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Hello.
My name is Jens Holst.
I'm Professor of Medical Physiology at the
University of
Copenhagen and I'm here to talk about
glucose regulation.
Let us begin by considering the normal
concentrations
of glucose in the circulating body fluids.
What should we choose?
Blood or plasma?
We will choose plasma because the
concentration
in the red blood cells is low.
What matters is the amount of glucose,
that can diffuse freely,
and reach target cells, serving as fuel or
exerting regulatory functions.
The concentration in plasma is around five
millimoles per liter,
corresponding to 90 milligrams per
deciliter, and is remarkably constant.
In healthy subjects, it rarely falls below
four millimoles per
liter and rarely increases beyond seven
millimoles per liter.
With this tight control one could imagine
that glucose
control is important and this is indeed
the case.
Numerous tissues depend on glucose for
energy supply
to support vital functions.
Particularly the central nervous system
cannot
operate without adequate supplies of
glucose.
And the same is true for the red blood
cells.
If glucose falls too much, this is what we
call hypoclycemia, we may experience
confusion, convulsions, loss of
consciousness
and eventually death.
Conversely, acute elevations of plasma
glucose are
associated with impaired neural functions,
especially cognitive functions.
But the real danger is the damage to a
large
number of proteins caused by a prolonged
elevations of plasma glucose.
This is what causes the devastating
diabetic complications.
Neuropathy, retinopathy, nephropathy.
The so called micro-vascular
complications.
Chronic hyperglycemia is also associated
with macro-vascular damage

which may lead to myocardial infarction,

stroke and
amputations. But how is it possible to
maintain this constant glucose level?
To answer this question, we must consider
the glucose
fluxes inside the body that occur during
daily life.
And that will reveal the consumption and
production
are so closely matched, that deviations
from five
millimolar are very rare, in spite of very
large flux differences depending on the
physiological state.
The glucose in plasma is either derived
from the diet and
absorbed from the gut into the
bloodstream, after digestion of dietary
carbohydrates.
Alternatively, it is produced in tissues
capable of producing glucose for export.
The amount of glucose from the diet varies
of course, but may amount to as much as
3000 millimoles or some 5000 grams or a
eight to nine kj per 24 hours.
Where does all this glucose go?
It enters the volume of distribution for
glucose.
And that is roughly equivalent to the
extracellular space.
This is because glucose cannot cross the
cell membranes, and
enter the cells, unless these are equipped
with special transporters.
The extracellular space roughly
corresponds to
about twenty percent of the body weight,
that is fourteen liters in a person with a
body weight of seventy kilograms.
3,000 millimoles in fourteen liters, this
would
amount to more than 200 millimoles per
liter which would be absolutely lethal.
But glucose is, of course, also removed
from the circulation.
The brain and the rest of the central
nervous system
needs a constant supply of some 35
millimoles per hour.
That's about half of the pool.
What is the pool?
So it's these 14 liters of extracellular
volume with a
concentration of five millimoles per
liter, and that equals 70 millimoles.
And then we have the muscles.
During maximal muscular work,
the muscles may
take up several hundreds of millimoles per

hour.
Which would off cause rapidly empty the
pool.
It's clear, that we need very efficient
mechanisms to ensure,
that the glucose concentration stays
normal in both of these situations.
So what can the body do with the absorbed
glucose?
There are two possibilities.
One is that it can be metabolized in the
tissues.
But this process is of course limited to
the energy requirements of the tissues.
Once these are satisfied, no more glucose
is disposed of in that way.
The second is to deposit the glucose.
This occurs in several tissues.
Them most important ones being the liver
and the skeletal muscular tissues.
Here glucose units are combined into large
molecular weight glycogen molecules,
facilitated by the glycogen synthase
pathway.
The glucose stored as glycogen can be
mobilized again.
The liver can split the glycogen molecules
again.
And actually re-export the individual
glucose units.
The latter is due to the fact that the
liver cells express an enzyme called
glucose-6-phosphatase.
Which allows exit of glucose.
The muscles can also split glycogen but
only for internal use.
They cannot very well export glucose.
Once the glycogen deposits are filled the
organism cannot store any more glucose.
But may instead convert the glucose into
fat.
Both the liver and fat cells of the
adipose tissue are
capable of synthesizing fatty acids
and eventually triglycerides from glucose.
It's well recognized, that storage in this
way is almost unlimited.
Can fat be mobilized to bring back
glucose to the blood stream.
Not readily.
The triglycerides may undergo lipolysis
where by the fatty acids are liberated.
The fatty acids may then be exported and
transported.
To tissues in need of energy, particularly
the muscles, for combustion.
The backbone of the triglycerides, the
glycerol
moiety, may also be exported and
transported

