable during glucose dyshomeostasis in neonates. The reasons for the
preferential involvement of the posterior regions are not known. Increased
energy demand due to active synaptogenesis and myelination in this region
may be responsible (63). However, a recent study found exclusive involvement of the posterior cortical regions in only 29% of the infants (65).
Widespread and bilateral white matter injuries were more common and
were associated with hemorrhage/infarction in severe cases. The cerebral
cortex, particularly the parasagittal area, was involved in 51% of the infants,
and basal ganglia/thalamus was involved in 40% of the infants. The cerebellum and brain stem were rarely affected (65). Thus, a more variable
pathology is likely after neonatal hypoglycemia.
The pattern of MRI changes was not affected by the underlying cause,
frequency, severity, and duration of hypoglycemia (6163, 65). The MRI
changes could be transient. In one series, the changes resolved within
2 months in 4 out of 6 infants (61). Most infants in that study later had
normal neurodevelopment, suggesting that their hypoglycemia was probably not very severe. Conversely, another study found psychomotor delay,
seizures, and vision defects on follow-up in 65% of the infants with
abnormal MRI after severe neonatal hypoglycemia (65). The pattern of MRI
changes in the newborn period correlated with the nature of the deficits
on follow-up. Unilateral infarction or involvement of the posterior limb
of internal capsule was associated with spastic hemiplegia, severe bilateral white matter injury with spastic quadriplegia, and global white matter injury with cognitive deficits (65). Similarly, other studies have found
associations between MRI changes in the parietal/occipital region and
vision defects (abnormal visual evoked potentials, strabismus, field defects,
and cortical blindness) on follow-up (64, 66, 67).
Thus, MRI studies may be useful after neonatal hypoglycemia. However, the studies thus far have been mostly performed in infants with
severe hypoglycemia. MRI changes after mild and transient neonatal
hypoglycemia are not known. Similarly, there is paucity of MRI studies in
preterm infants, despite their increased risk for hypoglycemia and its

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neurological effects. Well-controlled prospective studies that incorporate


age-appropriate control groups and longitudinal design are necessary
to improve the clinical utility of MRI in neonatal hypoglycemia.
Postneonatal Period
Despite advances in neuroimaging techniques and the long-standing
interest in the effects of hypoglycemia on the developing brain, there have
been fewer than 10 neuroimaging studies in youth with T1DM, and most
of these were published in the last 4 years (Table 5-1). The larger group
studies and the ones that performed whole-brain, voxel-wise analyses
have all found effects of previous hypoglycemia on the brain. Notably, only
1 of these studies used a prospective design, and only 4 analyzed the wholebrain volumes in a voxel-wise approach. In general, these studies found that
exposure to severe hypoglycemia is associated with differences in both gray
and white matter volumes. The hippocampus, thalamus, posterior parietal/
occipital cortex, and whole-brain gray matter show particular vulnerability,
although replication of these findings across independent samples has been
limited. Notably, the hippocampus was the only region to show enlargement in volume in association with past exposure to hypoglycemia; all
other regions showed reductions in volume or microstructural integrity.
Given the long-standing interest in the structure and function of the hippocampus in diabetes and its response to severe hypoglycemia, the authors
examined hippocampal volume in a cohort of children with T1DM using
unbiased stereologic measurements (69). The authors found that repeated
previous severe hypoglycemic episodes during childhood were associated
with larger hippocampal volumes. However, hippocampal volume was
not associated with hypoglycemia history in 2 smaller studies (70, 71),
and differences did not emerge in this region in whole-brain, voxel-wise
analyses (72, 73). The authors finding also contrasts with the existing,
although limited, case studies of adults who suffered profoundly severe
hypoglycemia, most of which reported neuronal death in the hippocampus
(7477). The authors speculate that the developing hippocampus could be
enlarged in response to hypoglycemia due to gliosis, disruption of normal
developmental pruning, or reactive neurogenesis.
Further research on the effects of hypoglycemia on the developing brain
would also benefit from careful attention to potential confounds, such as
the independent and possibly interactive effects of hyperglycemia exposure on the brain, the impact of age of onset, and the difficulty in characterizing the severity of hypoglycemia exposure. A major limitation in
the conclusions allowed by previous data is that the direction of the relationship between hypoglycemia and brain volumes is undetermined.

