c h a p t e r

35
Regulation of Intermediary
Metabolism During
Fasting and Feeding
Ralph A. DeFronzo and Ele Ferrannini

CHAPTER OUTLINE
ENERGY METABOLISM,  599 Dynamic Interaction Between Insulin Sensitivity and
GLUCOSE DISTRIBUTION,  600 Insulin Secretion,  610
GLUCOSE METABOLISM: METHODOLOGICAL Effect of Insulin on Hepatic and Peripheral
CONSIDERATIONS, 600 Glucose Metabolism,  612
GLUCOSE METABOLISM: BASAL Intracellular Pathways of Glucose Disposal,  614
(POSTABSORPTIVE) STATE,  601 Free Fatty Acid–Amino Acid–Glucose
Glucose Production,  601 Interactions, 618
Glucose Disposal,  605 Lipid Synthesis,  622
Glucose Cycles,  607 Ketone Metabolism,  623
GLUCOSE METABOLISM: FED Oral Glucose,  623
(POSTPRANDIAL) STATE,  608 Counterregulatory Hormones,  625
Quantitation of Insulin Sensitivity and Insulin
Secretion, 608

KEY POINTS
• D  uring fasting conditions, the rate of total body glucose uptake is precisely balanced by
endogenous glucose production from the liver (80%) and kidney (20%).
• Following ingestion of a meal, the rise in plasma glucose and insulin, in combination
with activation of the gut factor, combine to suppress endogenous glucose production
and stimulate glucose uptake in liver and muscle.
• Glucose uptake and metabolism following a meal is dependent upon the coordinate
activation of the insulin signal transduction system, glucose transport/phosphorylation,
glycogen synthase, the PDH complex, and the mitochondrial chain.
  

