Amy E. Halseth

Sustained Weight Loss Following 12-Month Pramlintide Treatment as an Adjunct to Lifestyle Intervention in Obesity

OBJECTIVE—To assess long-term weight loss efficacy and safety of pramlintide used at different dosing regimens and in conjunction with lifestyle intervention (LSI). RESEARCH DESIGN AND METHODS—In a 4-month, double-blind, placebo-controlled, dose-ranging study, 411 obese subjects were randomized to receive pramlintide (six arms: 120, 240, and 360 μg b.i.d. and t.i.d.) or placebo in conjunction with a structured LSI program geared toward weight loss. Of the 4-month evaluable subjects (n = 270), 77% opted to continue preexisting treatment during an 8-month single-blind extension (LSI geared toward weight maintenance). RESULTS—At month 4, mean weight loss from baseline in the pramlintide arms ranged from 3.8 ± 0.7 to 6.1 ± 0.8 kg (2.8 ± 0.8 kg with placebo). By month 12, initial 4-month weight loss was regained in the placebo group but was maintained in all but the 120-μg b.i.d. group. Placebo-corrected weight loss with 120 μg t.i.d. and 360 μg b.i.d. averaged 3.2 ± 1.2 kg (3.1 ± 1.1% body wt) and 3.3 ± 1.1 kg (3.1 ± 1.0% body wt), respectively, at month 4 (both P < 0.01; 4-month evaluable n = 270) and 6.1 ± 2.1 kg (5.6 ± 2.1% body wt) and 7.2 ± 2.3 kg (6.8 ± 2.3% body wt), respectively, at month 12 (both P < 0.01; 12-month evaluable n = 146). At month 12, 40 and 43% of subjects treated with 120 μg t.i.d. and 360 μg b.i.d., respectively, achieved ≥10% weight loss (vs. 12% for placebo). Nausea, the most common adverse event with pramlintide in the 4-month study (9–29% pramlintide vs. 2% placebo), was generally mild to moderate and occurred in <10% of subjects during the extension. CONCLUSIONS—When used over 12 months as an adjunct to LSI, pramlintide treatment, with low-dose three-times-daily or higher-dose two-times-daily regimens, helped obese subjects achieve greater initial weight loss and enhanced long-term maintenance of weight loss.

Overexpression of hexokinase II increases insulinand exercise-stimulated muscle glucose uptake in vivo

The hypothesis of this investigation was that glucose uptake would be increased in skeletal muscle of transgenic mice (TG) overexpressing hexokinase II (HK II) compared with their nontransgenic littermates (NTG) during euglycemic hyperinsulinemia and treadmill exercise. For insulin experiments, catheters were surgically implanted in the jugular vein and carotid artery for infusions and sampling, respectively. Conscious mice underwent experiments ∼5 days later in which 4 mU ⋅ kg-1 ⋅ min-1insulin and variable glucose ( n = 7 TG and n = 7 NTG) or saline ( n = 5 TG and n = 4 NTG) was infused for 140 min. Over the last 40 min of the experiments, 2-deoxy-[3H]glucose ([2-3H]DG) was infused, after which muscles were removed. For the exercise experiments, jugular vein catheters were surgically implanted. Five days later, mice received a bolus of [2-3H]DG and then remained sedentary ( n = 6 TG and n = 8 NTG) or ran on a motorized treadmill ( n = 12 TG and n = 8 NTG) for 30 min. TG and NTG had similar muscle [2-3H]DG 6-phosphate ([2-3H]DGP) accumulation in the basal state ( P > 0.05). In the hyperinsulinemic experiments, TG required ∼25% more glucose to maintain euglycemia ( P < 0.05), and muscle [2-3H]DGP accumulation normalized to infusate [2-3H]DG was similarly increased ( P < 0.05). In the exercise experiments, muscle [2-3H]DGP accumulation was significantly greater in TG than NTG ( P < 0.05). In conclusion, we did not detect an effect of HK II overexpression on muscle [2-3H]DGP accumulation under basal conditions. Hyperinsulinemia and exercise shift the control of muscle glucose uptake so that phosphorylation is a more important determinant of the rate of this process.