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T1DM Controls

T1DM Controls

T1DM Controls

T1DM Controls

T1DM Controls

2009

2010

2011

2011

In press

Hershey69

Aye110

Perantie109

AntenorDorsey111

T1DM

2008

Ho70

Northam73

T1DM Controls

2007

Perantie72

Groups

Year

First
author

73 30

75 25

27 18

95 49

79 51

62

108 51

Retrospective

Prospective

Retrospective

Retrospective

Retrospective

Retrospective

Retrospective

Design

Diffusion tensor imaging;


region of interest and
voxel-wise with multiple
comparison corrections

Voxel-wise gray and white


matter volume with multiple
comparison corrections

Whole-brain gray and white


matter volume; hippocampal
volume

Hippocampal, whole brain


volumes

Voxel-wise gray and white


matter volume

Clinical reading, hippocampal


volume, total gray, white matter
volume

Voxel-wise gray and white


matter volume with multiple
comparison corrections

Analysis

Lower white matter microstructural


integrity in superior parietal lobule and
other regions

Severe hypoglycemia associated with


reduced white matter volume over time
in occipital-parietal cortex

Smaller whole-brain gray and white


matter volume in those with hypoglycemic
seizures

Larger hippocampal volumes in those


with multiple severe hypoglycemia

Smaller thalamic gray matter volume in


those with severe hypoglycemia

Smaller total gray matter in those with


hypoglycemia-induced coma or seizure

Smaller gray matter volume in left


superior temporal region in those
with severe hypoglycemia

Findings Related to exposure to


Severe Hypoglycemia

TABLE 5-1. Structural Brain Imaging Findings Associated with Severe Hypoglycemia in youth with T1DM.

Longitudinal, prospective assessment is necessary to establish whether


hypoglycemia precedes brain volume changes, whether brain volume changes
precede hypoglycemia exposure, or if changes are not directly related to
hypoglycemia. Ultimately, this work could help determine the neural basis of
observed cognitive effects in children and adults with T1DM, and help establish whether there are developmental time periods during which certain
aspects of the central nervous system are particularly vulnerable to the
negative effects of severe hypoglycemia. Further, one may be able to identify networks of vulnerable structures and develop hypotheses to explain
the underlying biological mechanisms for their vulnerability.
Functional Effects
Neonatal Period
Since first reported in 1959 (78), over 45 studies have reported the immediate and long-term effects of neonatal hypoglycemia on neurodevelopment (79). Most are case reports or cross-sectional studies of small sample
size in selected populations, and most lack an appropriate control group
and adjustment for comorbidities. In their review, Boluyt et al (79) identified 18 case-control studies, comprising over 1500 infants, evaluating
neurodevelopment after neonatal hypoglycemia. In 16 (89%) of the studies, neonatal hypoglycemia was associated with psychomotor delay, epilepsy, microcephaly, visual and hearing deficits, and deficits in attention,
perception, and impulse control in infancy and/or childhood (49, 8084).
The risk of abnormal neurodevelopment was twofold to threefold higher
if hypoglycemia was associated with seizures (50% vs 15% in those without seizures) (83, 85). Symptoms other than seizures did not portend this
risk (81, 83, 86), likely reflecting their nonspecific nature. All at-risk
groups (preterm infants, small-for-date infants, infants of diabetic mothers,
and infants with persistent hyperinsulinism) were affected (49, 7984),
except large-for-date infants without maternal diabetes (87). In preterm
infants, recurrent hypoglycemia of moderate severity (plasma glucose,
0.6 to 2.6 mmol/L [11 to 47 mg/dL]) was more detrimental than a
single episode of severe hypoglycemia (plasma glucose, < 0.6 mmol/L
[<11 mg/dL]) (80, 81), presumably because preventive measures were
instituted after an episode of severe hypoglycemia. The magnitude of psychomotor deficits in these infants correlated with the number of days of
hypoglycemia, with a significant effect seen with at least 3 episodes (81).
Most neurological deficits resolved over time, with the exception of 0.5
standard deviation lower arithmetic and motor test scores, and poor head
growth at 5 to 8 years (80, 81). Conversely, a recent prospective study of