In the fasting (or postabsorptive) state, the plasma glucose
concentration in a healthy adult is maintained within a
very narrow range: 65 to 105 mg/dL (3.6 to 5.8 mmol/L).
Under these conditions, insulin-independent tissues, the
brain (50% to 60%), and splanchnic organs (20% to
25%) account for the majority of total body glucose uti-
lization. Muscle, an insulin-dependent tissue, is respon-
sible for most of the remaining 20% to 25% of glucose
disposal.1,2 The basal rate of tissue glucose uptake is pre-
cisely matched to the rate of glucose output by the liver; in
fact, fasting endogenous glucose release is best correlated
with body fat-free mass. After the ingestion or infusion of
598
glucose, this fine balance between hepatic glucose produc-
tion and tissue glucose utilization is disrupted, and main-
tenance of normal glucose homeostasis in the fed state is
dependent on four processes that occur simultaneously
and in a coordinated fashion: (1) in response to hyper-
glycemia, insulin secretion is stimulated; (2) the combi-
nation of hyperinsulinemia and hyperglycemia augments
glucose uptake by splanchnic (liver and gut) and periph-
eral (primarily muscle and fat) tissues; (3) both insulin
and hyperglycemia suppress hepatic glucose production;
(4) insulin inhibits lipolysis in adipocytes, and the
reduction in plasma free fatty acid (FFA) concentration
 35  REGULATION OF INTERMEDIARY METABOLISM DURING FASTING AND FEEDING
enhances muscle glucose uptake and facilitates the sup-
pression of hepatic glucose production.3 Glucose uptake
by fat cells accounts for <10% of an ingested or infused
glucose load in a lean adult in whom fat mass averages
25% of body weight in women and 15% in men. Adi-
pose tissue glucose uptake can increase to 15% to 20% of
ingested glucose in the obese subject. In this chapter, we
review the whole-body and cellular mechanisms by which
pancreatic hormones (insulin and glucagon) regulate the
normal trafficking of substrates between the splanchnic
tissues (liver and gastrointestinal tract) and the glucose-
utilizing organs in the fed and fasting conditions.
ENERGY METABOLISM
All living organisms require a constant generation of
energy to maintain viability. In humans, this energy
comes in the form of adenosine triphosphate (ATP),
which is derived from the oxidation of foodstuffs. Because
humans feed intermittently, it is necessary to build up a
sufficient energy reservoir that will be adequate to supply
a constant input of metabolic fuels for oxidation during
interfeeding periods. To accomplish this, the body has
developed an intricate metabolic network with multiple
checks and balances—hormonal, neural, and substrate—
which ensure a steady supply of metabolic fuels to the
tissues. This is particularly crucial for the brain and other
neural tissues that use glucose exclusively as their energy
source (except under unusual conditions of prolonged
fasting, when ketone bodies can substitute in part for glu-
cose). Because of the obligate dependence of the brain on
glucose and because of the intermittent feeding behavior
of humans, they must ingest more calories than necessary
for immediate energy use and store the excess calories in
body depots, which can be mobilized efficiently at a later
time for use by the tissues of the body.
From the quantitative standpoint, fat represents the
major energy source in the body (Table 35-1). An adult
of ideal body weight (70 kg) possesses approximately
12 kg of triglyceride, which is stored within adipose tissue.4
TABLE 35-1  Tissue and Circulating Energy
Content Provided by the Three Major Fuels: Fat,
Carbohydrate, and Protein
Fuel Mass (g) Energy (kcal)
Tissue Depots
Adipose Triglyceride 12,000 110,000
Muscle Protein 6,000 24,000
Muscle Glycogen 400 1,600
Circulation
Blood Glucose 20 80
Blood Fatty acids 0.3 3 large reservoir of energy. A 70-kg man possesses approxi-
Blood Triglycerides 3 30
Blood Ketones 0.2 0.8
Blood Amino acids 6 24
Data from Ruderman NB, Tornheim K, Goodman MN. Fuel
­homeostasis and intermediary metabolism of carbohydrate, fat, and
protein. In: Becker KL, ed. Principles and practice of endocrinology
and metabolism. Philadelphia: Lippincott; 1992: 1054-1064.
599
If this fat were completely mobilized and o ­ xidized, it
would provide about 110,000 kcal. Assuming an average
metabolic rate of 2000 kcal/day, this would be sufficient
to sustain the body’s energy needs for 55 days. In addi-
tion to its abundance, fat is a more efficient energy source
than either glycogen or protein, because 9.5 kcal is gen-
erated for every gram of fat that is completely oxidized.
The comparable energy value for glycogen and protein
is 4 kcal/g. Moreover, fat is a less cumbersome storage
form of energy because it exists in a nearly anhydrous
form in the adipocyte, whereas each gram of glycogen
and protein requires approximately 3 g of water. From
these considerations, it is obvious that the caloric den-
sity of adipose tissue (∼8.5 kcal/g of fat) is much greater
than the caloric density of either glycogen or protein
(∼1 kcal/g). Viewed in another way, if one were to replace
the amount of energy stored in fat with an equivalent
amount of energy in the form of glycogen or protein,
the body weight of our hypothetical 70-kg man would
expand to 160 kg. This has major adaptive disadvantages
for a species that depends on mobility for survival.
Because the major storage form of energy in the body
is fat, but the brain and other neural tissues have an obli-
gate need for glucose, the body must have a readily avail-
able form of carbohydrate. This is provided by glycogen.
In a 70-kg man, approximately 80 g of carbohydrate is
stored as liver glycogen and 400 g as muscle glycogen.4
Because muscle does not contain glucose-6-phosphatase
(G6Pase), it cannot generate free glucose for transporta-
tion to other tissues. However, glycogenolysis in muscle
can provide a readily available source of glucose for local
needs in response to acute muscular activity. In addi-
tion, muscle-derived lactate, pyruvate, and alanine can be
transported via the blood to the liver, where they are used
for gluconeogenesis during starvation or prolonged exer-
cise. In contrast to muscle, the liver contains all the neces-
sary enzymatic machinery to produce free glucose from
glycogen and to synthesize new glucose from gluconeo-
genesis precursors. Thus, for short-term metabolic needs,
liver glycogen represents the principal carbohydrate res-
ervoir for the energy needs of the brain. As can be seen in
Table 35-1, the amount of energy contained in circulating
glucose is quite small.
Glycogen metabolism is controlled by a cascade of
reversible phosphorylation-dephosphorylation reactions
that ultimately converge on the more proximal enzymes
that catalyze glycogen synthesis (glycogen synthase) and
glycogen degradation (glycogen phosphorylase). Both the
synthesis and breakdown of glycogen are regulated by
complex, interacting mechanisms involving substrates as
well as hormones and neural inputs. In subsequent sec-
tions of this chapter, we review some key aspects of the
control of glycogen metabolism.
From a theoretical standpoint, protein also represents a
mately 6 kg of protein, with a potential energy value of
24,000 kcal.4 However, each protein in the body has a
specific function—for example, an integral constituent of
cell membranes and organelles, an enzyme, a contractile
element such as actin or myosin, or a specific transporter of
some essential nutrient, element, or vitamin. An excessive
600 PART 5  DIABETES MELLITUS
breakdown of protein would lead to the disruption of nor-
mal cell function and eventually to death. Therefore, the
body has developed a complex metabolic and hormonal
response to fasting that minimizes proteolysis and release
of amino acids. Thus when fasting is prolonged beyond
2 to 3 days, there is a major shift from carbohydrate to fat
and ketone body utilization. After 1 to 2 weeks of star-
vation, the rates of gluconeogenesis and glucose utiliza-
tion are markedly reduced, and ketone bodies become an
important substrate for the energy needs of the brain and
other neuronal tissues. However, the brain always main-
tains a need for some glucose. Acetone, which is formed by
the nonenzymatic decarboxylation of acetoacetic acid, can
serve as a gluconeogenic precursor by being converted to
pyruvaldehyde in the liver or to 1,2-propanediol in extra-
hepatic tissues. The rise in circulating blood ketone levels
also provides a signal to the muscle to inhibit protein catab-
olism, thus sparing amino acids for vital cell functions.
GLUCOSE DISTRIBUTION
As a metabolic substrate, carbohydrate is present in organ-
isms in its simple monomeric form, α-D-glucopyranose,
and as a branched polymer of α-glucose, namely, glyco-
gen. Disaccharides of glucose include lactose, maltose,
and sucrose, but these are quantitatively less important.
In normal fasting subjects, glucose circulates in plasma
water at a basal concentration that ranges from 65 to
100 mg/dL (3.6 to 5.6 mmol/L). After a meal, the plasma
glucose concentration in healthy individuals does not
exceed 160 to 180 mg/dL (8.9 to 10 mmol/L). Circulat-
ing plasma glucose is in rapid equilibration with the red
blood cell (RBC) glucose concentration.5 A non–insulin-
regulatable transporter effects the facilitated diffusion of
glucose from plasma water into the RBC.6 Because of the
abundance of this transporter in RBCs, glucose diffuses
very rapidly across RBC membranes, with an estimated
equilibration time of only 4 seconds. After its transport
into the cell, the rate of glucose utilization via glycoly-
sis has been estimated to be approximately 25 μmol/
min or 6 μmol/min per square meter of diffusion surface
(each RBC is 7 μm in diameter and 2 μm thick; a total
RBC mass of 2 to 3 × 1013 cells exposes a surface area of
∼4 m2).5 Because this rate is ∼17,000 times slower than
the rate of glucose transport into the erythrocyte, the glu-
cose concentration will, in general, be the same in plasma
and erythrocyte water. Plasma proteins comprise some
8% of plasma volume, whereas RBC proteins and ghosts
occupy ∼38% of the packed RBC volume (which, in turn,
averages 40% of the total blood volume). Thus, 20%
(i.e., 0.38 × 0.4 + 0.08 × 0.6 = 0.2) of the total blood
volume is inaccessible to glucose. It follows that glucose
concentration should be identical in plasma and RBC
water under most circumstances and that a blood water
glucose concentration of 90 mg/dL (5.0 mmol/L) trans-
lates into a plasma glucose concentration of 83 mg/dL
(4.6 mmol/L) and a whole-blood glucose concentration of
72 mg/dL (4.0 mmol/L), that is, a 15% systematic differ-
ence between plasma and whole-blood glucose concentra-
tion under typical conditions of hematocrit, proteinemia,
and erythrocyte volume.
GLUCOSE METABOLISM: METHODOLOGICAL
CONSIDERATIONS
Because both RBCs and plasma transport glucose, the
total amount of the sugar reaching any given organ is the
product of the arterial whole-blood glucose concentra-
tion times the total blood flow to that organ. Similarly,
the total amount of glucose leaving a body region is the
product of whole-blood glucose level in the venous efflu-
ent times the blood flow rate. From this, it follows that
the net balance of glucose movement across a body region
is given by the product of blood flow and the arterio-
venous whole-blood glucose concentration difference, or
the Fick principle (Fig. 35-1). It should be emphasized
that the use of plasma flow rates and plasma glucose con-
centration systematically underestimates the net organ
balance of glucose (and, for that matter, of any substance
that is transported in plasma as well as in RBCs, e.g.,
lactate, some amino acids). Because the plasma flow
is less than the blood flow by an amount equal to the
hematocrit (∼40%), whereas the plasma glucose concen-
tration is higher than whole-blood glucose by only 15%
(0.6 × 1.15 = 0.69), this will lead to a 31% underestima-
tion of the net organ balance.
In muscle, which does not contain G6Pase, the net
organ balance is equivalent to the amount of glucose
that is taken up and metabolized. In the liver, however,
there can be simultaneous uptake and release (from
hepatic glycogen stores or gluconeogenesis). By com-
bining the organ balance technique with tracer glucose
(labeled with radioactive, e.g., tritium [3H], or stable
isotopes, e.g., deuterium [2H]), one can calculate the
uptake of glucose by an organ bed according to the
following equation7:
Uptake = (FE) (Blood flow) (Arterial glucose concentration)
where FE is the fractional extraction of tracer glu-
cose—calculated as (A* – V*)/A*—and A*—and V* rep-
resent the radioactivity of labeled glucose (or the tracer/
tracee ratio in the case of stable isotope tracers) in the
artery and vein, respectively. If one knows the net bal-
ance of glucose (or any other substrate) across an organ
bed and the unidirectional uptake, one can calculate the
release of glucose (or any other substrate) according to
the following relationship (see Fig. 35-1):
Net balance = Uptake ‐ Release
Net balance = uptake-release
= (flow)(A-V)
Release (R)
Inflow = F × A Outflow = F × V
Organ
Uptake (U)
Figure 35-1  Schematic representation of substrate (e.g., glucose)
e­ xchange across an organ (e.g., the liver) that both irreversibly removes
the substrate and adds it to the systemic circulation. A, Arterial concen-
tration; F, blood flow; V, venous concentration.
 35  REGULATION OF INTERMEDIARY METABOLISM DURING FASTING AND FEEDING
By employing the catheter technique to measure the net
organ balance of glucose in combination with tracer glu-
cose, much information can be gained about the interorgan
exchange of glucose and other substrates, as well as the met-
abolic pathways involved in the regulation of glucose utiliza-
tion. The use of a glucose tracer also allows one to measure
whole-body glucose (or other substrates) turnover.8 Because
of its simplicity, the isotope dilution method has become
popular among clinical investigators and has generated
large amounts of information. It therefore warrants a brief
description here; a more detailed explanation of the tracer
technique, as applied to glucose turnover measurement, can
be found in Reference 8. The choice of a tracer is dictated
by cost, ease of measurement, and safety (radiation burden
in the case of radioactively labeled tracers). The tracer can
be administered as a pulse injection or constant intrave-
nous infusion, depending on the type of information that
is desired. For metabolic studies, a primed continuous infu-
sion usually is employed. When both the tracee (i.e., cold
glucose) and tracer (e.g., radiolabeled glucose) are in steady
state, the glucose turnover rate (milligrams per minute) is
simply calculated by dividing the tracer infusion rate by
the equilibrium plasma glucose-specific activity. In normal
healthy subjects, equilibrium represents the time (usually ∼2
hours after starting the tracer infusion) when unchanging
plasma tracer and tracee concentrations indicate that glu-
cose specific activity has become uniform throughout its
distribution space. The calculation of the turnover rate as
described previously (infusion rate/plasma specific activity)
is not based on any assumptions and can be used to quan-
titate glucose turnover in the postabsorptive state. When
non–steady-state conditions apply, this approach cannot be
used. Such is the case after glucose ingestion or infusion.
Practical ways to circumvent this problem, however, have
been developed. Their common rationale is provided by the
theory that the degree and rate of change in glucose-specific
activity are the principal factors that affect non–steady-state
analysis of isotope data. The larger the swings in glucose-
specific activity are, the more uncertain is the estimation of
the actual rates of glucose appearance and disappearance
from plasma data. All the formal models that have been
proposed to represent the glucose system become progres-
sively weaker as plasma glucose–specific activity is allowed
to fluctuate freely. Therefore, one of two strategies can be
employed. Either the tracer administration is repeated when
the glucose system has reached a new, reasonably steady
state, or tracer glucose infusion rates can be adjusted empiri-
cally to “clamp” the plasma glucose–specific activity con-
stant close to the basal level. In both cases, the aim is to
minimize the changes in glucose-specific activity, thereby
meeting the conditions under which steady-state equations
can be used reliably. Therefore, in reporting results of glu-
cose turnover obtained under non–steady-state conditions,
we will make some selection of available data.
GLUCOSE METABOLISM: BASAL
(POSTABSORPTIVE) STATE
Glucose Production
By convention, the basal or postabsorptive state is defined
as the metabolic condition that prevails in the morning
601
after an overnight (10 to 14 hours) fast. For most indi-
viduals, this time represents the longest period of fasting
in everyday life. For the rest of the day, most people are
more or less in the fed state. Maintenance of the fasting
plasma glucose concentration is primarily the responsibil-
ity of the liver.9,10 The liver provides glucose for all tis-
sues of the body, either by breaking down its own stores
of glycogen or by synthesizing glucose from gluconeo-
genic precursors, of which the most important are lac-
tate, pyruvate, glycerol, alanine, and other gluconeogenic
amino acids. The central role of the liver in providing a
constant supply of glucose to the body is related to the
presence of G6Pase, which catalyzes the conversion of
glucose-6-phosphate (G6P) to glucose within the hepa-
tocyte. Although a number of tissues, including muscle
and adipocytes, possess the enzymatic machinery neces-
sary to degrade glycogen and synthesize G6P from lactate
and amino acids, they either completely lack or possess
too little of the key enzyme, G6Pase, to release significant
amounts of free glucose into the circulation. The kidney,
like the liver, also possesses the necessary enzymatic appa-
ratus to produce glucose via the gluconeogenic pathway
and to release it into the circulation. In normal subjects
after an overnight fast, the kidney contributes ∼10% of
total body glucose production.11 During prolonged star-
vation and metabolic acidosis, renal gluconeogenesis is
enhanced and may contribute as much as 25% of basal
glucose production. Unlike the liver, the major gluconeo-
genic precursor for the kidney is glutamine, and renal glu-
cose synthesis is coupled with ammoniagenesis.
Under postabsorptive conditions, glucose output in
healthy adults averages 140 mg/min (778 μmol/min) or
2.0 mg/min per kg of body weight (11 μmol/min per
kilogram) in a 70-kg individual (Fig. 35-2). The varia-
tion around this mean is significant (20% to 30%), with
an unknown contribution of genetic and environmental
factors. Little information is available concerning how
much the fasting glucose output varies as a consequence
of changes in dietary habits, caloric intake, or physi-
cal fitness. Intrafamilial covariance of this physiologic
2.0
Other
Glycogenolysis
Glycolysis
mg/kg-min
1.0 Glucose
Oxidation
?? Glycerol (2%)
Pyruvate (1%)
Lactate (16%) Splanchnic
glucose uptake
Amino acids (6%)
0
Endogenous Total body
glucose glucose
production uptake
Figure 35-2  Hepatic glucose production and tissue glucose uptake in
the postabsorptive state in healthy subjects. See text for a more detailed
discussion. (Reproduced from DeFronzo RA. Pathogenesis of type 2
diabetes: metabolic and molecular implications for identifying diabetes
genes. Diabetes Rev. 1997;5:177-269.)
602 PART 5  DIABETES MELLITUS
variable also is undetermined. Under standard nutri-
tional conditions, the normal liver contains approxi-
mately 80 g of glycogen (see Table 35-1), and during
fasting, liver glycogen stores decline at a rate of approx-
imately 110 mg/min (611 μmol/min) or 8% per hour.
From this, it follows that hepatic glycogen depots would
become empty after approximately 12 hours. Because
fasting can be prolonged well beyond 12 hours, it is
obvious that gluconeogenesis must progressively replace
glycogenolysis as the fast continues.12 In animals, the
basal rate of glucose turnover is considerably higher
than in humans—for example, dogs (3.6 mg/min per
kilogram) and rats (7.2 mg/min per kilogram)—and the
limited capacity of the liver to store glycogen confers an
increasing role to gluconeogenesis for the maintenance
of basal glycemia. This limitation on glycogen accumu-
lation has an anatomic basis, because stuffing the cyto-
plasm with glycogen granules impairs cellular functions
and results in liver damage, as seen in patients with
glycogen storage diseases. In healthy subjects, after a
10- to 12-hour overnight fast, gluconeogenesis accounts
for approximately 50% of total hepatic glucose release
(see Fig. 35-2).12 The substrates for this de novo glu-
cose synthesis remain somewhat elusive. Circulating
lactate, pyruvate, glycerol, alanine, and other gluco-
neogenic amino acids are natural candidate precursors
and have been shown to transfer their carbons to newly
synthesized glucose molecules, as documented by the
incorporation of labeled lactate into glucose, that is, the
Cori cycle. However, transsplanchnic catheterization in
humans has shown that the net uptake of known circu-
lating gluconeogenic precursors (lactate, pyruvate, glyc-
erol, amino acids) can account for only 15% to 20% of
total endogenous glucose production.13 The discrepancy
between radioisotopic estimates of basal gluconeogenic
rate and accountable circulating precursors suggests that
the bloodborne substrates may not be the only source of
gluconeogenic precursors. Within the splanchnic area,
the intestine returns 10% to 20% of its glucose uptake
to the liver as lactate, but this fills only part of the gap. It
has been suggested that intrahepatic proteolysis and/or
lipolysis (i.e., glycerol) could provide ample amounts of
gluconeogenic precursors in addition to those entering
from the systemic circulation.
The regulation of basal hepatic glucose production is
controlled by the sum of multiple neural, hormonal, and
metabolic stimuli, some stimulatory and others inhibi-
tory.9,10 Figure 35-3 portrays the control system as a
simple balance between inhibition and stimulation. Insu-
lin and glucagon provide the primary hormonal signals
that regulate the production of glucose by the liver under
postabsorptive conditions. Of the two, the action of insu-
lin normally predominates. Hepatic glucose production is
exquisitely sensitive to very small fluctuations in the cir-
culating plasma insulin concentration. Increments in the
plasma insulin concentration of as little as 5 to 10 μU/mL
cause a marked, rapid suppression of glycogenolysis and
a decline in hepatic glucose output, whereas inhibition of
gluconeogenesis is less sensitive.10
By restraining lipolysis and proteolysis, insulin also
reduces the delivery of potential glucose precursors
(glycerol and amino acids) from peripheral tissues
(adipocytes and muscle) to the liver, and this further
reduces hepatic glucose output. In its capacity as the
inhibitory signal for glucose release, insulin is greatly
favored by the anatomic connection between the pan-
creas and the liver. Because the pancreatic vein is a
tributary of the portal vein, insulin, which is secreted
by the β-cells, reaches the liver in fasting humans at a
concentration that is three to four times higher than the
peripheral (arterial) concentration (see Chapter 32).
This steep portosystemic gradient is maintained by
the high rate of insulin degradation by hepatic tissues
(fractional insulin extraction = 50%). Consequently, a
small secretory stimulus to the β-cells will dispropor-
tionately raise the portal insulin concentration, thereby
selectively acting on glucose production rather than
enhancing peripheral glucose utilization. In addition,
via the general circulation, pancreatic insulin release is
potentiated by a number of gastrointestinal hormones
(e.g., mostly by glucose-dependent insulinotropic poly-
peptide and glucagon-like peptide-1, with possible
contributions from secretin, cholecystokinin, pancreo-
zymin, and others, which are also released in response
to meal ingestion).14 Therefore, anatomic and physi-
ologic connections that comprise the gut-liver-pancreas
axis ensure that the primary station for the handling of
foodstuff, the liver, is under close control by a nearby,
well-informed unit, the β-cell.
Conversely, small decrements in the peripheral plasma
insulin concentration, as little as 1 to 2 μU/mL, lead to an
increase in hepatic glucose production.15 This highly sensi-
tive interaction between the liver and insulin plays a criti-
cal role in the maintenance of basal glucose levels when
fasting is prolonged. As glycogen stores become depleted,
there is a small decrease in the arterial glucose concentra-
tion, which in turn leads to a decline in pancreatic insulin
secretion and stimulation of glucagon release. The resul-
tant hypoinsulinemia removes the constraint on lipolysis,
and plasma FFA levels rise. By mass action, FFAs enhance
their own uptake by all cells in the body, including liver and
muscle. Enhanced FFA oxidation by the hepatocytes pro-
vides an energy source to drive gluconeogenesis, and the end
Regulation of hepatic glucose production
Decrease Increase
-4
+4
-3
+3
-2
-1 +2
0 +1 FFA
Cortisol
Glucagon
Insulin Epinephrine
Hyperglycemia Growth hormone
Parasympathetic Sympathetic
Figure 35-3  Balance of factors that regulate hepatic glucose produc-
tion. Stimulatory factors are shown by the positive numbers to the right;
inhibitory factors, of which insulin is dominant, are shown by the nega-
tive numbers to the left.
 35  REGULATION OF INTERMEDIARY METABOLISM DURING FASTING AND FEEDING
product of beta oxidation, acetyl-CoA, stimulates the first
committed enzyme, pyruvate carboxylase, in the gluconeo-
genic pathway (Fig. 35-4).1,2 The combination of hypoinsu-
linemia, hypoglycemia, and increased FFA and amino acid
supply also stimulates hepatic gluconeogenesis. In peripheral
tissues, enhanced FFA and ketone oxidation spare glucose
usage (Randle cycle; see subsequent discussion), thereby
minimizing the need for carbohydrate as an energy source.1,2
Another important consequence of the fasting-related
decline in plasma insulin concentration is the stimula-
tion of proteolysis.15 This augments the outflow of amino
acids, especially alanine, which accounts for approximately
50% of total α-amino nitrogen release. The predominance
of alanine in the amino acid efflux from muscle cannot be
explained by its presence in cellular proteins, of which ala-
nine accounts for only 7% to 10%. The major source of
alanine outflow from muscle during starvation is derived
from the transamination of glucose-derived (from muscle
glycogen and circulating glucose) pyruvate. The branched-
chain amino acids (valine, leucine, isoleucine) provide the
amino groups for muscle alanine synthesis. The alanine that
is released from muscle is transported via the bloodstream
to the liver, where it is converted to glucose, thus completing
the glucose-alanine cycle (see Fig. 35-4).13 The glucose-lac-
tate cycle (Cori cycle) also provides an important source of
three-carbon skeletons for gluconeogenesis during fasting.15
Insulinopenia enhances the breakdown of glycogen and
leads to accumulation of pyruvate. Because the Krebs cycle
has been inhibited by the accelerated rate of FFA oxidation
(Randle cycle), the pyruvate can either be transaminated to
alanine (glucose-alanine cycle) or converted to lactate and
released into the circulation, where it is carried to the liver
and synthesized into glucose (glucose-lactate cycle). From
the quantitative standpoint, approximately twice as many
carbon skeletons are recycled to glucose via the Cori cycle
compared with the alanine cycle.
↓ Insulin
Protein +
Glycogen
↑ Alanine
↑ GN AA
↑ Lactate
↑ FFA Glucose
↓ Insulin
Pyruvate
PEP
CK PDH –
+ ↑ Glycerol PC + Acetyl CoA
TG
OAA
FFA
↑ FFA
Figure 35-4  In the fasting state, the decrease in basal plasma insulin
concentration removes the inhibitory effect of the hormone on lipolysis
and plasma glycerol, and FFA levels increase. In the hepatocyte, en-
hanced delivery of FFA, in combination with a decreased insulin/glu-
cagon ratio, stimulates beta oxidation, leading to the accumulation of
acetyl-CoA. Increased acetyl-CoA, by inhibiting pyruvate dehydroge-
nase and stimulating pyruvate carboxylase in the liver, shuttles pyruvate
into the gluconeogenic pathway. Hypoinsulinemia also stimulates pro-
teolysis in muscle and the enhanced delivery of alanine, other gluconeo-
genic amino acids, glycerol, and lactate from peripheral tissues, thereby
providing the substrates for accelerated hepatic gluconeogenesis. AA,
Amino acids; FFA, free fatty acids; GN, gluconeogenic; OAA, oxalo-
acetic acid; PC, pyruvate carboxylase; PDH, pyruvate dehydrogenase;
PEPCK, phosphoenolpyruvate carboxykinase; TG, triglyceride.
603
The counterregulatory hormones (glucagon, ­epinephrine,
growth hormone, cortisol, thyroid hormones) all are capa-
ble of offsetting the action of insulin on the liver and work
by stimulating both glycogenolysis and gluconeogenesis.16
Glucagon plays a major role in the tonic support of basal
hepatic glucose release, and experimental suppression of
endogenous glucagon secretion with preservation of basal
insulin levels in humans and animals causes a 30% to 40%
decline in hepatic glucose production.17 This suppression
of glucose production involves both the glycogenolytic and
gluconeogenic pathways. Using insulin secretion rate (as
reconstructed from C-peptide deconvolution analysis), and
estimates of hepatic plasma flow and glucagon clearance,
it has been possible to calculate the pre-hepatic insulin-to-
glucagon molar concentration ratio.18 As depicted in F ­ igure
35-5, in the fasting state insulin is 5 to 10 times more abun-
dant in prehepatic plasma than glucagon; this molar ratio
rises ∼fivefold during the first hour following the inges-
tion of a mixed meal, and its time-course closely resembles
that of plasma glucose levels. This time pattern is typically
altered in patients with type 2 diabetes, in whom the initial
rise in the insulin-to-glucagon ratio is blunted.18 The pre-
cise quantitative contribution of the other counterregula-
tory hormones to the maintenance of basal glucose output
under normal conditions of fasting has not been assessed.
However, it is likely that they (i.e., epinephrine, cortisol, and
growth hormone) also exert a tonic effect on hepatic glucose
production in the postabsorptive state, and the withdrawal
of insulin (i.e., hypoinsulinemia) that occurs with prolonged
fasting allows their stimulatory effect on glycogenolysis and
gluconeogenesis to occur unopposed. The net result of their
unopposed action is an increase in hepatic glucose and renal
output.
During more pronounced hypoglycemia, as may occur
with insulin administration, all the counterregulatory
hormones are released and act synergistically to restore
normoglycemia.16 However, they do so with different
dose-response kinetics and time courses. Glucagon and
PRE-HEPATIC INSULIN/GLUCAGON RATIO:
MIXED MEAL
40
Pre-hepatic insulin/glucagon
30
T2D
(molar ratio)
20
10 Controls
0
0 50 100 150 200 250 300
Time (min)
Figure 35-5  Estimated pre-hepatic insulin-to-glucagon molar concen-
tration ratio in nondiabetic subjects in the basal postabsorptive state
and during the absorption of a mixed meal. The shaded area represents
mean ± SEM; the red dotted line is the mean value in a group of obese
patients with type 2 diabetes. (Redrawn from data in Camastra S, Mus-
celli E, Gastaldelli A, et al. Long-term effects of bariatric surgery on
meal disposal and β-cell function in diabetic and nondiabetic patients,
Diabetes. 2013;62:3709-3717.)
604 PART 5  DIABETES MELLITUS
catecholamines act rapidly, whereas cortisol, growth hor-
mone, and thyroid hormones (in that order) are involved
in the long-range control of hepatic glucose release. Small,
acute increases in plasma glucagon and epinephrine con-
centrations markedly stimulate both glycogenolysis and
gluconeogenesis. Acute elevations in plasma cortisol,
growth hormone, and thyroid hormones have no stimu-
latory effect on total hepatic glucose release. However,
both cortisol and growth hormone have been shown to
markedly potentiate the effects of epinephrine and gluca-
gon on hepatic glucose release.
In addition to hormonal regulation, the central ner-
vous system has an important role in the maintenance of
hepatic glucose production.19 Both parasympathetic and
sympathetic fibers reach the liver via the splanchnic nerves,
thereby supplying autonomic neural modulation of both
glucose production and uptake. In animals, parasympa-
thetic stimulation restrains glycogenolysis and enhances
glycogen synthesis, whereas activation of the sympathetic
fibers innervating the liver stimulates glucose output via
potentiation of both glycogenolysis and gluconeogenesis.
In humans, the influence of the sympathetic nervous sys-
tem on hepatic glucose metabolism can be demonstrated
under conditions of acute stimulation, but the contribution
of the autonomic nervous system to the maintenance of
basal hepatic glucose production remains undetermined.
A number of metabolic signals play an important role in
the control of hepatic glucose production in the postabsorp-
tive state.9,10,20 Hyperglycemia per se inhibits liver glucose
output. In normal adults, hyperglycemia and hyperinsu-
linemia occur concurrently, and in combination they pro-
vide a potent stimulus to suppress hepatic glucose release.
As shown in Fig. 35-6, physiologic hyperglycemia (main-
tained using the hyperglycemic clamp technique), while
8 although they can exchange their carbon moieties with
4 tribute to de novo glucose synthesis. Nonetheless, when
(µmol/min per kg)
0 with oleate or palmitate, new glucose formation from
−4
−8 Hyperglycemia
−12 +
+ +
Fasting Low ins. Basal ins. High ins.
−16
Figure 35-6 Splanchnic glucose uptake (blue columns) and hepatic
glucose production (green columns) in healthy subjects under four
­experimental conditions: overnight fast; hyperglycemia (+125 mg/dL)
with somatostatin blockade of endogenous insulin release (Low Ins.);
hyperglycemia (+125 mg/dL) with somatostatin plus insulin replace-
ment to maintain the fasting insulin concentration constant (Basal Ins.);
hyperglycemia (+125 mg/dL) with endogenous insulin (55 μU/mL) re-
lease. Note that hyperglycemia per se inhibits hepatic glucose produc-
tion and that hyperglycemia acts synergistically with insulin to inhibit
liver glucose output. In contrast, hyperglycemia stimulates glucose up-
take to approximately the same extent in the presence of low, basal,
or high insulin, that is, mostly by mass action. (Drawn from data in
DeFronzo RA, Ferrannini E, Hendler R, et al. Regulation of splanchnic
and peripheral glucose uptake by insulin and hyperglycemia in man.
Diabetes. 1983;32:35-45.)
maintaining basal insulinemia, is as effective as insulin in
suppressing hepatic glucose production. More impressive is
the observation that hyperglycemia in the presence of hypo-
insulinemia (hyperglycemic clamp with somatostatin) causes
a greater than 50% suppression of hepatic glucose release
(see Fig. 35-6). Conversely, hypoglycemia by itself provides
a trigger to increase hepatic glucose release. During insulin-
induced hypoglycemia in humans and animals, an increase
in plasma glucose occurs even when the counterregulatory
hormonal response is inhibited (glucose autoregulation).
Recent studies suggest that this effect of hypoglycemia is
mediated via glucose sensors in the hypothalamic region of
the brain, which activate hepatic glycogenolysis via sympa-
thetic connections to the liver.21
Altered substrate delivery to the liver also influences
glucose release by the liver. In nondiabetic humans, it is
difficult to demonstrate a detectable increase in hepatic
glucose production by infusing large quantities of glyc-
erol, lactate, or a mixture of amino acids, as long as
there occurs a physiologic increase in plasma insulin
concentration to balance out such gluconeogenic push.
However, even though total hepatic glucose output does
not increase, there is a marked stimulation of gluconeo-
genesis that is precisely counterbalanced by an inhibition
of glycogenolysis. The increased provision of gluconeo-
genic precursors leads to an increase in the intrahepatic
formation of G6P, but the eventual fate of this interme-
diate is glycogen rather than free glucose, because the
rate-limiting enzyme for glucose production, G6Pase, is
not simultaneously activated. FFAs play an important
role in setting the level of hepatic glucose production.
Only the odd-chain FFAs (i.e., propionate) can donate
their carbon atoms to oxaloacetate in the tricarboxylic
acid cycle and thus directly contribute to net gluconeo-
genesis. Most physiologic FFAs are of even chain, and
tricarboxylic acid cycle intermediates, they do not con-
the perfusion medium of isolated rat liver is enriched
lactate or pyruvate is enhanced. The biochemical mech-
anisms involved in this stimulation of gluconeogenesis
have been well worked out.22 The products of FFA oxi-
dation, citrate and acetyl-CoA, activate the key enzymes
that control gluconeogenesis, pyruvate carboxylase,
phosphoenolpyruvate carboxykinase, and G6Pase. In
addition, elevated plasma FFA concentrations in vivo
are usually accompanied by raised glycerol levels
because both result from the hydrolysis of triglycerides
(see Fig. 35-4). Therefore, accelerated lipolysis supplies
both the stimulus (FFA), the substrate (glycerol), and
the energy source (ATP) to drive gluconeogenesis. In
isolated hepatocytes, FFAs in micromolar amounts also
have been shown to inhibit glycogen synthase. This sug-
gests that an additional interaction of FFA metabolism
with hepatic glucose production may be at the level of
glycogen metabolism. In healthy volunteers, short-term
infusion of triglycerides (with heparin to activate lipo-
protein lipase) increases the plasma FFA concentration,
leading to the stimulation of hepatic glucose output
under conditions (i.e., hyperglycemia and insulinopenia
 35  REGULATION OF INTERMEDIARY METABOLISM DURING FASTING AND FEEDING 605