An Overview of Muscle Glucose Uptake during Exercise

The uptake of blood glucose by skeletal muscle is a complex process. In order to be metabolized, glucose must travel the path from blood to interstitium to intracellular space and then be phosphorylated to glucose 6-phosphate (G6P). Movement of glucose from blood to interstitium is determined by skeletal muscle blood flow, capillary recruitment and the endothelial permeability to glucose. The influx of glucose from the interstitium to intracellular space is determined by the number of glucose transporters in the sarcolemma and the glucose gradient across the sarcolemma. The capacity to phosphorylate glucose is determined by the amount of skeletal muscle hexokinase II, hexokinase II compartmentalization within the cell, and the concentration of the hexokinase II inhibitor G6P. Any change in glucose uptake occurs due to an alteration in one or more of these steps. Based on the low calculated intracellular glucose levels and the higher affinity of glucose for phosphorylation relative to transport, glucose transport is generally considered rate-determining for basal muscle glucose uptake. Exercise increases both the movement of glucose from blood to sarcolemma and the permeability of the sarcolemma to glucose. Whether the ability to phosphorylate glucose is increased in the working muscle remains to be clearly shown. It is possible that the accelerated glucose delivery and transport rates during exercise bias regulation so that muscle glucose phosphorylation exerts more control on muscle glucose uptake. Conditions that alter glucose uptake during exercise, such as increased NEFA concentrations, decreased oxygen availability and adrenergic stimulation, must work by altering one or more of the three steps involved in glucose uptake. This review describes the regulation of glucose uptake during exercise at each of these sites under a number of conditions, as well as describing muscle glucose uptake in the post-exercise state.

Analysis of insulin-stimulated skeletal muscle glucose uptake in conscious rat using isotopic glucose analogs

An isotopic method was used in conscious rats to determine the roles of glucose transport and the transsarcolemmal glucose gradient (TSGG) in control of basal and insulin-stimulated muscle glucose uptake. Rats received an intravenous 3- O-[3H]methylglucose (3- O-[3H]MG) infusion from -100 to 40 min and a 2-deoxy-[3H]glucose infusion from 0 to 40 min to calculate a glucose metabolic index (Rg). Insulin was infused from -100 to 40 min at rates of 0.0, 0.6, 1.0, and 4.0 mU ⋅ kg-1 ⋅ min-1, and glucose was clamped at basal concentrations. The ratios of soleus intracellular to extracellular 3- O-[3H]MG concentration and soleus glucose concentrations were used to estimate the TSGG using principles of glucose countertransport. Tissue glucose concentrations were compared in well-perfused, slow-twitch muscle (soleus) and poorly perfused, fast-twitch muscle (vastus lateralis, gastrocnemius). Data show that 1) small increases in insulin increase soleus Rg without decreasing TSGG, suggesting that muscle glucose delivery and phosphorylation can accommodate the increased flux; 2) due to a limitation in soleus glucose phosphorylation and possibly delivery, insulin at high physiological levels decreases TSGG, and at supraphysiological insulin levels the TSGG is not significantly different from 0; 3) maximum Rg is maintained even though TSGG decreases with increasing insulin levels, indicating that glucose transport continues to increase and is not rate limiting for maximal insulin-stimulated glucose uptake; and 4) muscle consisting of fast-twitch fibers that are poorly perfused exhibits a 35-45% fall in tissue glucose with insulin, suggesting that glucose delivery is a major limitation in sustaining the TSGG. In conclusion, control of glucose uptake is distributed between glucose transport and factors that determine the TSGG. Insulin stimulation of glucose transport increases the demands on the factors that maintain glucose delivery to the muscle membrane and glucose phosphorylation inside the muscle.