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| Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

preterm infants did not find any association between recurrent hypoglycemia during the first 10 days of life and increased risk of neurodevelopmental deficits at 15 years of age (88).
Thus, there is continuing debate whether neonatal hypoglycemia causes
permanent brain injury, especially in the absence of other risk factors
(56). As mentioned previously, most of the studies are case reports without adequate control for comorbidities. Most were performed during an
era when screening for intraventricular hemorrhage or periventricular
leukomalacia was not routine. The two large, long-term studies in preterm
infants were secondary analyses of data collected for a different purpose
(80, 81). In their review, Boluyt et al (79) found that all but 2 of the 18
case-control studies were of poor methodologic quality. Additionally, the
lack of uniformity in subject population, definition and treatment of hypoglycemia, outcome measures, and length of follow-up precludes pooling
of data from these studies. Prospective studies using an optimal design
(79) are necessary to establish the relationship between neonatal hypoglycemia and neurodevelopment.
Postneonatal Period
The potential impact of severe hypoglycemia on cognitive function in
adults and children has been examined for decades. In adults and children,
small cross-sectional studies have found support for the hypothesis that
repeated severe hypoglycemia episodes are associated with lower cognitive function in several domains, including verbal memory and learning,
verbal fluency, visuospatial and visuomotor skills, short-term memory,
and response speed (8993). However, a large, multicenter prospective
study of adults did not find an association between severe hypoglycemia
and cognitive performance on various neuropsychological measures (94,
95). Nevertheless, since most participants were enrolled as adults and had
no previous severe hypoglycemic episodes, this work leaves open the question of how cognitive function is affected by severe hypoglycemia experienced during brain development.
Studies focusing exclusively on children with T1DM have attempted to
fill this gap. In general, the cross-sectional, retrospective studies find that
a higher rate of severe hypoglycemic exposure is associated with poorer
cognitive function, particularly memory and attention, even when controlling for age of onset and hyperglycemia exposure (96102). The most
influential work in this area comes from Elizabeth Northams group in
Australia, which has served to reinforce the findings from these smaller
studies and also clarified some important additional issues for the field
(97, 103105). They assessed a large sample of newly diagnosed children

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with T1DM and followed this cohort and their community controls over
12 years. Importantly, at diagnosis, children with T1DM did not perform
differently than their control group on any cognitive test (104). However,
after 2 years of diabetes, the T1DM group performed worse than controls
on IQ, measures of verbal learning, and speed of processing. Severe hypoglycemia exposure over those 2 years was related to lower memory performance (97, 104). After 6 years of diabetes, groups were still different, and
severe hypoglycemic exposure was related to IQ scores (105). The most
recent analysis from this group reported on differences in cognitive function
after 12 years of diabetes (106). In this analysis, severe hypoglycemia exposure was related to working memory, speed of processing, and verbal skills.
An important caveat to these findings is that the test battery given has had
to change over time, and thus, the analyses presented are necessarily
cross-sectional, and do not reflect within-subject change. In addition, the
data have not been analyzed with respect to the timing of hypoglycemia
exposure during development. Nonetheless, this study has had a significant
impact on the field and suggests that cognitive risks may be associated with
diabetes, hyperglycemia, and hypoglycemia exposure during childhood.
After decades of research of this kind, the field has now progressed
to the point where meta-analyses can be performed. Two meta-analyses
have been published, one of which focuses explicitly on the effect of
severe hypoglycemia on cognitive function during childhood (107). The
other addresses the issue of cognitive function in children with diabetes
more generally (108). Blasetti et al (107) looked at over 1000 children with
T1DM from 12 studies and compared T1DM with and without a history of
severe hypoglycemia. Their analyses found a medium effect size for the
relationship between severe hypoglycemia and lower memory performance.
The analysis also noted small-to-medium effect sizes for learning, intelligence, and verbal tasks. Limitations to this analysis are the same as those
for the individual studies that it relies upon: differing definitions of severe
hypoglycemia, limited information on clinical characteristics of the hypoglycemic events, differing sensitivity and specificity of tasks, failure to
fully account for age of onset or timing of hypoglycemia, and the inherent
limitations of retrospective, cross-sectional designs. In comparison, the
Guadieri meta-analysis (108) examined over 1000 children with T1DM
and approximately, 750 nondiabetic controls from 19 studies (many
of which naturally overlap with the studies in Blasettis analysis). They
found strong effects of early age of onset on learning and memory, attention, and executive function. Their assessment of severe hypoglycemia
was limited to those events that included seizures, and they found only
very small and inconsistent effects. However, their analyses could not