Figure 35-7  Schematic representation of organ glucose metabolism and blood flow in the basal (or postabsorptive) state. Average data compiled
for healthy adults from the literature are indicated. Periphery encompasses all tissues other than the liver, gut, kidneys, brain, and heart; gut includes
organs (i.e., spleen, pancreas) draining their blood supply into the portal circulation. Organ blood flow is shown in mL/min, and glucose fluxes are
shown in mmol/min or μmol/min). CA, Carotid arteries; HA, hepatic artery; HV, hepatic vein; MA, mesenteric arteries; PV, portal vein; RV, renal
veins; VA, vertebral artery. (Redrawn from Ferrannini E, DeFronzo RA. Insulin actions in vivo: glucose metabolism. In: DeFronzo RA, Ferrannini E,
Keen H, Zimmet P, eds. International textbook of diabetes mellitus. Chichester, UK: John Wiley & Sons; 2004: 277-318.)

induced by somatostatin plus glucose infusion) that
mimic the diabetic state.23 A large part of this effect can
be reproduced by infusing, under the same experimen-
tal circumstances, glycerol alone. On the other hand,
when endogenous insulin is allowed to increase or when
exogenous insulin is administered, the stimulatory effect
of triglyceride infusion to increase the plasma FFA con-
centration on hepatic glucose release is easily overcome.
In summary, the long-chain FFAs can regulate hepatic
glucose production both by acting on the key enzymes
of gluconeogenesis (through buildup of the products of
FFA oxidation) and by virtue of the substrate push of
glycerol. This regulatory loop is operative particularly
when insulin secretion is not stimulated (i.e., in the basal
state). Conversely, studies in both animals and humans
have documented that a significant part of the suppres-
sive action of insulin on hepatic glucose production is
mediated via the hormone’s antilipolytic effect on adi-
pocytes.10,24 If the plasma FFA concentration is main-
tained during insulin infusion, the inhibitory effect of
physiologic hyperinsulinemia on hepatic glucose pro-
duction is impaired.
Glucose Disposal
In the basal (postabsorptive) state, the rate of whole-
body glucose disposal equals the rate of hepatic glu-
cose production, and the plasma glucose concentration
remains approximately constant.1,2 Information about
the contribution of individual organs and tissues to
total glucose uptake has been obtained in regional
catheterization studies performed in combination with
glucose tracers and indirect calorimetry.25 By collat-
ing the available information, the organ circulation
model depicted in Figure 35-7 can be constructed.5 In
this synthesis, steady-state interorgan exchanges of glu-
cose, tissue blood flow, and regional glucose gradients
are calculated based on a rate of hepatic glucose pro-
duction of 140 mg/min (778 μmol/min). For a 70-kg
man, this equals 2.0 mg/min per kilogram or 11 μmol/
min per kilogram. In the postabsorptive state, approxi-
mately 70% of basal glucose disposal takes place in
insulin-independent tissues (brain, liver, kidney, intes-
tine, RBCs). Of these, the brain predominates and
accounts for almost half of the total hepatic glucose
production. The liver plus gastrointestinal (splanchnic)
tissues account for an additional 20%. It also can be
appreciated that the fractional extraction of glucose
(as defined earlier) is quite low everywhere in the body
(ranging from 1.0% to 3.5%) except in the brain (9%)
(Table 35-2). Because skeletal muscle represents 40%
of total body weight and receives 16% of the cardiac
output, one can calculate that muscle accounts for one
third of the overall glucose disposal in the basal state
(i.e., ∼245 μmol/min or 44 mg/min) (see Fig. 35-7).1,2,5
As shown in Table 35-2, the muscle glucose clearance
averages 1.3 mL/min per kilogram of tissue. Glucose
clearance is a useful metabolic concept and is defined
as the amount of plasma that is completely cleared of
glucose in a given period; as such, it provides an index
of the efficiency of tissue glucose removal. In the rank
606 PART 5  DIABETES MELLITUS
TABLE 35-2  Regional Glucose Disposal in the
Basal State
Clearance*
Blood Flow Uptake (mL/min
Organ Weight (kg) (L/min) (μmol/min) Extraction per kg)
Brain 1.2 0.85 385 9.1 64
Liver 1.5 1.50 110 2.3 15
Kidneys 0.28 1.10 20 1.9 15
Heart 0.3 0.25 20 1.7 13
Gut 5.0 1.20 60 1.0 20.4
Muscle 28.0 1.05 245 3.5 1.3
*Organ clearance rate divided by organ weight.
of efficiency of tissue glucose clearance in the basal
state, resting muscle is last, being 10 times less active
than the liver and 50 times less avid than the brain. It
is noteworthy that tissues (brain, liver, kidneys) that
have a high glucose clearance in the basal state are
insulin independent. Increasing the plasma insulin con-
centration above fasting values has no effect on glucose
clearance by these tissues (i.e., brain, liver, kidneys),
whereas in muscle, glucose clearance increases by a
factor of 10 or greater over the physiologic range of
insulin concentrations. The intermediate position of
heart muscle in the list is accounted for by its constant
working state.
These organ-specific glucose clearance characteris-
tics (see Table 35-2) represent the physiologic equiva-
lent of the type and abundance of facilitative glucose
transporters (GLUTs, encoded by the SLC2A gene) the
various tissues express (Table 35-3).26 They also help
to define the concept of an insulin-independent tissue.
Thus, in tissues in which an increase in the plasma
insulin concentration does not accelerate the glucose
clearance, the GLUT is not responsive to acute changes
in the plasma insulin concentration. At present, several
GLUT isoforms have been isolated.26 A ubiquitously
expressed, non–insulin-regulatable GLUT (GLUT-1)
effects facilitated glucose transport in RBCs. The abun-
dance of this transporter in RBCs ensures rapid dif-
fusion of glucose across the RBC membrane, and this
characteristic confers on RBCs an important role in
the interorgan exchange of glucose. The same GLUT-1
transporter is present in the endothelial cells lining
the blood vessels of the brain. Because of its low Km
(∼1 mmol/L), it saturates at plasma glucose concentra-
tions well below the normal fasting plasma glucose con-
centration (∼5 mmol/L), thereby ensuring a constant
flux of glucose into brain cells. This is an important
adaptive mechanism that provides the cerebral tissues
an adequate supply of fuel, even in the face of hypo-
glycemia. Another unique feature of GLUT-1 is its low
Vmax (∼3 mmol/L). This protects the brain against acute
fluid shifts and cerebral edema that otherwise would
accompany hyperglycemia. Thus, GLUT-1 is well suited
for its physiologic function, especially in the individual
with insulin-dependent diabetes in whom wide swings
in plasma glucose concentration (from hypoglycemia to
hyperglycemia) are common. Another important corol-
lary of GLUT-1 is that an increase in plasma glucose
TABLE 35-3  Classification of Main Glucose
Transporters and Their Couplers in Various Tissues
Organ Transporter Coupler Classification
Brain GLUT-1 HKI Glucose dependent
Erythrocyte GLUT-1 HKI Glucose dependent
Adipocyte GLUT-4 HKII Insulin dependent
Muscle GLUT-4 HKII Insulin dependent
Liver GLUT-2 HKIVL Glucose sensor
β-cell GLUT-2 HKIVB Glucose sensor
Gut SGLT-1 GLUT-1 Sodium dependent
Kidney SGLT-2 GLUT-2 Sodium dependent
GLUT, Glucose transporter; HK, hexokinase; SGLT, sodium-glucose
co-transporter.
concentration above fasting levels (i.e., >5 mmol/L) will
necessarily lead to a decline in brain glucose clearance
because the transporter saturates at approximately 3
mmol/L. Moreover, because under postabsorptive con-
ditions the brain is responsible for approximately half
of the total body glucose disposal (see later), it follows
that an increase in fasting plasma glucose concentra-
tion (with or without an increase in plasma insulin)
will be associated with a decline in whole-body glucose
clearance.
A totally distinct (from the physiologic standpoint)
GLUT, GLUT-2, is present in liver and pancreatic β-cells.26
It has a high Km (∼15 to 20 mmol/L), and, as a conse-
quence, the free glucose concentration in cells express-
ing this transporter increases in direct proportion to the
increase in plasma glucose concentration. This character-
istic allows these cells to behave as “glucose ­sensors.”1,2
As the ambient glucose concentration increases, more
glucose enters the β-cell, which responds by appropri-
ately augmenting its secretion of insulin, whereas the liver
reads the rising plasma glucose level and decreases its
output of glucose. As a corollary of this, an increase in
the plasma glucose concentration is associated with a pro-
portional increase in glucose uptake by these tissues with
an unchanging glucose clearance. Because GLUT-2 does
not respond to insulin, hyperinsulinemia is not associated
with an increase in hepatic or β-cell glucose clearance.
It is noteworthy that each GLUT is associated with a
specific hexokinase, which has a Km that parallels that
of its associated GLUT.27 For liver and β-cells, the phos-
phorylating enzyme is hexokinase IV or glucokinase. Its
high Km constant has led investigators to propose glu-
cokinase as the β-cell sensor. Consistent with this, recent
studies have demonstrated that some forms of maturity-
onset diabetes of the young (MODY) are associated with
mutations in the glucokinase gene, and the physiologic
counterpart of this is a defect in insulin secretion (see
Chapter 38). Insulin-sensitive tissues, such as skeletal
muscle and adipocytes, express GLUT-4 and its physio-
logic coupler, hexokinase II. GLUT-4 has a Km constant
of approximately 5 mmol/L, which is close to that of
the plasma glucose concentration. In the basal state, the
majority of GLUT-4 transporters are not located in the
plasma membrane but reside in vesicles within the cell.
After exposure to insulin, the concentration of GLUT-4 in
the plasma membrane of adipocytes and muscle increases
 35  REGULATION OF INTERMEDIARY METABOLISM DURING FASTING AND FEEDING
markedly, and there is a reciprocal decline in the intra-
cellular GLUT-4 pool.28 Insulin not only enhances their
translocation and insertion into the plasma membrane
but also augments their intrinsic activity. Thus, muscle
glucose clearance increases markedly, tenfold or greater,
in response to increments in plasma insulin concentration
within the physiologic range.1,2,29 GLUT-3 is the major
neuronal transporter in brain tissues. Another family of
glucose transporters, the sodium-glucose co-transporters
(SGLTs), participate in the process of glucose absorption
in several tissues.30 SGLT-2, a low-affinity, high-capacity
member of the family encoded by the SLC5A2 gene, is
expressed at high levels in the S1-S2 segment of the proxi-
mal renal tubule, where it affects the bulk of reabsorption
of filtered glucose. This isoform couples with the activity
of GLUT-2 (expressed on the basolateral membrane) to
extrude glucose from the intracellular space to the inter-
stitium and bloodstream. Mutations in SLC5A2 (as in
familial renal glycosuria) or pharmacologic inhibition of
SLGT2 are associated with marked glycosuria.31 SGLT-
1, a high-affinity, low-capacity co-transporter encoded
by the SLC5A1 gene, is predominantly expressed on the
brush border membrane of enterocytes, where it affects
absorption of glucose and galactose through coupling
with GLUT-1 (see Table 35-3). These transporters play a
crucial role in glucose homeostasis by regulating its entry
into the body and preventing its loss via the kidney.
The intracellular disposition of transported glucose
can be studied in vivo by using glucose tracers and then
measuring the appearance of the label in specific meta-
bolic products such as lactate (i.e., anaerobic glycolysis)
and carbon dioxide (i.e., complete oxidation).8 These
techniques, even when correctly applied, provide only
estimates of the metabolic fate of plasma glucose. For
example, should glycogen in muscle be oxidized directly,
the plasma glucose–specific activity would miss it com-
pletely because plasma glucose does not equilibrate with
the intracellular free-glucose pool. To circumvent this
problem, investigators have employed indirect calorim-
etry, which measures total carbon dioxide production
from all carbohydrate sources, both intracellular and
extracellular.32 Although indirect calorimetry depends
on a number of assumptions, these are reasonable and
have been largely validated. Moreover, this technique is
easy to apply and noninvasive. Indirect calorimetry also
provides a good estimate of the rate of energy expendi-
ture and complements information obtained by tracer
methods. In the basal state and under ordinary nutri-
tional circumstances, oxygen consumption averages 250
mL/min, whereas carbon dioxide production is 200 mL/
min—that is, the whole-body respiratory quotient equals
0.8 (respiratory quotient = carbon dioxide production/
oxygen consumption). From the equations depicted in
Table 35-4, whole-body carbohydrate oxidation can be
estimated to account for approximately 60% of total
glucose uptake in the postabsorptive state.25 Because
the brain uses 46% of the total glucose turnover (see
Table 35-2), and because essentially all brain glucose
uptake is accounted for by oxidation, it follows that
three fourths (i.e., 46/0.6 or 77%) of basal glucose oxi-
dation occurs in the brain. Little is left for other tissues,
607
TABLE 35-4  Indirect Calorimetry: Calculation
of Carbohydrate and Lipid Oxidation and Energy
Expenditure
Net carbohydrate oxidation 25.3 × VCO2 – 17.8 × VO2 –
μmol/min) 16.0 • N
Net lipid oxidation μmol/min) 6.5 × (VO2 – VCO2) – 7.5 × N
Energy expenditure (kJ/min) 0.0164 × VO2 + 0.0046 ×
VCO2 – 0.014 × N
N, Urinary nonprotein nitrogen excretion (in mg/min); VCO2, carbon
­dioxide production (in mL/min); VO2, oxygen consumption (in mL/min).
which preferentially derive their metabolic energy from
the oxidation of FFAs and other lipids under postab-
sorptive conditions. Skeletal muscle, for example, has a
respiratory quotient of 0.75 and relies on fat oxidation
for the production of 80% of the energy that it needs in
the resting state. Thus, the basal state is characterized
by parsimonious use of glucose as a metabolic fuel.15
Moreover, the glucose is selectively channeled to organs
that cannot rely on alternative energy sources. In the
postabsorptive state, more than half of the total energy
production is generated via oxidation of fat, of which
there are plentiful stores (see Table 35-1). Insulin is the
principal regulator that determines the metabolic mix of
fuels in the basal state. A small decrement in the circu-
lating hormone level releases the brake on lipolysis, and
the plasma FFA concentration increases, thereby allow-
ing fat to override glucose in the competition between
the two substrates. Although these very small changes in
plasma insulin concentration are sufficient to promote
a shift in fuel metabolism from carbohydrate to fat, the
plasma insulin level is still sufficiently elevated to main-
tain glucose transport and metabolism in target tissues at
minimal rates and to restrain protein breakdown, which
contributes only ∼15% to basal energy metabolism.15
The role that counterregulatory hormones (glucagon,
epinephrine, cortisol, growth hormone, thyroid hor-
mones) play in basal glucose uptake is less well defined
but probably centers on the maintenance of lipolysis,
because all the insulin antagonistic hormones are more
or less potent lipolytic stimuli.
Glucose Cycles
After entry of glucose into the cell through a specific
GLUT, the sugar does not necessarily follow a direct path
to its eventual fate, be it glycogen, lactate, carbon diox-
ide, or pentoses. Rather, it may in part reach its destina-
tion via a number of circuitous routes that have become
known as futile cycles. A metabolic futile cycle is one in
which a precursor is converted into a product by a for-
ward reaction and then resynthesized to the precursor. In
such a reaction, there is no net product accumulation, but
energy (ATP) is used. There are multiple examples of such
futile cycles in the glucose metabolic pathway.33 The first
involves the conversion of glucose to G6P by glucokinase
and its subsequent reconversion to intracellular free glu-
cose by G6Pase in the liver. Each turn of this cycle uses
one molecule of ATP. Another example of a futile cycle
is represented by the conversion of G6P to fructose-6-­
phosphate and back through the phosphoglucoisomerase
608 PART 5  DIABETES MELLITUS
reaction. Perhaps the best-studied futile cycle that is
under the control of insulin is the conversion of fruc-
tose-6-phosphate to fructose-1,6-bisphosphate in the
liver. The reverse reaction is regulated by fructose-1,6-­
bisphosphatase, whereas the forward reaction is catalyzed
by phosphofructokinase (PFK). The latter enzyme is con-
trolled by the energy status of the cell and key intracellu-
lar metabolites. High levels of ATP, acidosis, and citrate
inhibit PFK, whereas ADP and alkalosis stimulate PFK.
The most potent activator of PFK is fructose-2,6-bispho-
sphate, whose synthesis is stimulated by the enzyme fruc-
tose-2,6-bisphosphate kinase. This latter enzyme is under
the control of insulin, and the PFK step, therefore, rep-
resents an important regulatory control point for insulin
action.34
In general terms, whenever bidirectional flux through
a metabolic pathway is simultaneously operative, there
exists a cycle, regardless of the number of intermediate
reactions and regardless of whether one or more tissues
are involved. In the examples cited previously, the cycles
occurred within individual cells. However, cycles also can
exist between organs. In this regard, lipolysis in adipose
tissue followed by partial reesterification of FFAs in the
liver is a complete cycle. Another important cycle is the
breakdown of proteins in the liver or other tissues. The
glucose-alanine and glucose-lactate (Cori) loops13 also
represent important cycles (see previous discussion) that
provide conservation of carbon skeletons and transfer of
α-amino groups between muscle and liver.
The negative connotation of futility has traditionally
been reserved for those cycles that go on in the same cell.
These cycles are, however, anything but futile. As ele-
gantly discussed by Newsholme and Leech,33 a metabolic
cycle with a reverberating internal loop provides the best
kinetic stratagem to maintain the enzymes of a dormant
pathway at a minimum of activity, while at the same time
ensuring a high sensitivity gain for rapid amplification of
incoming signals. The ATP cost of these cycles is itself
a means of increasing the efficiency of energy dissipa-
tion. The fact that the activity of these cycles is under
hormonal control (e.g., catecholamines, glucagon, and
thyroid hormones enhance the cycling rate) establishes
a mechanism for rapid modulation. In this way, these
cycles become components of facultative thermogenesis.
Equally important, the operation of these futile or sub-
strate cycles allows the generation of metabolic interme-
diates that can modulate the activities of key enzymes and
allow allosteric regulation.
GLUCOSE METABOLISM: FED
(POSTPRANDIAL) STATE
The fed state refers to the period of active nutrient
absorption from the gastrointestinal tract and lasts until
the plasma insulin concentration and glucose metabolism
have returned to basal values. In normal humans, car-
bohydrates are ingested with lipids and protein (i.e., a
mixed meal). In the typical diet, carbohydrates comprise
approximately 50% of the caloric contents, with fat and
protein contributing about 35% and 15%, respectively.
However, there is considerable interindividual variation
in the distribution of the three major dietary constituents.
The rate of absorption of dietary carbohydrates is mark-
edly influenced by their chemical form (refined sugars ver-
sus complex carbohydrates) and by the composition of the
meal. Protein and fat, in particular, retard gastric empty-
ing and delay carbohydrate absorption. Furthermore, the
disposition of dietary carbohydrates is indirectly affected
by the dietary fat and protein content to the extent that
these latter (1) compete with glucose as substrates in
muscle, (2) impair the suppression of hepatic glucose
production by providing gluconeogenic precursors, and
(3) alter the balance of glucoregulatory hormones (FFAs
and some amino acids are insulin secretagogues, whereas
most amino acids stimulate glucagon secretion).
The rate-limiting factor for the absorption of glucose
is gastric emptying, which is influenced by meal compo-
sition and shows wide interindividual variation. Gastric
emptying is determined by the integration of motor activ-
ity of the stomach and upper small intestine, controlled
by electrical slow waves generated by the interstitial cells
of Cajal. The chyme is pumped across the pylorus in a
pulsatile manner. The entire process of transfer of gastric
contents to the gut is regulated primarily by inhibitory
feedback arising from the interaction of nutrients with
the small intestine, and modulated by both stimulation
of the vagus nerve and the secretion of gut hormones,
including glucagon-like peptide-1 (GLP-1), glucose-
dependent insulinotropic polypeptide (GIP), cholecysto-
kinin (CCK), and peptide YY (PYY).35 The dynamics of
gastric emptying are a strong determinant of the shape of
the oral glucose tolerance curve. Once glucose enters the
small intestine, it is rapidly transported by specific trans-
port systems (mainly, SGLT-1) that are sodium depen-
dent.36 Sodium is transported from the intestinal lumen
into the epithelial cell down a favorable sodium gradient.
Both sodium and glucose are bound to the transporter,
and cellular entry of sodium brings with it glucose, which
then exits via the GLUT-1 present in the basolateral
membrane. For glucose transport to continue, sodium
also must be pumped out via the basolateral membrane to
maintain the favorable sodium gradient for sodium entry
from the lumen. This active step is efficiently carried out
by a Na+/K+-ATPase pump. This coupled system, which
effectively and rapidly transports glucose from the intes-
tinal lumen into the interstitial fluid, has a high capacity
and is independent of insulin. SGLT activity and glucose
sensing on the luminal surface of chemosensitive entero-
endocrine cells (e.g., L and K cells) mediate the release of
gastrointestinal hormones (e.g., GLP-1, GIP) by glucose
(as well as nonmetabolizable sugars) in a dose-dependent
manner.37 Vagal afferent activity, triggered by a number
of enteroendocrine hormones including GLP-1 and GIP,
provides a further level of control of glucose entry into
the bloodstream.
Quantitation of Insulin Sensitivity and Insulin Secretion
Because of the difficulties involved in following the gas-
trointestinal absorption of glucose and the continuously
changing plasma glucose and insulin concentrations, the
regulation of glucose homeostasis during the fed state has
classically been investigated using intravenous glucose,
 35  REGULATION OF INTERMEDIARY METABOLISM DURING FASTING AND FEEDING
which can be administered in formats that are more
suitable for formal analysis. The most detailed informa-
tion concerning glucose utilization by the whole body,
organs, and specific intracellular pathways has come
from studies employing the insulin/glucose clamp tech-
nique38 in combination with indirect calorimetry, iso-
tope turnover methodology, and limb (forearm and leg)
catheterization. Because the insulin-glucose clamp tech-
nique has become the reference method for the study of
glucose metabolism, this procedure is described briefly.
The euglycemic insulin version of the clamp technique is
shown in Figure 35-8. An exogenous infusion of regular
insulin is started at time zero and is given as a prim-
ing dose followed by a constant infusion (usually at a
rate of 1 mU/min per kilogram or 40 mU/min per square
meter of body surface area or 240 pmol/min per square
meter). Such an infusion quickly establishes a hyperinsu-
linemic plateau of approximately 70 to 80 μU/mL. A few
minutes after starting the insulin, an infusion of 20%
glucose is begun. Based on the plasma glucose concen-
tration, which is measured every 5 to 10 minutes, and
using the negative feedback principle, the glucose infu-
sion rate is adjusted periodically to maintain the plasma
glucose concentration constant at basal level. In response
to the hyperinsulinemic stimulus, there is an initial delay
in the onset of insulin-stimulated glucose disposal that
lasts approximately 15 to 20 minutes.38 After this delay,
there is a rapid increase in glucose utilization from 20 to
80 minutes, and this reaches a near–steady-state value
of 5 to 10 mg/min per kilogram of body weight (27 to
54 μmol/min per kilogram) during the last 40 minutes
of the insulin clamp in healthy young subjects. Because
endogenous glucose production is completely or nearly
completely (>90%) suppressed by insulin, and the plasma
glucose concentration is clamped at the basal level, the
rate of exogenous glucose infusion must equal the rate of
glucose uptake by all tissues of the body and provides a
quantitative measure of the amount of glucose metabo-
lized (M). In insulin-resistant conditions (e.g., obesity
and type 2 diabetes mellitus1,2), hepatic glucose produc-
tion (measured with radiolabeled glucose or a stable
isotope of glucose) is incompletely suppressed and must
be added to the rate of exogenous glucose infusion to
obtain the true rate of total body glucose utilization. The
higher the glucose metabolic rate (M), the more sensitive
the individual is to insulin. The euglycemic insulin clamp
6 60
80
Insulin (µU/ml)
Glucose (mM)
4 36
40
2 ‘M’
0 0
0 60 80
Time (min)
Figure 35-8  Schematic representation of the euglycemic insulin clamp
technique. See text for a detailed description.
609
technique has the following advantages: 1) Any desired
combination of plasma glucose and insulin levels can
be achieved and maintained; 2) the time course of insu-
lin action can be determined with a time resolution of
approximately 10 minutes; 3) other techniques, such as
tracer glucose infusion, indirect calorimetry, limb cath-
eterization, magnetic resonance imaging/spectroscopy,
and muscle biopsy, can be combined with the clamp pro-
tocol; 4) because hypoglycemia is avoided, the release of
counterregulatory hormones (which antagonize insulin
action) is prevented, and one can derive a pure measure
of tissue sensitivity to insulin; 5) the interaction of other
hormones or substrates with insulin action can be quan-
titated by simultaneously infusing them during a clamp
study; 6) the achievement of constant or nearly constant
levels of insulin, glucose, tracer glucose-specific activ-
ity (or enrichment), and glucose metabolic rate allows
one to make quantitative measurements under steady-
state conditions and thus avoid interpretive problems
encountered when plasma glucose and insulin concen-
trations and glucose flux rates are constantly changing
(i.e., during an oral glucose tolerance test or intravenous
glucose tolerance test). The hyperglycemic version of
the glucose clamp is depicted in Figure 35-9.38 In this
procedure, the plasma glucose concentration is acutely
increased by a priming infusion of glucose that is admin-
istered in a logarithmically decreasing manner over
15 minutes. Thereafter, the plasma glucose concentra-
tion is clamped at the designed plateau by periodically
adjusting an exogenous glucose infusion as described in
the euglycemic version. The hyperglycemic step evokes
an endogenous insulin response that is typically biphasic.
During the initial 10 minutes, there is an early burst of
insulin release that is followed by a gradual, continuous
increase in the plasma insulin concentration. The initial
(0 to 10 minutes) peak of insulin represents the release of
preformed hormone that is stored within β-cell granules.
The late (10 to 120 minutes) phase, which is believed
to represent the release of insulin packaged in immature
granules or newly synthesized insulin, lasts until the glu-
cose stimulus is withdrawn. By analogy with the euglyce-
mic insulin clamp counterpart, the hyperglycemic clamp
also provides a quantitative measure of the total amount
of glucose taken up and metabolized (M) by the body in
response to the combined stimuli of endogenous hyper-
insulinemia plus hyperglycemia.
60
48
Glucose infusion rate
Insulin (µU/mL)
Glucose infusion rate
Glucose (mM)
80 10
(µmol/min kg)
(µmol/min kg)
36
24
40 5
12 ‘M’ 12
0
0 60 120
Time (min)
Figure 35-9  Schematic representation of the hyperglycemic clamp
technique. See text for a detailed description.
610 PART 5  DIABETES MELLITUS