to the liver where it can serve

as substrate for the process designated
gluconeogenesis,
whereby new molecules of glucose are
synthesized.
Clearly the liver plays a central role
in the regulation of the plasma glucose
concentration.
It does so, not only because of its
ability to take up
considerable amounts of glucose but also
to produce glucose if needed.
To summarize, the liver takes up glucose
and stores
it as glycogen, in the process named
glycogenesis, but it
can also produce glucose for export to
the circulation,
either by mobilizing its stores of
glycogen, so called glycogenolysis,
or by production of new glucose
from various substrates, so-called
gluconeogenesis.
We mentioned glycerol as a substrate, but
there are other important substrates.
This include lactate, derived from
anaerobic
metabolism of glucose in the tissues
as well as amino acids liberated
from peripheral tissues, for instance
during fasting.
It is possible to measure the fluxes
of glucose in humans with minimal
invasion by
infusing at a constant rate isotopically
labeled
glucose, which allows one to follow the
fate
of the molecules in the body.
By measuring the varying dilution of the
tracer, the radioactive glucose,
in the glucose pool it is
possible to determine both
the formation of glucose in the body, the
so-called rate of appearance,
and the total glucose disposal,
the rate of disappearance.
We should mention that also the kidneys
are
capable of producing small amounts of
glucose by glyconeogenesis.
The kidneys may also help to dispose of
glucose at very high concentrations.
The maximum capacity for reabsorption of
glucose in the kidneys
is reached at a plasma concentration
around 10 millimoles per liter.
And at higher concentrations glucose is
therefore lost in the urine.
Clearly this is not important for healthy

individuals, but
occurs frequently in diabetes where we talk
about glucosuria.
Since the excretion of glucose is
accompanied by a considerable loss of
water, so-called osmotic diuresis, glucosuria
may lead to
serious loss of fluid and electrolytes,
in patients with dysregulated diabetes.
Thus, with a person in nutritional
balance, dietary carbohydrates are either
combusted or rapidly deposited as glycogen
in muscles and liver.
In the interdigestive periods when glucose
uptake from the
gut has ceased, the liver starts to export
glucose.
And is capable of maintaining a
constant plasma glucose concentration for
lengthy periods.
In the beginning the predominating
mechanism
will be glycogenolysis, but the liver can
only store glycogen enough to support to
bodily needs for about 24 hours.
However long before the stores are
exhausted,
the liver starts to produce glucose by
gluconeogenesis.
And this pathway is sufficient to
maintain plasma glucose levels for many
days.
As is evident from studies of people subjected to
starvation,
which does normally not cause
hypoglycemia.
This situation is obviously extremely
demanding
with respect to supplies of substrates.
Which eventually will result in a
catabolic state where
the gluconeogenic substrates is amino
acids from body proteins.
The question then arises.
Where are the sensors and regulatory
mechanism in glucose homeostasis?
What makes the liver switch its functions
according to the metabolic demands?
What makes skeletal muscle switch from
carbohydrate to fatty acid oxidation?
The answer is of course the pancreatic
endocrine islets of Langerhans.
Albeit several other mechanisms may play a
role as well.
Our approximately two million pancreatic
islets which make up one to
two percent of the pancreatic volume,
contain five endocrine cell type.
The two most important ones making up more
than 90% of the cells are the insulin