152 | Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

address the question of timing of hypoglycemic episodes, and whether


early hypoglycemia exposure could be mediating the effect of early onset
of T1DM on cognitive function.

Summary, Conclusions, and Future Directions


This chapter demonstrates that the questions raised by the authors initial
case study are still being addressed in the literature. While some progress
has been made in establishing a differential risk of hypoglycemia on the
brain during development, there is a need for prospective, truly longitudinal cognitive and neuroimaging studies that focus on the earliest time
points possible. Untangling the impact of hypoglycemia on the developing brain will require knowledge of the developmental stage at which
each hypoglycemic event occurred, the context in which it occurred
(eg, chronic hyperglycemia), and the features of each event (eg, duration,
severity, and frequency). There are several ongoing studies that have
begun to tackle these issues in neonates, young and older children, and
adolescents with and without T1DM (109, 110). These studies will shed
light on how the developmental trajectory of the brain responds to hypoglycemic events.
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| 159

CME Post Test


Translational Endocrinology & Metabolism: Posterior Pituitary
Update
Please select the best answer to each question on the online answer sheet. Go
to http://www.endojournals.org/translational/

Epidemiology and Impact of


Hypoglycemia on Patients With
Diabetes
1.

Which one of the following


statements is true regarding the
predictive factors of hypoglycemia
risk?
A. Increasing age is associated
with a decreased risk of
hypoglycemia
B. Approximately 1 in
30 persons with diabetes
mellitus has impaired
awareness of hypoglycemia
C. Duration of diabetes mellitus
greater than 15 years is
associated with a 3 times
higher risk of severe
hypoglycemia compared with
the risk in a patient with newly
diagnosed diabetes
D. Renal impairment contributes
to hypoglycemic risk by
accelerating the clearance of
insulin and metabolites of
sulfonylureas
E. Underrcorrection of
elevated blood glucose
concentrations may contribute
to loss of hypoglycemia
awareness and risk of
subsequent severe
hypoglycemic episodes

2.

Which one of the following


changes in endocrine defenses has
been observed over time in diabetic
patients with hypoglycemia?
A. Impaired epinephrine response
B. -Cells failing to recognize
hypoglycemia as a stimulus for
glucagon secretion
C. Resetting of the glycemic
threshold for activation at a
higher blood glucose level
D. Enhanced sympathoadrenal
activation
E. Intensied cholinergic symptoms

3.

Which one of the following


statements is true about mortality
and hypoglycemia?
A. The VADT, ACCORD, and
ADVANCE trials established a
causal relationship between a
severe hypoglycemic episode
and downstream mortality
B. Hypoglycemic mortality rates
are consistently reported to be
15% in young adults
C. Direct precipitation of an acute
cardiovascular event by
hypoglycemia is common
D. Acquired long QT syndrome
caused by insulin-induced
hypoglycemia may be a
possible mechanism for sudden
death in type 1 diabetes mellitus

Translational Endocrinology & Metabolism, Volume 3, Number 4, 2012 | 161

A. Before the exercise session starts,


ensure blood glucose values are
above the target range
B. If there has been marked
hypoglycemia in the preceding
24 hours, avoid exercise
C. If preexercise glucose values are
low, consume low-glycemic
index carbohydrates
immediately before commencing
the session
D. Self-monitor blood glucose
values every 60 to 90 minutes
during the rst session of the
new exercise regimen
E. Immediately before endurancetype exercise, perform 5 to
10 minutes of intense
anaerobic exercise

E. Dead-in-bed syndrome in
persons with type 1 diabetes
mellitus is hypothesized to
result from hypoglycemic
cerebral damage
Prevention and Management of
Hypoglycemia in the Active
Patient With Diabetes
4.