One disadvantage of the hyperglycemic clamp or any
study in which glucose is administered intravenously is
the inability to examine the effect of incretins on insulin
secretion.14 Thus, when glucose is administered orally, the
insulin response is significantly greater than when the same
arterial glucose profile is created by intravenous glucose
administration (Fig. 35-10). This phenomenon is generally
known as the incretin effect. The size of the incretin effect
has been shown to be directly related to the strength of the
oral stimulus; thus, ascending doses of oral glucose induce
progressively larger incretin effects in the healthy subject.39
A defective incretin effect has been demonstrated in nondia-
betic obese subjects as well as in subjects with type 2 dia-
betes.40 Among gastrointestinal hormones, GLP-1 and GIP
contribute to the incretin effect significantly because of their
ability to potentiate glucose-induced insulin secretion.14,39
Dynamic Interaction Between Insulin Sensitivity and
Insulin Secretion
In normal, healthy individuals, the euglycemic insulin
clamp technique has demonstrated that insulin sensitivity
10
Plasma glucose
declines with age,41 in part because of the age-related
increase in adiposity.42 More importantly, within the
normal population insulin sensitivity ranges widely.
Among young, healthy, normal, glucose-tolerant subjects,
insulin-mediated glucose disposal varies up to eightfold.43
A number of factors are known to influence insulin sen-
sitivity (see Chapters 36, 40, and 43). In addition to
age, adipose tissue mass, fat topography, and degree of
physical fitness all are powerful determinants of insulin-
mediated glucose disposal.1,2 Increased total body fat
content and especially increased visceral fat,3 as well as
decreased VO2max,44 are associated with impaired insulin
action. Increased metabolites of triglyceride and FFAs
(fatty acylcoenzyme A, diacylglycerol, and ceramide)
within muscle and liver cells are associated with insulin
resistance in these organs.3 Diet composition (increased
fat and reduced carbohydrate) also has been shown to
impair insulin sensitivity. However, even when these factors
are taken into account, one cannot fully explain the wide
variability in insulin sensitivity among healthy adult indi-
viduals.43 Studies in whites, Pima Indians, and Mexican
Americans1,2,45 have demonstrated that genetic factors
play an important role in the distribution of insulin sensi-
tivity (as measured by the glucose disposal rate during a
euglycemic insulin clamp).

8
Glucose homeostasis results from a fine balance
(mmol/L)

between tissue sensitivity to insulin and insulin secre-

tion.46 This implies that the β cell must be able to sense
6
the defect in insulin action and precisely augment its
secretion of insulin to offset the insulin resistance. In fact,
4 insulin resistance is neither necessary nor sufficient to
–30 0 30 60 90 120 150 180 cause dysglycemia so long as the β-cell functional reserve
is large enough to cope even with severe insulin resistance.
1000 The typical case is the morbidly obese subject with normal
glucose tolerance, in whom insulin output can be tenfold
800 Oral
higher than in lean individuals43 and decrease to near-
Plasma insulin

normal levels following major weight loss.47 β-cell dys-

(pmol/L)

600
function, on the other hand, is necessary and sufficient
400
to produce hyperglycemia; type 1 diabetes is the proto-
200 type of primary β-cell failure. In recent years, clinically
0
IV significant advances have also been made in the area of
–30 0 30 60 90 120 150 180 in vivo β-cell function.48 First, it has been recognized
that absolute insulin secretion (whether fasting or post-
meal) reflects the set-point of β-cell secretory function
600 (i.e., secretory capacity) of which insulin resistance and
presumably β-cell mass are positive determinants. However,
(pmol·min–1·m–2)
Secretion rate