producing beta cells and the glucagon

producing alpha
cells. In total a couple of thousands per
islet.
The remaining cell types are firstly the
somatostatin producing delta cells,
which probably exert important paracrine
regulatory functions within the islets.
Secondly, cells producing pancreatic
polypeptide
with no known function.
And finally, ghrelin-producing cells, the
importance of which is also unclear.
The arrangement of the cells in the islets
varies somewhat between the species.
And appears somewhat irregular in humans.
The arrangement is probably very important
for intra-islet regulatory processes.
For example, somatostatin powerfully inhibits
the secretion of both insulin and glucagon,
and insulin is thought to inhibit
glucagon secretion, while glucagon
stimulates insulin secretion.
For two such cells lying next to each
other, it
is easy to image that they might influence
each other's functions.
But these interrelationships are not very
well worked out.
Nevertheless, the main function of the
endocrine pancreas is well established.
It reacts by increasing insulin secretion,
as the concentration of glucose in the
plasma
that perfuses it, rises and with increasing
secretion of glucagon if the glucose
concentration falls.
One way of studying this is to isolate
surgically the pancreas and keep
it alive with artificial media for which
one can control glucose concentrations.
The mechanism of glucose stimulation of
the beta cells
has been worked out in considerable
detail.
The beta cell is a glucose sensor and
controller in one.
It reacts to changes in plasma glucose
concentrations by producing appropriate
amounts of insulin.
So what is the glucose sensor?
Like in other cells, glucose cannot
directly
pass into the beta cells.
But it is equipped with a glucose
transporter,
a transmembrane protein that facilitates
passage of glucose.
This particular transporter is called Glut

2 and it is characterized
by having a KM close to the normal plasma
glucose concentration.
This causes the transporter to operate
with first order kinetics for glucose.
And therefore insures that plasma glucose
transport into the
beta cell is proportional to the exterior glucose concentration.
Once in the beta cell, the glucose is
phosphorylated
by a specific enzyme, glucokinase, with a
similar KM as the transporter, so
that the phosphorylation rate is roughly
proportional to the plasma concentrations.
These two molecules, the transporter and
the
glucokinase, constitute the glucose sensor
of the beta-cells.
Since together they allow formation of
glucose-6-phosphate
at a rate that is proportionate to plasma
glucose.
Phosphorylated glucose then enters
glycolysis with ensuing formation of ATP.
This cytosolic ATP interacts with a
certain ATP-sensitive
potassium channels, in the beta cell
membrane, the K-ATP channels,
where increased ATP reduces the opening
probability of the channel.
Again, to an extent that is proportional,
to plasma glucose.
The reduction diminishes the influx of
potassium ions from the cell.
Since the membrane potential of the beta
cells to a large extent is generated by
efflux of positively charge potassium
ions, this
means that the cell will become
depolarized.
The depolarization in turn will increase
the opening probability.
of voltage gated calcium channels, and
because of
the steep gradient for calcium, the 10,000
times higher concentration,
outside compared to inside the cell,
calcium will enter the cell.
An elevated intracellular level of free ionized
calcium is exactly
what is needed to initiate the process of
exocytosis, where by
intracellular insulin containing granules
are transported to the cell
membranes where they open and release
their contents to the exterior.
Clearly any other process that causes
depolarization
or elevated intracellular calcium levels
may also influence secretion.

Thus other fuels including lipids and amino acids

may also generate ATP and influence
secretion.
Certain hormone and neurotransmitter
receptors are coupled to intracellular
signalling pathways that may elevate
intracellular calcium from intracellular
stores.
Some hormones, notably the incretin
hormones, which we will talk about later,
activate receptors coupled to the membrane
associated adenylate cyclase.
Leading to the formation of cAMP,
which may both directly and indirectly
influence both the KATP channels and
exocytosis.
Interestingly, the sulfonylurea, among the
most widely used anti-diabetic drugs,
excert their action by binding to and
blocking the KATP
channels and in this way activating the
machinery for insulin release.
By acting on the KATP channels they bypass
glucose metabolism.
And therefore, will cause insulin
secretion regardless of
the glucose levels, surrounding the the
beta cells.
This explains that they may produce
inappropriate
amounts of insulin and therefore cause
unintended hypoglycemia.
The alpha cells share some of the
biochemical features of the beta cells.
But react, as mentioned, with decreasing
secretion and response to increasing
glucose concentrations,
as nicely illustrated in these
experiments in healthy volunteers,
exposed to both high and low plasma
concentrations of glucose.
The mechanisms responsible for this have
still not been completely worked out.
Undoubtedly because, pure isolated alpha
cells are not easy to get hold of.
There is good evidence that one of the
functions of
the somatostatin-secreting delta cells is to
regulate glucagon secretion.
As mentioned, the main regulatory mechanisms for
the islets is their ability to react to
changing concentration of glucose in
plasma with appropriate
alterations in the secretion of insulin
and glucagon.
But is this enough to keep plasma glucose
constant?
Indeed the islets will respond to several
other important stimuli
for instance what is the role of other