5.

Which one of the following


statements is true regarding
counterregulatory responses to
low glucose levels during exercise
in patients with diabetes?
A. The glucagon response to both
hypoglycemia and exercise is
absent in type 1 diabetes
B. The pronounced sexual
dimorphism in autonomic
nervous system responses
during exercise results in
increased exercise-related
hypoglycemia in women
C. Inadequate hypothalamicpituitary-adrenal axis response
to hypoglycemia is the most
common counterregulatory
hormone dysfunction in type 1
diabetes in the setting of exercise
D. Previous hypoglycemia can
blunt counterregulatory
responses during subsequent
exercise
E. Epinephrine and
norepinephrine responses to
submaximal exercise are
comparable between persons
with type 1 diabetes and those
without diabetes
Which one of the following reects
the best advice for a patient with
type 1 diabetes who would like to
begin an exercise regimen?

6.

Which one of the following


statements is true regarding
insulin therapy in the context
of exercise in patients with
diabetes mellitus?
A. Mixed insulin preparations
are easier to adjust than a
basal-bolus regimen or insulin
pump therapy to accommodate
exercise
B. A patient should never
disconnect from an insulin
pump during exercise
C. Sensor-augmented pump
therapy eliminates the risk of
exercise-induced hypoglycemia
D. Insulin injection sites during
exercise should include arms
and legs
E. For insulin pump therapy, lower
temporary basal rates can be
set in anticipation of potential
late hypoglycemia occurring
after exercise

162 | Translational Endocrinology & Metabolism: Hypoglycemia in Diabetes Update

Hypoglycemia in Diabetes: Patient


Resources from the Hormone
Health Network

The Hormone Health Network, The Endocrine


Societys patient education enterprise, helps patients
have more informed discussions about hormones,
health, disease, and treatment with endocrinologists, primary care physicians, and other healthcare providers. The Networks goal is to
move patients from educated to engaged, from informed to active partners in their
health care, fostering better health care outcomes. The Networks educational resources
are based on the most advanced clinical and scientific knowledge from The Endocrine
Society.
Among its patient education offerings are the award-winning Hormones and You
fact sheet series in English and Spanish, and patient guides based on The Endocrine
Societys Clinical Practice Guidelines. The easy-to-read fact sheets provide basic information about the causes, symptoms, diagnosis, and treatment of a broad array of hormonerelated conditions. Patient guides offer more detail about the evaluation and diagnosis
of a specific disorder and how patients can work with their physicians to achieve the
therapeutic goals of treatment.
For patients who experience or may be at risk for hypoglycemia, the Hormone Health
Network offers the following publications:
Continuous Glucose Monitoring
Diabetes and Exercise
Diabetes and Insulin
Diabetes and Low Blood Glucose (Hypoglycemia)
Diabetes and Nutrition: Carbohydrates
Self-monitoring of Blood Glucose
Patient Guide on the Diagnosis and Management of Hypoglycemic Disorders
(Low Blood Sugar) in Adults
In addition, the Network offers resources on a broad range of diabetes-related topics
at www.hormone.org/Resources/diabetes.cfm.
Developed with The Endocrine Societys leading clinical and scientific experts, the
Hormone Health Networks free online resources provide easy-to-understand information
on more than 80 hormone-related topics. Visit www.hormone.org to view and download
fact sheets, patient guides, brochures, and more.

Translational Endocrinology & Metabolism, Volume 3, Number 4, 2012 | 163

CME Answers: 1, C; 2, A; 3, D; 4, D; 5, B; 6, E.

164

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