400 the strongest determinant of glucose tolerance is the abi­

200
0 ies serve to emphasize the importance of this dynamic
–30 0 30 60 90 120 150
Time (min)
Figure 35-10  The incretin effect: Following oral glucose (75 g) admin-
istration (full line) and isoglycemic intravenous glucose infusion (top) in
the same nondiabetic subjects, plasma insulin concentrations (middle)
and insulin secretion rates (bottom) are markedly potentiated with the
oral as compared to the IV route of administration. Plots are mean ±
SEM. (Redrawn from Muscelli E, Mari A, Casolaro A, et al. Separate
impact of obesity and glucose tolerance on the incretin effect in normal
subjects and type 2 diabetic patients. Diabetes. 2008;57:1340-1348.)
lity of the secretory machinery to rapidly and adequately
cope with the acute changes in glucose induced by feeding.
This aspect of β-cell function, called glucose sensitivity,
is largely independent of insulin resistance. Recent stud-
180 interaction between insulin sensitivity and insulin secre-
tion.49,50 In these studies, both insulin sensitivity (by the
euglycemic insulin clamp technique) and β-cell function
(by mathematical modeling of C-peptide concentra-
tions51) were measured in lean and obese subjects with
and without type 2 diabetes. As shown in Figure 35-11,
in nondiabetic subjects, both fasting insulin secretion
and total insulin output in response to an oral glucose
tolerance test (OGTT) are inversely related to insulin
 35  REGULATION OF INTERMEDIARY METABOLISM DURING FASTING AND FEEDING
Figure 35-11  Reciprocal relationship between insulin sensitivity (mea-
sured by the euglycemic insulin clamp technique38) and insulin secre-
tion (as reconstructed by the C-peptide deconvolution technique51) in
the fasting state (top) and in response to a 75-g oral glucose load over
2 hours (bottom) in lean, nondiabetic subjects (rightmost symbols), in
obese nondiabetic subjects (split into tertiles of 2-hour plasma glucose
concentrations (middle symbols), and in subjects with impaired glu-
cose tolerance (IGT) (leftmost symbols). (Redrawn from Ferrannini E,
Gastaldelli A, Miyazaki Y, et al. Beta-cell function in subjects spanning
the range from normal glucose tolerance to overt diabetes: a new analy-
sis. J Clin Endocrinol Metab. 2005;90:493-500.)
sensitivity. When including type 2 diabetic patients with
progressively worse glycemic control, the relation of
the different parameters of glucose metabolism to glu-
cose tolerance is strikingly different (Fig. 35-12). Insulin
output shows a biphasic time pattern, initially increas-
ing as glucose tolerance deteriorates, to eventually fall
below normal values in severe diabetes. Insulin sensitiv-
ity drops by 35% in the passage between lean and obese
nondiabetic subjects (first two dots to the left of the pan-
els) and continues to fall slowly in the transition from
the following two tertiles of glucose tolerance, through
impaired glucose tolerance (IGT), to progressively more
severe hyperglycemia. In contrast, β-cell glucose sensitiv-
ity declines monotonically in parallel with progressively
higher 2-hour plasma glucose concentrations. Thus, indi-
viduals in the highest tertile of what would be consid-
ered to represent normal glucose tolerance (i.e., 2-hour
plasma = 120 to 139 mg/dL) have lost 50% of β-cell glu-
cose sensitivity, whereas IGT individuals have lost 65%
of β-cell function (see Fig. 35-12). Log-transformation of
these variables demonstrates that the glucose sensitivity
611
Figure 35-12 Relationship between plasma glucose concentrations
measured 2 hours following the ingestion of 75 g of glucose (abscis-
sae) and total insulin output (top), insulin sensitivity (middle), and β-cell
glucose sensitivity (bottom) in different groups of subjects: from left to
right, lean nondiabetic controls, obese nondiabetic subjects by tertile of
2-hour plasma glucose levels, IGT subjects, and patients with overt type
2 diabetes by quartile of 2-hour plasma glucose levels. IGT, Impaired
glucose tolerance. (Redrawn from Ferrannini E, Gastaldelli A, Miyazaki
Y, et al. Beta-cell function in subjects spanning the range from normal
glucose tolerance to overt diabetes: a new analysis. J Clin Endocrinol
Metab. 2005;90:493-500.)
is continuously and linearly related to the 2-hour plasma
glucose concentration in a reciprocal fashion throughout
the range from low-normal to very high (Fig. 35-13), con-
firming that β-cell glucose sensing is a critical determinant
of glucose tolerance. The separate quantitative contribu-
tion of insulin sensitivity and β-cell glucose sensitivity to
glucose tolerance (as the 2-hour plasma glucose level) is
shown in Figure 35-14, which also illustrates the com-
plex, nonlinear interaction of these two main physiologic
determinants of glucose tolerance.
Recent genomewide scan association analyses in dia-
betic52 and nondiabetic cohorts53 have consistently iden-
tified common mutations in genes more or less directly
related to β-cell function (see Chapter 40). Although the
risk conferred by such variants is small, it is conceivable
that individuals carrying one or, more likely, several of
these gene polymorphisms start with an inherently poor
β-cell glucose sensitivity, which may be compounded by
a degree of “essential” insulin resistance. Obesity and
insulin resistance initially provide compensation by rais-
ing the secretory set-point; eventually, however, aging
and glucose toxicity—even that engendered by slight
chronic elevations in plasma glucose levels—wear out
β-cells (especially intrinsically defective β-cells), leading to
612 PART 5  DIABETES MELLITUS
Figure 35-13  Continuous, inverse association between β-cell glucose
sensitivity and insulin sensitivity (individual data from Fig. 35-11). Note
the logarithmic scale for both parameters. (Redrawn from Ferrannini E,
Gastaldelli A, Miyazaki Y, et al. Beta-cell function in subjects spanning
the range from normal glucose tolerance to overt diabetes: a new analy-
sis. J Clin Endocrinol Metab. 2005;90:493-500.)
25
2-h plasma glucose (mmol/l)
20
15
10
5 5
0 0
Insu
lin r
e o se le)
(qu sistan
artil ce
e) β -ce
Figure 35-14 Independent contribution of insulin resistance and
β-cell glucose insensitivity to glucose tolerance (as the 2-hour plasma
glucose level following a standard 75-g oral glucose tolerance test) in
subjects spanning the range from normal glucose tolerance to overt dia-
betes (data as in Figs. 35-11 and 35-12). (Redrawn from Ferrannini E,
Gastaldelli A, Miyazaki Y, et al. Beta-cell function in subjects spanning
the range from normal glucose tolerance to overt diabetes: a new analy-
sis. J Clin Endocrinol Metab. 2005;90:493-500.)
diabetes. This paradigm of the evolution of hyperglyce-
mia from normoglycemia under the separate pressures of
insulin resistance and β-cell glucose sensitivity, schema-
tized in Figure 35-15, is supported by longitudinal studies
in nondiabetic humans.54,55
Effect of Insulin on Hepatic and Peripheral
Glucose Metabolism
The maintenance of normal glucose homeostasis requires
the closely coordinated effects of insulin and hyperglycemia
to simultaneously 1) suppress endogenous (primarily
hepatic) glucose production; 2) stimulate glucose uptake
Insulin
resistance
Normal range
β-cell Glucose sensitivity
Insulin output
Plasma
glucose
Time (years)
Figure 35-15  Schematic representation of the natural history of type 2
diabetes. Shaded areas represent the normal ranges for insulin resistance
(top), β-cell function (middle), and plasma glucose concentrations (bot-
tom). Insulin resistance may start from values close to the upper limit
of normal in predisposed individuals (indicated by the star) and worsen
under the pressure of obesity and a sedentary lifestyle. Insulin output
(dotted line) initially increases to cope with the ensuing insulin resis-
tance and obesity. β-cell glucose sensitivity, however, may initially be
close to the lower limit of normal in genetically predisposed individuals
(double star) and declines continually thereafter. Plasma glucose con-
centrations creep up slowly through the prediabetic phase, eventually to
rise rather rapidly into the diabetic range.
25
Insulin
20
Hepatic glucose production
15 12
(µmol/min-kg)
10
8
4
0
ity -40 0 40 80 120
itiv
ns
se Time (min)
luc rti Figure 35-16  Time course for suppression of hepatic glucose produc-
ll g (qua
tion in healthy adults during a euglycemic insulin clamp. (Redrawn
from Cobelli C, Mari A, Ferrannini E. The non-steady-state problem:
error analysis of Steele’s model and developments for glucose kinetics.
Am J Physiol. 1987;252:E679-E687.)
by peripheral tissues, primarily muscle; 3) stimulate
glucose uptake by the liver; and 4) inhibit lipolysis and
reduce the plasma FFA concentration.1,2 The decrease in
circulating plasma FFA levels plays an important role in
enhancing the suppression of hepatic glucose production
and augmenting muscle glucose uptake in response to a
physiologic increase in plasma insulin concentration.3
Using the euglycemic insulin clamp technique, insulin
can be shown to exert a potent suppressive action on
hepatic glucose production such that portal insulin con-
centrations of less than 100 μU/mL completely abolish glu-
cose entry into the circulation.9,19,56 Figure 35-16 shows
the typical time course for suppression of endogenous
(hepatic) glucose production after an acute increase in
plasma insulin to levels of 60 to 70 μU/mL in healthy
subjects.57 Dose-response curves relating the calculated por-
tal plasma insulin concentration to inhibition of hepatic
 35  REGULATION OF INTERMEDIARY METABOLISM DURING FASTING AND FEEDING
glucose production (Fig. 35-17) indicate a half-maximal
effect at a level of approximately 30 μU/mL, correspond-
ing to an increment in the portal insulin concentration
of only 5 to 10 μU/mL.19,56 These results indicate the
exquisite sensitivity of the liver to very small increments
in the circulating plasma insulin concentration. Note that
in its capacity of a glucose-producing organ, the liver is
extremely sensitive to insulin, whereas the ability of insulin
to augment hepatic glucose uptake under conditions of
euglycemia is quite modest. In the presence of hypergly-
cemia, insulin has a small stimulatory effect on hepatic
glucose uptake.58,59 Hyperglycemia, induced by intra-
venous glucose administration, strongly synergizes this
inhibitory action of insulin on hepatic glucose production
(see Fig. 35-6). Under euglycemic conditions, the apparent
maximal stimulation is approximately 15 mg/min per
kilogram (∼80 μmol/min per kilogram) in healthy adult
subjects and occurs with plasma insulin concentrations
of approximately 250 μU/mL; the half-maximal stimula-
tion of glucose uptake occurs with a plasma insulin con-
centration of 70 to 110 μU/mL. A dose-response curve
of similar shape is derived when progressively higher
insulin doses are infused locally into the forearm or leg
tissues, approximately 70% of which consists of skeletal
muscle. By extrapolating from forearm or leg muscle to
total body muscle mass, it can be estimated that with pre-
vailing peripheral plasma insulin concentrations in the
high physiologic range (60 to 90 μU/mL), approximately
70% of total glucose disposal occurs in muscle tissue.25
Obviously, this percentage increases further with progres-
sively higher insulin levels, because the contribution of
insulin-independent tissues declines. By combining the
insulin clamp technique (plasma insulin concentration,
70 to 80 μU/mL) with leg and hepatic vein catheteriza-
tion, a composite picture of whole-body glucose disposal
can be generated (Fig. 35-18). Brain (1.2 mg/min per kilo-
gram) and splanchnic (liver plus gastrointestinal tissues)
15
2.0
Total glucose disposal
12
(µmol/min-kg)
production (µmol/min-kg)
1.5
9 (offset) after the circulating concentration has returned to
Hepatic glucose
1.0
6 Splanchnic
3 0.5
0 0
2 10 30 50 100 300 500 1000 1700
Plasma insulin conc (µU/ml)
Figure 35-17  Dose-response relationship between the plasma insulin
concentration (note the log scale) versus hepatic glucose production and
whole-body glucose uptake in healthy subjects studied with the euglyce-
mic insulin clamp technique. The insulin concentrations are peripheral
levels in the case of total glucose uptake and portal levels in the case of
hepatic glucose production. (Reproduced from DeFronzo RA, Ferran-
nini E, Hendler R, et al. Regulation of splanchnic and peripheral glucose
uptake by insulin and hyperglycemia in man. Diabetes. 1983;32:35-45.)
613
(0.5 mg/min per kilogram) glucose uptake are unaf-
fected by insulin infusion.1,2 White adipose tissue in adult
humans, though insulin-sensitive, has traditionally been
considered to be relatively inert and to contribute only
a very small percentage of whole-body glucose disposal.
However, more recent studies60 combining the euglyce-
mic insulin clamp technique with 18Fluoro-deoxyglucose
(18FDG) administration and positron-emitting tomogra-
phy (PET) scanning of adipose depots (identified by mag-
netic resonance imaging [MRI]) have demonstrated that
adipose tissue is metabolically very active despite carry-
ing large, inert lipid droplets (70% to 90% by weight).
Thus, under clamp conditions, glucose uptake per unit
tissue weight in subcutaneous adipose tissue in abdomi-
nal and femoral depots is roughly one third of muscle
glucose uptake, and fat mass contributes an estimated
10% of whole-body glucose uptake. Of note, visceral
fat depots are even more insulin sensitive than subcuta-
neous fat60; moreover, in obese individuals, fat behaves
as a metabolic sink for glucose, and its contribution to
whole-body glucose disposal rises to 15% to 20%. In any
event, muscle represents the primary tissue responsible for
insulin-mediated glucose uptake under euglycemic condi-
tions.25 When hyperglycemia (plasma glucose raised from
90 to 180 mg/dL) is superimposed on the same level of
hyperinsulinemia (70 to 80 μU/mL), a doubling of whole-
body glucose utilization occurs (Fig. 35-19); consequently,
glucose clearance remains unchanged. As can be seen in
Figure 35-18, essentially all the additional increase in
glucose disposal above that observed under euglycemic
conditions occurs in muscle. In the presence of hypergly-
cemia, insulin has a small stimulatory effect on hepatic
glucose uptake, which amounts to approximately 10% of
the whole-body glucose disposal.59
The regulation of glucose production and utilization
by insulin is dependent on both the hormone concentra-
tion and time. At any given insulin concentration, there
is a finite period before the effect of the hormone is seen
and reaches its maximum. Such onset time is the sum
of a circulatory delay (delivery of insulin from arterial
blood to cell surface membrane) and a cellular lag (insulin
receptor binding and effector activation). Similarly, insu-
lin’s effect on glucose metabolism remains for some time
Adipose
6
Glucose metabolism
(mg/kg-min)
4
Muscle
2
Brain
0
Figure 35-18  Summary of tissue glucose disposal during a euglyce-
mic (90 mg/dL) hyperinsulinemic (+80 μU/mL) clamp in healthy sub-
jects. (Reproduced from DeFronzo RA: Lilly lecture. The triumvirate:
β-cell, muscle, liver: a collusion responsible for NIDDM. Diabetes.
1988;37:667-687, 1988.)
614 PART 5  DIABETES MELLITUS
basal levels. Figure 35-20 shows the activation and deac-
tivation times of insulin calculated at euglycemia over a
wide range of plasma hormone levels (as high as 1000
μU/mL).61 With the reservations inherent in the analy-
sis of non–steady-state tracer data, the results shown
in Figure 35-20 provide evidence that activation and
deactivation are inversely related to one another. Thus
at higher plasma insulin concentrations, the hormone’s
effect is more rapid in onset and takes longer to wane.
From the physiologic standpoint, it also is noteworthy
that the relationship between onset and offset time is dif-
ferent for the liver (suppression of glucose release) and
for peripheral tissues (stimulation of glucose uptake). At
any insulin dose, the liver is activated more rapidly, and
the effect persists longer. The more rapid onset of action
in the liver may be related to the shorter diffusion time
of bloodborne substances into highly perfused organs
(1 mL/min per gram of tissue in the liver versus a cor-
responding value of 0.04 mL/min per gram in resting
16
Splanchnic
Glucose metabolism (mg/kg-min)
Adipose
12
8
Muscle
4 glycogen formation (Fig. 35-22) closely follows the time
Brain
0 nonoxidative glucose disposal as muscle glycogen forma-
Figure 35-19  Summary of tissue glucose disposal during a hyperglyce-
mic (180 mg/dL) hyperinsulinemic (80 μU/mL) clamp.
Figure 35-20  Relationships between activation and deactivation times
for stimulation of peripheral glucose uptake and inhibition of hepat-
ic glucose production during three insulin infusion rates: 15 mU/m2
per minute (blue circles), 40 mU/m2 per minute (green triangles), and
120 mU/m2 per minute (yellow squares). (Reconstructed from Prager R,
Wallace P, Olefsky JM. In vivo kinetics of insulin action on peripheral
glucose disposal and hepatic output in normal and obese ­subjects. J Clin
Invest. 1986;78:472-481.)
skeletal muscle; see Table 35-1) and to anatomic differ-
ences between liver capillaries (which are fenestrated) and
muscle capillaries (which are not fenestrated).
Intracellular Pathways of Glucose Disposal
Overview
By combining indirect calorimetry with dose-response
studies using the euglycemic insulin clamp technique, it
has been possible to quantitate the two major compo-
nents of whole-body glucose disposal, that is, glucose
oxidation and nonoxidative glucose disposal.1,2,62 The
latter primarily (>90%) represents glycogen synthesis, the
remainder being accounted for by anaerobic metabolism,
that is, net lactate production. Figure 35-21 shows that
the dose-response curves relating glucose oxidation and
nonoxidative glucose disposal (glycogen synthesis) to the
plasma insulin concentration both retain the sigmoidal
shape of the curve for whole-body glucose uptake, but
with distinctly different dose kinetics. Thus, glucose oxi-
dation is more sensitive (lower half maximum) but satu-
rates earlier (lower maximum) than glycogen synthesis;
the latter behaves as a pathway with low sensitivity and
high capacity. Skeletal muscle has been identified as the
predominant site of insulin-mediated net glycogen syn-
thesis.63 However, the increment in carbohydrate oxida-
tion that follows systemic insulin administration occurs
in muscle as well as other tissues (probably the liver) in
an approximate ratio of 1 to 2 (oxidation to glycogen
synthesis). With the use of nuclear magnetic resonance
spectroscopy, one can directly quantitate muscle glycogen
synthesis. The time course of insulin-stimulated muscle
course of nonoxidative glucose uptake by the whole
body.63 By extrapolation from leg muscle to whole-body
muscle, one can account for the great majority (∼90%) of
tion. Under physiologic conditions of hyperinsulinemia,
approximately two thirds of G6P is converted to glycogen
and one third enters glycolysis.25,63 Of the glucose that
enters the glycolytic pathway, the majority (80% to 90%) is
Figure 35-21  Dose-response relationship between the plasma insulin
concentration and total body glucose uptake, glucose oxidation, and
nonoxidative glucose disposal in healthy subjects during a euglycemic
insulin clamp. (Drawn from Thiebaud D, Jacot E, DeFronzo RA, et al.
The effect of graded doses of insulin on total glucose uptake, glucose
oxidation, and glucose storage in man. Diabetes. 1983;31:957-963.)
 35  REGULATION OF INTERMEDIARY METABOLISM DURING FASTING AND FEEDING
Figure 35-22  Time course of stimulation of muscle glycogen forma-
tion by combined hyperinsulinemia (100 μU/mL) and hyperglycemia
(200 mg/dL) in healthy subjects as determined by nuclear magnetic res-
onance spectroscopy. (Redrawn from Shulman GI, Rothman DL, Jue T,
et al. Quantitation of muscle glycogen synthesis in normal subjects and
subjects with non-insulin-dependent diabetes by 13C nuclear magnetic
resonance spectroscopy. N Engl J Med. 1990;322:223-228.)
Glucose
Glucose
transport unit
Glucose
Hexokinase
Glucose-6-P
Glycogen Pyruvate
synthase dehydrogenase
Glycogen Oxidation
Figure 35-23  Schematic representation of glucose transport, glucose
phosphorylation, and the intracellular partitioning of glucose into
its two major metabolic pathways: glucose oxidation and glycogen
­synthesis.
oxidized in the Krebs cycle to carbon dioxide and water,
and the remainder is converted to lactate.64
For insulin to exert its biological effects on glucose
metabolism, it must first bind to specific receptors that
are present on the cell surface of all insulin target tissues2
(see Chapter 33). After insulin has bound to and acti-
vated its receptor, second messengers are generated, and
these second messengers initiate a series of events invol­
ving a cascade of phosphorylation-dephosphorylation
reactions2,65-67 that eventually result in the stimulation
of intracellular glucose metabolism. The initial step in
glucose metabolism involves activation of the glucose
transport system, leading to influx of glucose into insu-
lin target tissues, primarily muscle (Fig. 35-23).2,6,28,68
The free glucose that has entered the cell is subsequently
metabolized by a series of enzymatic steps that are under
the control of insulin. Of these, the most important are
glucose phosphorylation (catalyzed by hexokinase), gly-
cogen synthase (which controls glycogen synthesis), and
phosphofructokinase (PFK) and pyruvate dehydrogenase
615
Figure 35-24  Schematic representation of the insulin receptor and the
cascade of intracellular signaling molecules that have been implicated in
insulin action. See text for a more detailed discussion. GLUT, Glucose
transporter; MAP, mitogen-activated protein; PI-3-Kinase, phosphati-
dylinositol kinase; SNAP, soluble NSF attachment 23-kD protein; SYN,
syntaxin; VAMP, vesicle-associated membrane.
(PDH) (which regulate glycolysis and glucose oxidation,
respectively).
Insulin Receptor/Insulin Receptor Tyrosine Kinase
The insulin receptor is a glycoprotein consisting of
two α subunits and two β subunits linked by disulfide
bonds2,65-67 (see Chapter 33 and Fig. 35-24). The α sub-
unit of the insulin receptor is entirely extracellular and
contains the insulin-binding domain. The β subunit has
an extracellular domain, a transcellular domain, and an
intracellular domain that express insulin-stimulated kinase
activity directed toward its own tyrosine residues. Insulin
receptor phosphorylation of the β subunit, with subse-
quent activation of insulin receptor tyrosine kinase, rep-
resents the first step in the action of insulin on glucose
metabolism. Mutagenesis experiments have shown that
insulin receptors devoid of tyrosine kinase activity are
completely ineffective in mediating insulin stimulation
of cellular metabolism. Similarly, mutagenesis of any of
the three major phosphorylation sites (at residues 1158,
1163, and 1162) impairs the insulin receptor kinase acti­
vity, and this is associated with a marked decrease in the
acute metabolic and growth-promoting effects of insulin.
Insulin Receptor Signal Transduction
After activation, insulin receptor tyrosine kinase phos-
phorylates specific intracellular proteins, of which at
least nine have been identified (see Chapter 33 and Fig.
35-24).65 Four of these belong to the family of insulin-
receptor substrate (IRS) proteins: IRS-1, IRS-2, IRS-3,
IRS-4 (the others include Shc, Cbl, Gab-1, p60[dok], and
APS). In muscle, IRS-1 serves as the major docking protein
that interacts with the insulin receptor tyrosine kinase
and undergoes tyrosine phosphorylation in regions con-
taining amino acid sequence motifs (YXXM or YMXM)
which, when phosphorylated, serve as recognition sites for
proteins containing src-homology 2 (SH2) domains.68,69
Mutation of these specific tyrosines severely impairs the
ability of insulin to stimulate glycogen and DNA synthesis,
establishing the important role of IRS-1 in insulin signal
616 PART 5  DIABETES MELLITUS
Insulin
Ca++
– –
+ +
Synthase Protein
Kinase Kinase
Glycogen Glycogen
Synthase Synthase
(inactive) (active)
Phosphatase
+ +
Insulin
Figure 35-25  Schematic representation of the control of glycogen synthesis and breakdown. Sites of insulin regulation are indicated. See text
for a detailed discussion. Cyclic AMP, Cyclic adenosine monophosphate; G1P, glucose 1-phosphate; G6P, glucose 6-phosphate; UDPG, uridine-
diphosphate glucose.
transduction. In liver, IRS-2 serves as the primary dock-
ing protein that undergoes tyrosine phosphorylation and
mediates the effect of insulin on hepatic glucose pro-
duction, gluconeogenesis, and glycogen formation. In
adipocytes, Cb1 represents another substrate that is phos-
phorylated after its interaction with the insulin receptor
tyrosine kinase and is required for stimulation of GLUT-4
translocation. Phosphorylation of Cb1 occurs when the
CAP/Cb1 complex associates with flotillin in caveolae, or
lipid rafts, containing insulin receptors.70
In muscle, the phosphorylated tyrosine residues on
IRS-1 mediate an association between the SH2 domains
of the 85-kD regulatory subunit of phosphatidylinosi-
tol-3-kinase (PI-3-kinase), leading to activation of the
enzyme65-67,69 (see Fig. 35-24). PI-3-kinase is a heterodi-
meric enzyme composed of an 85-kD regulatory subunit
and a 110-kD catalytic subunit. The latter catalyzes the
3’-phosphorylation of phosphatidylinositol (PI) in the
plasma membrane glycolipids, thereby converting PI-
4,5-bisphosphate to PI-3,4,5-triphosphate and PI-4-phos-
phate to PI-3,4 biphosphate. PI-(3,4,5)-P3 and PI-(3,4)-P2
lead to the stimulation of glucose transport. Activation of
PI-3-kinase by phosphorylated IRS-1 also leads to activa-
tion of glycogen synthase65,69 via a process that involves
activation of protein kinase B/Akt and subsequent inhibi-
tion of kinases such as GSK-3 and activation of protein
phosphatase-1 (PP-1). Inhibitors of PI-3-kinase impair
glucose transport by interfering with the translocation of
GLUT-4 from their intracellular location and block the
activation of glycogen synthase and hexokinase (HK)-II
expression.28,65-69 The action of insulin to increase protein
synthesis and inhibit protein degradation also is mediated
by PI-3-kinase and involves the activation of mTOR.71
Mammalian target of rapamycin (mTOR) controls the
translation machinery by phosphorylation and activation
of p70 ribosomal S6 kinase [p70(rsk)] and phosphoryla-
tion of initiation factors.71 Insulin also promotes hepatic
Cyclic AMP
Phosphorylase
Kinase
Glycogen
Glycogen Glycogen
Phosphorylase Phosphorylase
(active) (inactive)
UDPG G–1–P
Phosphatase
G–6–P
Glucose Insulin
triglyceride synthesis by increasing the transcription fac-
tor steroid regulatory element-binding protein (SRBP)-
1c, and this lipogenic effect of insulin also appears to be
mediated via the PI-3-kinase pathway.65
Other proteins with SH2 domains, including the
adapter protein Grb2 and Shc, also interact with IRS-1
and become phosphorylated after exposure to insu-
lin.65,66,69 Grb2 and She serve to link IRS-1/IRS-2 to the
mitogen-activated protein signaling pathway (see Fig.
35-24), which plays an important role in the generation
of transcription factors.65,69 After the interaction between
IRS-1/IRS-2 and Grb2 and She, Ras is activated, leading to
the stepwise activation of Raf, mitogen-activated protein
kinase (MEK), and extracellular signal-regulated kinase.
Activated extracellular signal-regulated kinase then trans-
locates into the nucleus of the cell, where it catalyzes the
phosphorylation of transcription factors that promote
cell growth, proliferation, and differentiation.565,66,69,72,73
Blockade of the MEK pathway prevents the stimulation
of cell growth by insulin but has no effect on the metabolic
actions of the hormone.
Under anabolic conditions, insulin stimulates glycogen
synthesis by simultaneously activating glycogen synthase
and inhibiting glycogen phosphorylase74-76 (Fig. 35-25).
The effect of insulin is mediated via the PI-3-kinase path-
way, which inactivates kinases such as glycogen synthase
kinase-3 and activates phosphatases, particularly PP-1. It
is believed that PP-1 is the primary regulator of glyco-
gen metabolism.74-76 In skeletal muscle, PP-1 associates
with a specific glycogen-binding regulatory subunit, caus-
ing dephosphorylation (activation) of glycogen synthase.
PP-1 also phosphorylates (inactivates) glycogen phos-
phorylase. The precise steps that link insulin receptor
tyrosine kinase/PI-3-kinase activation to stimulation of
PP-1 have yet to be defined. Some evidence suggests that
p90 ribosomal S6-kinase may be involved in the activa-
tion of glycogen synthase.65 Akt also has been shown to
 35  REGULATION OF INTERMEDIARY METABOLISM DURING FASTING AND FEEDING
phosphorylate and thus inactivate GSK-3. This decreases
glycogen synthase phosphorylation, leading to activation
of the enzyme. A number of studies have convincingly
demonstrated that inhibitors of PI-3-kinase inhibit gly-
cogen synthase and abolish glycogen synthesis.65,66 From
the physiologic standpoint, it makes sense that activa-
tion of glucose transport and glycogen synthase should
be linked to the same signaling mechanism to provide a
coordinated and efficient stimulation of intracellular glucose
metabolism.
Glucose Transport
Activation of the insulin signal transduction system in
insulin target tissues leads to the stimulation of glucose
transport. The effect of insulin is brought about by the
translocation of a large intracellular pool of GLUTs (asso-
ciated with low-density microsomes) to the plasma mem-
brane.2,6,28,68 There are five major, different facilitative
GLUTs with distinctive tissue distributions6,68,77,78 (see
Table 35-3). GLUT-4, the insulin-regulatable transporter,
is found in insulin-sensitive tissues (muscle and adipo-
cytes), has a Km of approximately 5 mmol/L, which is
close to that of the plasma glucose concentration, and is
associated with HKII.79-81 In adipocytes and muscle, its
concentration in the plasma membrane increases markedly
after exposure to insulin, and this increase is associated
with a reciprocal decline in the intracellular GLUT-4 pool.
Acute physiologic hyperinsulinemia does not increase the
total number of GLUT-4 transporters in muscle, even
though several studies have demonstrated an increase in
muscle GLUT-4 mRNA. Using a novel isotopic dilution
technique, the in vivo dose-response curve for the action
of insulin on glucose transport in human forearm skeletal
muscle has been described (Fig. 35-26). GLUT-1 repre-
sents the predominant GLUT in the insulin-independent
tissues (brain and erythrocytes) but is also found in mus-
cle and adipocytes. It is located primarily in the plasma
membrane, where its concentration changes little after
40
Transport rate constants (min-1)
Kin
30
20
Kout
10
0
10 100 1000
Plasma insulin (pM)
Figure 35-26  Insulin action on glucose transport. Insulin dose-re-
sponse curve for inward (Kin) and outward (Kout) rate constants for the
transmembrane transport of 3-O-methyl-glucose in forearm skeletal
muscle at different plasma insulin concentrations. * P < 0.05 versus bas-
al; ** P < 0.01 versus basal. (Reproduced from Bonadonna RC, Cobelli
C, Saccomani MP et al. Glucose transport in human skeletal muscle: the
in vivo response to insulin. Diabetes. 1993;42:191-198, 1993.)
617
the addition of insulin. It has a low Km (∼1 mmol/L) and
is well suited for its function, which is to mediate basal
glucose uptake. It is found in association with HK-I.79-
81 GLUT-2 predominates in the liver and pancreatic β
cells, where it is found in association with a specific HK,
HK-IV79-82 In the β cell, HK-IV is referred to as glucoki-
nase.82 GLUT-2 has a high Km (15 to 20 mmol/L); as a
consequence, the glucose concentration in cells express-
ing this transporter increases in direct proportion to the
increase in plasma glucose concentration. This characte­
ristic allows these cells to respond as glucose sensors. In
summary, each tissue has a specific GLUT and associated
HK that allow it uniquely to carry out its specialized func-
tion to maintain whole-body glucose economy.
Glucose Phosphorylation
Glucose phosphorylation and glucose transport are
tightly coupled phenomena. Isoenzymes of HK (HKI
to HKIV) catalyze the first committed intracellular step
of glucose metabolism, the conversion of glucose to
G6P79-82 (see Table 35-3). HKI, HKII, and HKIII are
single-chain peptides that have a number of properties in
common, including a very high affinity for glucose and
product inhibition by G6P. HKIV, also called glucoki-
nase, has a lower affinity for glucose and is not inhibited
by G6P. Glucokinase (HKIVB) is the glucose sensor in
the β cell, whereas HKIVL plays an important role in the
regulation of hepatic glucose metabolism. In both rat and
human,80,83 skeletal muscle HKII transcription is regu-
lated by insulin. HKI also is present in human skeletal
muscle but is not regulated by insulin. In response to
physiologic euglycemic hyperinsulinemia, HKII cytosolic
activity, protein content, and mRNA levels increase by
50% to 200% in healthy subjects,83 and this is associated
with the translocation of HKII from the cytosol to the
mitochondria.84 In contrast, insulin has no effect on HKI
activity, protein content, or mRNA levels.
Glycogen Synthesis
After glucose enters the cell and is phosphorylated, it can
either be converted to glycogen or enter the glycolytic
pathway. Of the glucose that enters the glycolytic path-
way, approximately 90% is oxidized. In the low physi-
ologic range of plasma insulin concentrations, glycogen
synthesis and glucose oxidation are of approximately
equal quantitative importance. With increasing plasma
insulin concentrations, glycogen synthesis becomes pre-
dominant.56,62 If the rate of glucose oxidation is sub-
tracted from the rate of whole-body insulin-mediated
glucose disposal (determined from the insulin clamp), the
difference represents nonoxidative glucose disposal (or
glucose storage), which primarily reflects glycogen syn-
thesis.1,2,63 Glucose conversion to lipid accounts for less
10000
than 5% of total glucose disposal,85 and 5% to 10% of
the glucose taken up by muscle is released as lactate.64
Using nuclear magnetic resonance imaging spectros-
copy and measuring insulin-stimulated incorporation
of [1H,13C]-glucose into muscle glycogen,63 the rate of
nonoxidative glucose disposal (glucose storage) has been
shown to correlate closely with the rate of glycogen syn-
thesis (see Fig. 35-22).
618 PART 5  DIABETES MELLITUS