nutrients? Lipids have

limited effects on both insulin and
glucagon secretion but recent evidence
suggests that beta cells are equipt with a
number of receptors,
for both long and short chained fatty
acids, which
may play a role in it's maintenance of
insulin secretion.
Otherwise the effects of lipids are most
often discussed into the context of
lipotoxicity.
Deleterious effects on beta cells
function of
high lipid levels, as seen in obesity.
However, as briefly mentioned, several
amino acids provide a
powerful stimulus to both insulin and
glucagon secretion.
Indeed, both alpha and beta cell function
may be evaluated with arginine tests,
where arginine is injected intravenously
and insulin and
glucagon responses are measured in plasma
shortly after.
Protein-rich meals likewise produce a
strong stimulus.
The combined action on both hormones makes
sense.
The insulin response serves to enhance
peripheral uptake of amino acids and
their incorporation into tissue proteins
in
agreement with insulin's general anabolic
activity.
However, if the meal does not contain an
equivalent amount
of carbohydrate one could fear that the
insulin response might result
in hyperglycemia but this is prevented by the
simultaneous stimulation of glucocon
secretion. That this actually happens,
has been demonstrated in simulation
experiments.
The presence of cholinergic and other
neurotransmitter receptors on the beta
and
alpha cells, suggest that the autonomic
innovation of the islets also plays a role.
Thus, vagal stimulation provides a
powerful stimulus to both insulin and
glucagon secretion, suggesting that for
instance meal stimulation, in addition
to the effects of absorbed nutrients, also
engages a neural component.
Indeed, there are numerous reports, on the
existence
of a cephalic phase, for insulin secretion.
But the sympathetic division of the
autonomic

nervous system may be even more important.

Stimulation of the sympathetic nerve
supply to the pancreas
will strongly inhibit insulin secretion,
and enhance glucagon secretion.
This is one of the mechanisms engaged
during muscular work. And as we shall see
later, these changes are essential for the
maintenance of plasma glucose levels in
this situation.
But are hormones from outside the pancreas
also important for islet function.
The answer is yes.
In fact it turns out that up to 70% of the
postprandial insulin response is
caused by actions of hormones secreted
from the gut, the so-called incretin
hormones.
The amplification of insulin secretion by
gut hormones is called the incretin
effect.
The incretin effect is normally evaluated
by
comparing the insulin responses to an oral
glucose
load and to an intravenous infusion of
glucose adjusted to result in similar
glucose concentrations.
This is shown in this figure.
It is clear that the oral route causes
much higher insulin secretion.
The incretin effect is very important for
keeping down, postprandial glucose levels.
Have a look at these experiments in
healthy individuals.
Here, glucose in amounts ranging from 25
to 100 grams, were given orally.
And the resulting excursions were copied
by intravenous infusions.
The most surprising observation is that
the glucose excursions are virtually
identical in spite of up to four fold
differences in glucose loads.
It is the incretin effect.
And the next figure, we see the
insulin responses, to various glucose
loads.
And it's clear that insulin secretion, is
dramatically and
dose dependently increased in response to the
increasing oral loads.
In other words, the incretin effect,
ensures that plasma glucose
excursions after carbohydrate loading are
kept at a low
and relatively constant level regardless
of the amount of carbohydrate ingested.
Which are the hormones responsible for the
incretin effect?
The two most important ones are

glucose-dependent insulinotropic
polypeptide. In short, GIP.
And, the glucagon-like peptide-1, GLP-1.
Both have remarkable effects on the beta
cells.
The incretin effect is of particular
clinical
interest because it is almost completely
lost
in patients with type two diabetes and
this loss contributes considerably
to the inability of these patients to
secrete sufficient amounts of insulin.
Fortunately one of the hormones GLP-1 is
nevertheless
capable of stimulating insulin secretion
in supraphysiological doses.
And because of this, it is possible to
treat type two diabetes with GLP-1
agonists.
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