Glycogen synthase is the key insulin-regulated Figure 35-28, plasma FFA concentrations decline steeply
enzyme that controls the rate of muscle glycogen for- in response to small increments in circulating insulin
mation.74-76,86-88 Insulin enhances glycogen synthase levels under conditions of euglycemia. This decrease is the
activity by stimulating a cascade of phosphorylation-­ result of a drastic reduction in the rate of FFA appearance
dephosphorylation reactions74,75,88 (see the section enti- into the circulation. The concomitant decline in plasma
tled “Insulin Receptor Signal Transduction”), which glycerol concentration is consistent with in vitro studies
ultimately lead to the activation of PP-1 (also called gly- and indicates that lipolysis is inhibited. The consequence
cogen synthase phosphatase).87,88 The regulatory subunit of the reduced availability of FFA is a parallel reduction
(G) of PP-1 has two serine phosphorylation sites, called in both FFA oxidation and nonoxidative FFA disposal,
site 1 and site 2. Phosphorylation of site 2 by cyclic ade- that is, reesterification (Fig. 35-29). The inverse patterns
nosine monophosphate-dependent kinase (PKA) inac- of change in glucose disposal and oxidation on the one
tivates PP-1, while phosphorylation of site 1 by insulin hand, and lipid utilization on the other, introduce the
activates PP-1, leading to the stimulation of glycogen important concept of substrate competition. Glucose and
synthase.88,89 Phosphorylation of site 1 of PP-1 by insu-
lin in muscle is catalyzed by insulin-stimulated protein
kinase-1, which is part of a family of serine/threonine
protein kinases termed ribosomal S6-kinases. Because
of their central role in muscle glycogen formation, and
because impaired insulin-stimulated glycogen synthesis
is a characteristic defect in patients with type 2 diabetes
mellitus, considerable attention has been focused on the
three enzymes—glycogen synthase, PP-1, and insulin-
stimulated protein kinase-1—in the pathogenesis of insu-
lin resistance in individuals with type 2 diabetes. The
effect of insulin on glycogen synthase gene transcription
and translation in vivo has been studied by employing the
euglycemic insulin clamp in combination with muscle
biopsies. Most studies83 have shown that insulin does not
increase glycogen synthase mRNA or protein expression
in human muscle in vivo. Rather, insulin converts the Figure 35-27  Schematic representation of the control of pyruvate
inactive (phosphorylated) form of glycogen synthase to ­dehydrogenase. Sites of insulin regulation are shown. See text for a
­detailed discussion. NAD+, oxidized nicotinamide adenine dinucleo-
the active (dephosphorylated) form of the enzyme.74-76,86 tide; NADH, reduced nicotinamide adenine dinucleotide; PDH, pyru-
vate dehydrogenase.
Glycolysis/Glucose Oxidation
Glucose oxidation accounts for approximately 90% of
1000
total glycolytic flux, while anaerobic glycolysis accounts
for the other 10%.64 Two enzymes, PFK and PDH, play
Plasma FFA
(µmol/L)

central roles in the regulation of glycolysis and glucose

oxidation, respectively. PFK represents a key functional 500
step in control of glycolysis.90 Insulin does not exert any
direct effect on this enzyme, which is primarily regulated
by the energy (ATP) and fuel (citrate, acetyl-CoA) status 0
of the cell. However, insulin indirectly stimulates PFK by
300
increasing fructose-2,6-bisphosphate, a potent activator of
PFK. Insulin has no effect on muscle PFK activity, mRNA
levels, or protein content in nondiabetic individuals.91
(µmol/m2-min)
FFA turnover

Insulin also regulates flux through glycolysis by increas-
ing the activity of the multienzyme complex, PDH.34,90
This enzyme is activated by insulin, which stimulates
PDH-phosphatase, thus converting the enzyme from its
inactive phosphorylated form to its active dephosphory-
lated form (Fig. 35-27). The PDH complex enzyme also
is inhibited by its products, acetyl-CoA and reduced nico-
tinamide adenine dinucleotide (NADH).
Free Fatty Acid–Amino Acid–Glucose Interactions
A major part of insulin’s stimulatory action on glucose
metabolism is indirect and is mediated via changes in sub-
strate metabolism. In contrast to the hormone’s stimu-
latory effect on glucose utilization, insulin is a powerful
inhibitor of lipolysis and lipid oxidation.56 As shown in
200
100
0
0 50 100 200
Plasma insulin (µU/mL)
Figure 35-28  Dose-response relationship between the plasma insulin
concentration and plasma free fatty acid (FFA) concentration (top) and
rate of plasma FFA turnover (bottom) in healthy subjects during euglyce-
mic insulin clamp studies. (Reproduced from Groop LC, Bonadonna RC,
Del Prato S, et al. Glucose and free fatty acid metabolism in non–in-
sulin-dependent diabetes mellitus: evidence for multiple sites of insulin
resistance. J Clin Invest/ 1989;84:205-213.)
 35  REGULATION OF INTERMEDIARY METABOLISM DURING FASTING AND FEEDING 619

long-chain FFAs are the first and best-known example
of substrate competition in insulin-dependent tissues.92
Physiologically, the increases in plasma glucose (by mass
action) and insulin (stimulation of glucose transport)
concentrations increase the rate of glucose uptake into
fat cells. The resultant increase in intracellular α-glycerol
phosphate generated during the stimulation of glycolysis
supplies the substrate for augmented reesterification of
tissue FFAs, while at the same time insulin stimulates
α-glycerol phosphate acyltransferase, the rate-limiting
100
(µmol/m2-min)
FFA oxidation
enzyme for triglyceride synthesis. These combined effects
limit the release of FFAs into the bloodstream. In addi-
tion, the glucose-induced increase in plasma insulin
concentration quickly inhibits lipolysis by stimulating
hormone-sensitive lipase in the adipocyte, and this further
reduces the supply of lipid substrates to the oxidative
machinery in muscle and liver. A decrease in FFA oxi-
dation by these tissues causes a reciprocal stimulation of
glucose oxidation and glycogen synthesis by reversal of
the Randle cycle in muscle (see later) and inhibition of
gluconeogenesis in the liver.
The glucose-mediated inhibition of FFA metabolism
is counterbalanced by an FFA-mediated inhibition of

glucose metabolism, creating an FFA–glucose substrate

interaction known as the Randle cycle.92 When their
50 plasma concentration is elevated, by mass action FFAs
are transported into muscle and liver cells by simple dif-
fusion across the membrane. The intracellular free FFA
0
concentration is maintained low by a specific FFA-bind-
200 ing protein, and this ensures a favorable transport gradi-
ent. Once inside the cell, FFAs are transported into the
FFA metabolism
(µmol/m2-min)
Non-oxidative

mitochondria, where they undergo beta oxidation (Fig.

100
0 by the appropriate acyl-CoA synthetase. Because the
0 50 100 200
Plasma insulin (µU/mL)
Figure 35-29  Dose-response relationship between the plasma insulin
concentration versus the rate of whole-body free fatty acid (FFA) oxida-
tion (top) and the rate of nonoxidative FFA disposal, that is, reesteri-
fication (bottom) in healthy subjects during euglycemic insulin clamp
studies. (Reproduced from Groop LC, Bonadonna RC, Del Prato S
et al. Glucose and free fatty acid metabolism in non-insulin-dependent
diabetes mellitus: evidence for multiple sites of insulin resistance. J Clin
Invest. 1989;84:205-213.)
35-30). Before entering the mitochondria, the long-chain
fatty acids (oleic, palmitic, stearic, linoleic, and palmi-
toleic) are first activated to their acyl-CoA derivative
inner mitochondrial membrane is not permeable to the
fatty-acyl-CoA, a specific transport system is necessary
to transport the fatty-acyl derivative into the mitochon-
dria (see Fig. 35-30).93 The enzyme carnitine acyltrans-
ferase-1 in the outer membrane transfers the cytosolic
fatty acyl-CoA to carnitine, and the resulting fatty-acyl
carnitine derivative is transported through the mitochon-
drial membrane. At the inner mitochondrial membrane,
carnitine acyltransferase 2, the rate-limiting enzyme for

Figure 35-30  Free fatty acid (FFA) and ketone body metabolism in the liver. After transport into the hepatocyte, FFAs are activated to their acyl-
CoA derivative. Depending on the hormonal, metabolic, and energy status of the cell, the fatty acyl-CoA moiety is either transported into the mito-
chondrion and oxidized or synthesized into triglyceride. Malonyl-CoA, which is a potent inhibitor of carnitine palmitoyl transferase 1, plays a pivotal
role in the switch from FFA oxidation to lipid synthesis. Insulin enhances the formation of malonyl-CoA by stimulating acetyl-CoA-carboxylase.
Insulin also favors triglyceride synthesis by inhibiting triacylglycerol lipase, the rate-limiting step for lipolysis. ATP, Adenosine triphosphate; CAT,
carnitine acyltransferase; TAG, triacylglycerol.
620 PART 5  DIABETES MELLITUS

beta oxidation, catalyzes the transfer of the fatty-acyl unit According to the FFA-glucose cycle originally pro-
from fatty-acyl carnitine back to CoA, and the fatty acyl- posed 5 decades ago by Randle and colleagues,92 the
CoA then undergoes beta oxidation with the resultant increase in FFA oxidation restrains glucose oxidation
generation of acetyl-CoA. in muscle by altering the redox potential of the cell and
As beta oxidation proceeds, acetyl-CoA accumulates inhibiting key glycolytic enzymes. The excessive FFA
within the cell and becomes a powerful inhibitor of the oxidation, in addition to causing the intracellular accu-
PDH enzyme complex (Fig. 35-31).92,93 In addition, the mulation of acetyl-CoA (a potent inhibitor of PDH) and
accelerated rate of FFA oxidation consumes nicotinic increasing the NADH/NAD ratio (causing a slowing of
adenine dinucleotide (NAD) and generates NADH. This the Krebs cycle), results in the accumulation of citrate,
shift in redox potential further inhibits PDH and impairs a powerful inhibitor of PFK. Randle and colleagues pro-
the Krebs cycle. Fatty acyl-CoA derivatives also have posed that inhibition of PFK caused product inhibition of
been shown to inhibit glycogen synthase in muscle and the early steps involved in glucose metabolism, leading to
liver94,95 (see Fig. 35-31). In healthy humans, a physio-
logic elevation in the plasma FFA concentration (created
by Intralipid/heparin infusion) stimulates FFA oxidation
and inhibits both glucose oxidation and glucose storage
(glycogen synthesis),23,96 thus providing experimental
validation of the Randle cycle. In nondiabetic subjects,
a physiologic increment in the plasma insulin level
(+100 μU/mL) causes a 50% to 60% decline in plasma
FFA concentration and a parallel decline in lipid oxida-
tion (Fig. 35-32). Infusion of Intralipid during the insulin
clamp, to maintain or increase the plasma FFA level (see
Fig. 35-32), inhibits insulin-mediated stimulation of both
glucose oxidation and glucose storage (glycogen synthe-
sis) (Fig. 35-33). These data demonstrate that the Randle
cycle operates in vivo in humans in response to physi-
ologic changes in the plasma FFA concentration. The
inhibitory effect of elevated plasma FFA levels is observed
at all plasma insulin concentrations, spawning the physi-
ologic and pharmacologic range.96 The inhibitory effect
of an acute increase in plasma FFA concentration on Figure 35-32  Plasma free fatty acid (FFA) concentration and total
body lipid oxidation (measured by indirect calorimetry) in the basal
muscle glucose metabolism is time dependent. Thus the state and during a 100-μU/mL euglycemic insulin clamp performed
earliest (within 2 hours) observed abnormality is a defect with and without Intralipid (IL) infusion. Intralipid was infused at two
in glucose oxidation, as would be predicted by operation rates to maintain (low IL infusion) or increase (high IL infusion) the
of the Randle cycle.92 This is followed (between 2 and basal plasma FFA concentration. The high-dose Intralipid infusion rate
maintained the rate of total body lipid oxidation constant at the basal
3 hours) by defects in glucose transport and phosphoryla- value. (Reproduced from Thiebaud D, DeFronzo RA, Jacot E, et al. Ef-
tion and eventually (after 3 to 4 hours) by impaired gly- fect of long-chain triglyceride infusion on glucose metabolism in man.
cogen synthesis.3,97 Metabolism, 1982;21:1128-1136.)

Figure 35-31  Schematic representation of

the intracellular biochemical and molecular
events that are inhibited by fatty acyl-CoAs
and their intracellular metabolites. See text
for a more detailed discussion. AcCoA,
Acyl-CoA; F6P, fructose-6-phosphate; FA-
CoA, fatty acyl-CoA; FFA, free fatty acid;
G1P, glucose-1-phosphate; G6P, glucose-
6-phosphate; GLUT, glucose transporter;
HK, hexokinase; NAD, nicotinamide adenine
dinucleotide; PDH, pyruvate dehydrogenase;
PFK, phosphofructokinase; PI3K, phosphati-
dylinositol kinase; UDP, uridine diphosphate.
 35  REGULATION OF INTERMEDIARY METABOLISM DURING FASTING AND FEEDING
Figure 35-33  Inhibitory effect of Intralipid (IL) infusion and enhanced
lipid oxidation on insulin-mediated rates of glucose oxidation and non-
oxidative glucose disposal. (See legend to Fig. 35-31 for description of
the experimental protocol.) (Reproduced from Thiebaud D, DeFronzo
RA, Jacot E, et al. Effect of long-chain triglyceride infusion on glucose
metabolism in man. Metabolism. 1982;21:1128-1136.)
the accumulation of G6P, which in turn inhibited HKII.
The block in glucose phosphorylation caused a buildup of
intracellular free glucose, which restrained glucose trans-
port into the cell via GLUT-4. The resultant decrease in
glucose transport, in turn, resulted in impaired glycogen
synthesis. This sequence of events by which accelerated
plasma FFA oxidation inhibits muscle glucose transport,
glucose oxidation, and glycogen synthesis is now referred
to as the Randle cycle.92 It should be noted that the same
scenario would ensue if the FFA were derived from tri-
glycerides stored in muscle or from plasma.96
The original description of the Randle cycle was formu-
lated based on experiments performed in rat diaphragm
and heart muscle.92 More recent studies performed in
human skeletal muscle implicate mechanisms in addition
to those originally proposed by Randle and colleagues, in
the FFA-induced insulin resistance. Several groups98 have
failed to observe an increase in G6P, or in muscle citrate
levels, or an inhibition of PFK, when insulin-stimulated
glucose metabolism was inhibited by a lipid infusion to
increase the plasma FFA concentration. Thus, although
increased FFA/lipid and decreased glucose oxidation are
closely coupled, as originally demonstrated by Randle and
colleagues, mechanisms other than product (i.e., elevated
intracellular G6P and free glucose concentrations) inhi-
bition of the early steps of glucose metabolism must be
invoked to explain the defects in glucose transport, glucose
phosphorylation, and glycogen synthesis (see Fig. 35-31).
Studies in humans and animals have shown a strong
negative correlation between insulin-stimulated glucose
metabolism and increased intramuscular lipid pools,
including triglyceride, diacylglycerol, ceramides, and
long-chain fatty acyl-CoAs.3,99-101 An acute increase in
the plasma FFA concentration leads to an increase in
muscle fatty acyl-CoA and diacylglycerol concentrations.
Both long-chain fatty acyl-CoAs and diacylglyc-
erol activate protein kinase C-θ, which increases serine
621
Figure 35-34  Net glucose, lactate, and pyruvate balances across the
human forearm of healthy subjects in the fasting state (30 to 0 minutes)
and during a 100-minute intraarterial insulin infusion calculated to in-
crease the local insulin concentration by approximately 120 μU/mL.
(Reproduced from Natali A, Buzzigoli G, Taddei S et al. Effects of in-
sulin on hemodynamics and metabolism in human forearm. Diabetes.
1990;39:490–500.)
phosphorylation with subsequent inhibition of IRS-1
tyrosine phosphorylation. In human muscle, elevated
plasma FFA levels inhibit insulin-stimulated tyrosine
phosphorylation of IRS-1, the association of the p85
subunit of PI 3-kinase with IRS-1, and activation of PI
3-kinase98,102 (see Fig. 35-31). Direct effects of long-
chain fatty acyl-CoAs to inhibit glucose transport, glu-
cose phosphorylation, and glycogen synthase also have
been demonstrated in muscle (see Fig. 35-32). Last,
increased muscle ceramide levels (secondary to increased
long-chain fatty acyl-CoAs) interfere with glucose trans-
port and inhibit glycogen synthase in muscle via multiple
mechanisms involving alterations in a variety of intracel-
lular lipid-signaling molecules that exert their inhibitory
effects on multiple steps of glucose metabolism (insulin
signal transduction system, glucose transport, glucose
phosphorylation, glycogen synthase, PDH, Krebs cycle).
The extent to which insulin action in target tissues is
direct rather than mediated by shifts in substrate sup-
ply can be appreciated by comparing systemic with local
insulin administration. When infused intraarterially into
the human forearm, insulin does not alter the circulat-
ing substrate supply, in that neither FFA nor glucose
concentrations change in the arterial blood recirculating
to the forearm tissues. Under these conditions, insulin
stimulates forearm glucose uptake and lactate release in a
time-dependent manner (Fig. 35-34) but does not induce
any detectable change in the local respiratory quotient
(0.76) in the blood draining the forearm tissues.103 This
observation indicates that the forearm tissues, and the
muscle in particular, continue to rely mostly on lipid oxi-
dation for energy production, and that the vast majority
of insulin-stimulated glucose uptake is channeled to gly-
cogen. In contrast, when comparable hyperinsulinemia is
created by systemic infusion of insulin while maintaining
622 PART 5  DIABETES MELLITUS
Figure 35-35  Schematic representation of the regulation of hepatic
glucose production and hepatic gluconeogenesis. Sites of stimulation of
free fatty acids are shown by the asterisk. See text for a more detailed
discussion. PEP, Phosphoenolpyruvate.
euglycemia, the leg respiratory quotient increases from
0.74 to almost 1.00, that is, glucose oxidation increases,
whereas lipid oxidation is markedly reduced. In sum-
mary, the direct effects of insulin are to promote glucose
transport and phosphorylation, glycolysis, and glycogen
synthesis; the stimulatory effect of the hormone on glu-
cose oxidation is both direct and indirect, the latter being
mediated by a fall in lipid availability.
The liver plays a central role in the regulation of glucose
metabolism.1,2,9,10,104 After ingestion of a carbohydrate
meal, it is essential that the liver suppress its basal rate
of glucose production. In addition, the liver ultimately
takes up approximately one third of the glucose in the
carbohydrate meal. Collectively, suppression of hepatic
glucose production and augmentation of hepatic glucose
uptake account for approximately half of the mainte-
nance of plasma glucose homeostasis after ingestion of
a carbohydrate meal. The regulation of hepatic glucose
production is controlled by a number of factors (see Fig.
35-3), of which insulin (inhibits hepatic glucose produc-
tion) and glucagon and FFA (stimulate hepatic glucose
production) are the most important. In vitro studies have
demonstrated that plasma FFA are potent stimulators of
hepatic glucose production and do so by increasing the
activity of pyruvate carboxylase and phosphoenolpyru-
vate carboxykinase, the rate-limiting enzymes for gluco-
neogenesis.105 FFAs also enhance the activity of G6Pase,
the enzyme that ultimately controls the release of glucose
by the liver106 (Fig. 35-35).
In normal subjects, an acute physiologic increase in
plasma FFA concentration stimulates gluconeogenesis,
whereas a decrease in plasma FFA concentration reduces
gluconeogenesis.107 A significant portion (as much as
25%) of the suppressive effect of insulin on hepatic
glucose production is mediated via inhibition of lipoly-
sis and a reduction in circulating plasma FFA concen-
tration.10,24 The relationship between increased plasma
FFA concentration, FFA oxidation, and hepatic glucose
production can be explained as follows: 1) Increased
plasma FFA levels, by mass action, augment FFA uptake
by hepatocytes, leading to accelerated lipid oxidation
and accumulation of acetyl-CoA. The increased concen-
tration of acetyl-CoA stimulates pyruvate carboxylase,
the rate-limiting enzyme in gluconeogenesis, as well as
G6Pase, the rate-controlling enzyme for glucose release
from the hepatocyte (see Fig. 35-35). 2) The increased
rate of FFA oxidation provides a continuing source of
energy (in the form of ATP) and reduced nucleotides
(NADH) to drive gluconeogenesis. The net result is an
enhanced flux of three carbon precursors from pyru-
vate to oxaloacetate and thus into the gluconeogenic
pathway. Finally, it should be noted that an increase in
plasma FFA concentration need not be associated with
an increase in hepatic glucose production, even though
gluconeogenesis is enhanced. This is especially true in
nondiabetic subjects in whom, except under very unique
experimental conditions, elevation of the plasma FFA
level rarely leads to an accelerated rate of hepatic glucose
output, because the stimulation of hepatic gluconeogen-
esis by FFA is precisely offset by an inhibition of glycoge-
nolysis, thereby yielding no net change in hepatic glucose
production. This hepatic autoregulation in response to
FFA infusion is similar to that observed during the infu-
sion of gluconeogenic precursors.108 Thus, in dogs and
nondiabetic humans, intravenous administration of ala-
nine, lactate, and glycerol augments gluconeogenesis but
fails to increase total hepatic glucose production because
of a reciprocal decline in glycogenolysis. The situation
in insulin-resistant states, such as obesity and diabetes,
appears to be different. Here, FFA infusion impairs the
suppression of hepatic glucose production by insulin and
in some instances may actually elevate the basal rate of
hepatic glucose production.109,110
Amino acids also can enter into a substrate competi-
tion cycle with glucose, although somewhat less effec-
tively than FFAs.111 Increased amino acid provision
enhances glucose production under conditions of insu-
lin deficiency or resistance and limits glucose utilization
in the insulinized state. Furthermore, an increase in the
plasma FFA concentration exerts a hypoaminoacidemic
effect in humans.112 In summary, each of the three major
substrates (i.e., glucose, FFAs, amino acids), if present in
excessive amounts (whether by endogenous production
or exogenous administration), can lower the level of the
other two by stimulating insulin release. In this situa-
tion, glucose metabolism obviously is favored because it
is a much more potent insulin secretagogue than fat or
amino acids. In addition, multiple substrate effects (not
mediated by insulin) participate in the regulation of the
substrates themselves: high FFA and amino acid concen-
trations increase glucose, whereas a high FFA concentra-
tion lowers the amino acid levels. The net result is the
creation of a glucose-FFA-amino acid cycle in which each
member of the triad influences its fellow members both
directly and indirectly through the stimulation of insulin
secretion (Fig. 35-36).
Lipid Synthesis
In addition to its potent restraining effect on lipoly-
sis and inhibition of FFA oxidation, the increase in
plasma insulin concentration that occurs in the fed
 35  REGULATION OF INTERMEDIARY METABOLISM DURING FASTING AND FEEDING
FFA
− +
− −
Amino
acids
Glucose
− formation. Conversely, in the starved or diabetic state,
+ decrease in malonyl-CoA concentration, and fatty acid
Figure 35-36  The glucose–free fatty acid–amino acid cycle. Because
glucose, free fatty acids (FFAs), and amino acids are all insulin secreto-
gogues, isolated increases of each of them lower the circulating levels of
the other two via hyperinsulinemia (inner ring). By substrate competi-
tion (outer ring), an increased supply of either FFAs or amino acids will
spare glucose. In addition, FFAs have a hypoaminoacidemic effect of
their own. See text for a detailed discussion. (Reproduced from Ferran-
nini E, DeFronzo RA. Insulin actions in vivo: glucose metabolism. In
DeFronzo RA, Ferrannini E, Keen H, Zimmet P, eds. International text-
book of diabetes mellitus. Chichester, UK: John Wiley & Sons; 2004:
277–318.)
state stimulates fatty acid synthesis and storage as tri-
acylglycerols in adipose depots throughout the body.
As discussed previously, these fat stores are mobilized
during conditions of fasting and serve as an important
metabolic fuel for skeletal muscle, heart, kidney, liver,
and other organs. In addition to its important role in
lipid synthesis, insulin also enhances cholesterol for-
mation and cholesterol ester storage and promotes
phospholipid metabolism.
In humans, adipose tissue and the liver represent the
primary sites of fatty acid synthesis. Insulin augments
fatty acid synthesis in these tissues primarily by acti-
vating acetyl-CoA carboxylase33 (see Chapter 43). This
enzyme converts acetyl-CoA in the cytosol to malonyl-
CoA (see Fig. 35-30). Insulin directly activates acetyl-
CoA carboxylase by increasing its phosphorylation state
and enhancing its synthesis. Insulin also indirectly acts
on the enzyme by increasing the supply of citrate, which
activates acetyl-CoA carboxylase, and by stimulating the
pentose phosphate cycle, thus providing the necessary
reducing equivalents (NADH) for fat biosynthesis. Insu-
lin also phosphorylates, thereby activating, ATP-citrate
lyase, the step immediately preceding that catalyzed by
acetyl-CoA carboxylase (see Fig. 35-30).33 The increase
in cytosolic malonyl-CoA concentration simultaneously
activates fatty acid synthase and binds to carnitine pal-
mitoyl transferase-1, inactivating the enzyme and inhibit-
ing fatty acid oxidation.93 The net result is an enhanced
availability of fatty acyl-CoA for triglyceride synthesis.
Insulin appears to have little effect on any of the enzymes
involved in triacylglycerol synthesis. This is in marked
contrast to insulin’s powerful inhibitory action on triacyl-
glycerol lipase, the rate-limiting enzyme in the regulation
of lipolysis.93 In addition to the stimulatory effect of insu-
lin on triglyceride synthesis, the hormone also appears to
enhance cholesterol formation through an effect exerted
on hydroxymethylglutaryl-CoA reductase.
623
Ketone Metabolism
Ketones are formed in the liver from the oxidation of
FFA, and their synthesis is tightly regulated by the cir-
culating levels of insulin and glucagon as well as malo-
nyl-CoA. In the fed state, insulin levels rise, lipolysis is
inhibited, and intracellular malonyl-CoA levels rise93 (see
Chapter 46). This latter key intermediate inhibits carni-
tine acyltransferase-1, thus favoring triglyceride synthe-
sis and retarding fatty acid oxidation and ketone body
plasma insulin levels decline and glucagon increases. The
decrease in insulin-to-glucagon ratio is associated with a
oxidation and ketogenesis are favored (see Fig. 35-31).
With the exception of the liver, most tissues can oxidize
ketone bodies. Their utilization by peripheral tissues,
including muscle, is primarily regulated by their plasma
concentration. Ketone bodies represent a major fuel for
muscle during prolonged fasting, once their circulating
blood levels increase to 1 to 3 mmol/L. Reversal of the
reduced insulin-to-glucagon ratio after feeding rapidly
inhibits ketogenesis, and the associated decline in plasma
ketone levels abolishes ketone utilization by peripheral
tissues.
Oral Glucose
At any given point in time, the glycemic response to an
exogenous glucose load represents the balance between
the rate of glucose appearance in the systemic circulation
from all sources (i.e., ingested glucose entering via the
gastrointestinal tract and endogenous glucose produc-
tion) and the rate at which glucose is disposed of by all
tissues in the body.104,113 Oral glucose appearance in the
systemic circulation depends on 1) the rate at which the
gastric contents are passed on to the small intestine; 2)
the rate of intestinal glucose absorption; 3) the extent of
gut glucose utilization; 4) the degree of hepatic glucose
trapping; 5) the dynamics of glucose transfer through the
gut, liver, and posthepatic circulation to the right heart;
and 6) the rate of systemic plasma glucose clearance. The
contribution of endogenous glucose production to the
glycemic response to feeding depends on the extent and
rate of change of hepatic glucose release. Initially, dispo-
sition of an ingested glucose load depends on changes in
the pattern of hormonal stimuli and substrate availabil-
ity. Because it represents a summation phenomenon, the
response to oral glucose explores the whole of glucose
tolerance, not the individual contribution of the various
components. As discussed previously in this chapter, the
rate-limiting step in the transfer of ingested glucose from
the stomach to the liver is the rate of gastric emptying.
This depends on the volume, temperature, osmolarity,
and sodium content of the glucose solution when glucose
alone is ingested. Glucose absorption through the intesti-
nal epithelial cells is rapid, efficient, and well in excess of
ordinary needs. Glucose utilization by intestinal tissues is
small when glucose is presented from the vascular side,
that is, when there is no oral glucose (see Table 35-2).
The major fuels used by the gastrointestinal tissues in
the postabsorptive state are FFA and glutamine. In the
presence of glucose at high concentrations on the luminal
624 PART 5  DIABETES MELLITUS

side, it appears that gut glucose metabolism increases 75 g glucose

in response to the increased energy needs for absorp- 60
tion; the quantitative aspects of this stimulation of gut

(µmol·min–1·kFFM–1)
50
glucose utilization remain undetermined in the human.

Oral glucose
The possibility also exists that systemic hyperglycemia 40
and/or hyperinsulinemia may impede intestinal glucose 30
absorption. 20
Glucose uptake by the liver is stimulated by portal
10
hyperglycemia (see later),9,10,114 and this has a major
impact on hepatic glucose release. The traversal of glu- 0
cose through the hepatic space is relatively quick, and this –30 0 30 60 90 120 150 180
is unlikely to introduce a significant delay in the systemic
appearance of oral glucose. In summary, the dynamics 12
of oral glucose appearance are essentially determined by

Glucose clearance
(ml·min–1·kgFFM–1)
10
gastric emptying, whereas intestinal transport, transit
8
across the gastrointestinal mucosa into the portal blood,
and transhepatic passage together introduce only a small 6
time delay. Stated otherwise, if neither gastrointestinal 4
nor liver tissues used glucose, the time course of oral glu- 2
cose appearance in the systemic circulation would follow
that of gastric emptying, with a time shift of a few min- 0
utes. For this reason, the gastric transfer step represents a –30 0 30 60 90 120 150 180
major component of the shape of the glycemic response to
glucose. Figure 35-37 shows the pattern of appearance of 18
Endogenous glucose
(µmol·min–1·kFFM–1)
ingested glucose in healthy individuals, as reconstructed 15
by a double tracer technique.104 Glucose appearance in 12
the systemic circulation peaks within 30 to 45 minutes, 9
declines slowly thereafter, but remains significantly above
6
zero at 180 minutes after glucose ingestion. At least 4 to
5 hours are necessary for the complete absorption of an 3
oral glucose load, and this is further prolonged by the 0
presence of fat and protein in the meal. Fig. 35-37 also –30 0 30 60 90 120 150 180
shows the time course of suppression of endogenous glu- Time (min)
cose release by oral glucose. A sustained nadir is reached
between 60 and 120 minutes, and this is followed by Figure 35-37  Glucose turnover after glucose ingestion. The rate of
appearance of the oral glucose load (top), the rate of whole-body glu-
a slow return to the fasting rate; however, hepatic glu- cose clearance (middle), and the rate of endogenous (hepatic) glucose
cose production is still significantly inhibited 180 min- production (bottom) are shown after the ingestion of 75-g glucose in
utes after the glucose challenge. Overall suppression of healthy adults. Plots are mean ± SEM. (Redrawn from data in Bonuc-
hepatic glucose production during the 3- to 4-hour period celli S, Muscelli E, Gastaldelli A, et al. Improved glucose tolerance to se-
quential glucose loading (Staub-Traugott effect): size and mechanisms.
after glucose ingestion averages 50%. This is surprisingly Am J Physiol Endocrinol Metab. 2009;297:E532-E537, 2009.)
less than what would be expected based on the com-
bined portal hyperglycemia and hyperinsulinemia (see
Fig. 35-6). Because circulating levels of insulin antago- perturbations induced by oral glucose extend beyond the
nistic hormones (except norepinephrine) do not change time that it takes for the plasma glucose concentration to
after oral glucose, it is likely that activation of the sym- return to its preingestion level. Figure 35-38 depicts the
pathetic nervous system, and specifically those nerves time-course of oral and endogenous glucose appearance
innervating the liver, keeps liver glucose outflow open.19 observed in nondiabetic individuals and in type 2 diabetic
The resemblance of oral glucose appearance rate to the patients when the same glucose load as in the standard
plasma glucose curve is readily evident, especially during OGTT (see Fig. 35-37) is mixed with protein and fat.18
the first 60 to 90 minutes. Less appreciated is the fact that The shape of the oral absorption curve is similar—if
absorption is still incomplete 3 to 4 hours after ingestion. somewhat slower—to that of oral glucose alone, with
After a lag of approximately 30 minutes, plasma glucose substantial oral glucose still appearing in the systemic cir-
clearance is stimulated by 50% to 100% throughout culation at the end of 5 hours; suppression of endogenous
the period of observation. Hyperglycemia (mass action glucose release is marked and protracted despite the rise
effect of glucose to promote its own uptake) contributes in plasma glucagon levels elicited by protein (see Fig.
more to whole-body glucose disposal during the first half 35-5). In diabetic subjects, on the other hand, oral glucose
hour; thereafter, hyperinsulinemia provides the predomi- appearance is similar to controls, but endogenous glucose
nant stimulus. Oral glucose also elicits a marked vasodi- production shows a significantly lower degree of suppres-
lation of the splanchnic vascular bed, and this regional sion between 60 and 160 minutes after ingestion, in line
increase in splanchnic blood flow persists for at least 4 with the blunted rise in the estimated prehepatic insulin-
hours. Thus, both the metabolic and the hemodynamic to-glucagon molar concentration ratio (see Fig. 35-5).18
 35  REGULATION OF INTERMEDIARY METABOLISM DURING FASTING AND FEEDING
Mixed meal
30
25
(µmol·min–1·kgffm–1)
Oral glucose
20 T2D Controls
15
10
5 splanchnic (hepatic) glucose uptake.114,117 Recent studies
0
0 30 60 90 120 150 180 210 240 270 300
10
9
Endogenous glucose
(µmol·min–1·kgffm–1)
8
7 lactate release by the intestinal tissues into the portal vein
6 is markedly increased. It has been estimated that approxi-
5 mately 5% of the ingested glucose load is converted into
4
3 gen via the indirect pathway of gluconeogenesis. Because
0 30 60 90 120 150 180 210 240 270 300
Time (min)
Figure 35-38  Rate of appearance of glucose (75-g) in a mixed meal
(top) and the corresponding rate of endogenous glucose production
(bottom) in healthy subjects. Note that oral glucose is still appearing
at the end of 5 hours after meal ingestion while endogenous glucose
production is still suppressed. Shaded areas are mean ± SEM. The red
dotted line is the mean value of a group of obese patients with type 2
diabetes (see also Fig. 35-5). (Redrawn from data in Camastra S, Mus-
celli E, Gastaldelli A, et al. Long-term effects of bariatric surgery on
meal disposal and β-cell function in diabetic and nondiabetic patients.
Diabetes. 2013;62:3709-3717, 2013.)
The tissue destination of absorbed glucose has been
the subject of intense investigation. Although the liver
was classically reputed to be responsible for the even-
tual disposal of the majority of an oral glucose load,
more recent studies that have employed the hepatic vein
catheter technique in combination with radioisotope
methodology have demonstrated that peripheral tis-
sues dispose of approximately two thirds of the ingested
glucose, whereas the splanchnic tissues account for the
remaining one third.115,116 However, it must be remem-
bered that the splanchnic tissues (i.e., liver) also contrib-
ute to glucose conservation by reducing their output of
glucose. When this amount of glucose is added to that
which is taken up by the liver, it can be seen that splanch-
nic (hepatic) and peripheral tissues contribute approxi-
mately equally to the maintenance of normal glucose
homeostasis. Obviously, these approximate proportions
vary according to the period during which the study
is conducted, as well as with the nature of individual
responses to glucose ingestion. A robust insulin secretory
response directs more posthepatic glucose to the periph-
eral tissues, whereas a large increase in splanchnic blood
flow channels the delivery of incoming sugar to the liver.
In humans, for example, a glucose drink sipped slowly
625
over 3.5 hours rather than swallowed in one bolus gen-
erates the same overall glucose curve but a 50% smaller
endogenous insulin response. Last, the route of glucose
administration exerts an important influence on the met-
abolic fate of glucose in that the portosystemic glucose
concentration gradient per se enhances hepatic glucose
uptake independently of portal glycemia and total glu-
cose delivery to the liver.10 In humans, the oral route of
glucose administration also has been shown to enhance
also have shown that the liver takes up glucose in pro-
portion to delivery.118
After glucose ingestion, glucose oxidation in the
brain continues unabated during the absorptive period.
Approximately 50% of the glucose that is taken up by
peripheral tissues (muscle) is oxidized, and the remainder
is stored as muscle glycogen or as lactate in the lactate
pool. During absorption from the gastrointestinal tract,
three carbon precursors (lactate, pyruvate, and alanine)
that are passed on to the liver and synthesized into glyco-
the lactate concentration in the hepatic vein also increases
after glucose ingestion, it follows that the sum of hepatic
lactate production and gut lactate formation must exceed
hepatic lactate extraction. Liver glycogen formation dur-
ing absorption of oral glucose occurs both directly from
glucose and indirectly via gluconeogenesis.118 The rela-
tive contributions of the direct (from glucose) versus indi-
rect (from gluconeogenic precursors) pathway to hepatic
glycogen synthesis in humans remain uncertain owing to
methodological difficulties. However, current data sug-
gest that gluconeogenesis participates in liver glycogen
repletion to a much lesser extent in humans than in rats.
Counterregulatory Hormones
A review of the role of the insulin counterregulatory hor-
mones (glucagon, epinephrine, cortisol, growth hormone,
and thyroid hormones) and their roles in intermediary
metabolism is beyond the scope of this chapter, and the
reader is referred to Chapter 47 and reference 16. The most
important role of the counterregulatory hormones is in the
defense against hypoglycemia. Glucagon and epinephrine
play an important role in the acute recovery from hypogly-
cemia by stimulating both glycogenolysis and gluconeogen-
esis. When hypoglycemia is prolonged, cortisol and growth
hormone contribute to the restoration of normoglycemia
by impairing the tissue’s ability to respond to insulin. Epi-
nephrine also is a potent peripheral insulin antagonist.
Except for glucagon (whose concentration increases dur-
ing fasting, leading to a stimulation of hepatic glucose
production primarily by augmenting gluconeogenesis), it
is unclear what role if any these insulin antagonistic hor-
mones play in glucoregulation during the transition from
the fed to the fasted state. More likely, these counterregu-
latory hormones contribute to the mobilization of com-
petitive substrates, especially FFAs, from adipose depots
to the liver and muscle, where they serve as an important
energy source. Circulating levels of these counterregulatory
626 PART 5  DIABETES MELLITUS
hormones (except glucagon) do not increase during fast-
ing. Rather, the plasma insulin concentration declines in
response to the decrease in blood glucose, and the resultant
hypoinsulinemia leaves the lipolytic and ketogenic activi-
ties of the counterregulatory hormones unopposed, thus
facilitating the shift from glucose to FFA metabolism.
•
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