Effect of physical activity and fasting on gut and liver proteolysis in the dog

The aim of this study was to determine how gut and liver protein kinetics adapt to acute exercise in the 18-h-fasted dog ( n = 7) and in dogs glycogen depleted by a 42-h fast ( n = 8). For this purpose, sampling (artery and portal and hepatic veins) and infusion (vena cava) catheters and Doppler flow probes (portal vein and hepatic artery) were implanted with animals under general anesthesia. At least 16 days later, an experiment, consisting of a 120-min equilibration period, a 30-min basal sampling period, and a 150-min exercise period, was performed. At the start of the equilibration period, a constant rate infusion of [1-13C]leucine was initiated. Gut and liver leucine appearance and disappearance rates were calculated in these studies by combining a novel stable isotopic method and arteriovenous difference methods. In the determination of tissue leucine kinetics the tissue inflow of both α-[13C]ketoisocaproic acid and [13C]leucine was taken into account. The results of this study show that 1) the splanchnic bed (liver plus gut) contributes ∼40% to the whole body proteolytic rate in the basal state and during exercise in dogs fasted for either 18 or 42 h, 2) the contributions of the gut and liver to splanchnic bed proteolysis is about equal in the basal state in both 18- and 42-h-fasted dogs, and 3) exercise in the 18-h-fasted dog leads to a greater emphasis on gut proteolysis and a lesser emphasis on hepatic proteolysis. These studies highlight the important contribution of gut and hepatic proteolysis to whole body proteolysis and the ability of the gut to acutely adapt to changes in physical activity.The aim of this study was to determine how gut and liver protein kinetics adapt to acute exercise in the 18-h-fasted dog (n = 7) and in dogs glycogen depleted by a 42-h fast (n = 8). For this purpose, sampling (artery and portal and hepatic veins) and infusion (vena cava) catheters and Doppler flow probes (portal vein and hepatic artery) were implanted with animals under general anesthesia. At least 16 days later, an experiment, consisting of a 120-min equilibration period, a 30-min basal sampling period, and a 150-min exercise period, was performed. At the start of the equilibration period, a constant rate infusion of [1-13C]leucine was initiated. Gut and liver leucine appearance and disappearance rates were calculated in these studies by combining a novel stable isotopic method and arteriovenous difference methods. In the determination of tissue leucine kinetics the tissue inflow of both alpha-[13C]ketoisocaproic acid and [13C]leucine was taken into account. The results of this study show that 1) the splanchnic bed (liver plus gut) contributes approximately 40% to the whole body proteolytic rate in the basal state and during exercise in dogs fasted for either 18 or 42 h, 2) the contributions of the gut and liver to splanchnic bed proteolysis is about equal in the basal state in both 18- and 42-h-fasted dogs, and 3) exercise in the 18-h-fasted dog leads to a greater emphasis on gut proteolysis and a lesser emphasis on hepatic proteolysis. These studies highlight the important contribution of gut and hepatic proteolysis to whole body proteolysis and the ability of the gut to acutely adapt to changes in physical activity.

Regulation of hepatic glutamine metabolism during exercise in the dog

The goal of this study was to determine how liver glutamine (Gln) metabolism adapts to acute exercise in the 18-h-fasted dogs (n = 7) and in dogs that were glycogen depleted by a 42-h fast (n = 8). For this purpose, sampling (carotid artery, portal vein, and hepatic vein) and infusion (vena cava) catheters and Doppler flow probes (portal vein, hepatic artery) were implanted under general anesthesia. At least 16 days later an experiment, consisting of a 120-min equilibration period, a 30-min basal sampling period, and a 150-min exercise period was performed. At the start of the equilibration period, a constant-rate infusion of [5-15N]Gln was initiated. Arterial Gln flux was determined by isotope dilution. Gut and liver Gln release into and uptake from the blood were calculated by combining stable isotopic and arteriovenous difference methods. The results of this study show that 1) in the 18-h-fasted dog, approximately 10% and approximately 35% of the basal Gln appearance in arterial blood is due to Gln release from the gut and liver, respectively, whereas approximately 30% and approximately 25% of the basal Gln disappearance is due to removal by these tissues; 2) extending the fast to 42 h does not affect basal arterial Gln flux or the contribution of the gut to arterial Gln fluxes but decreases hepatic Gln release, causing a greater retention of gluconeogenic carbon by the liver; 3) moderate-intensity exercise increases hepatic Gln removal from the blood regardless of fast duration but does not affect the hepatic release of Gln; and 4) Gln plays an important role in channeling nitrogen into the ureagenic pathway in the basal state, and this role is increased by approximately 80% in response to exercise. These studies illustrate the quantitative importance of the splanchnic bed contribution to arterial Gln flux during exercise and the ability of the liver to acutely adapt to changes in metabolic requirements induced by the combined effects of fasting and exercise.The goal of this study was to determine how liver glutamine (Gln) metabolism adapts to acute exercise in the 18-h-fasted dogs ( n = 7) and in dogs that were glycogen depleted by a 42-h fast ( n = 8). For this purpose, sampling (carotid artery, portal vein, and hepatic vein) and infusion (vena cava) catheters and Doppler flow probes (portal vein, hepatic artery) were implanted under general anesthesia. At least 16 days later an experiment, consisting of a 120-min equilibration period, a 30-min basal sampling period, and a 150-min exercise period was performed. At the start of the equilibration period, a constant-rate infusion of [5-15N]Gln was initiated. Arterial Gln flux was determined by isotope dilution. Gut and liver Gln release into and uptake from the blood were calculated by combining stable isotopic and arteriovenous difference methods. The results of this study show that 1) in the 18-h-fasted dog, ∼10% and ∼35% of the basal Gln appearance in arterial blood is due to Gln release from the gut and liver, respectively, whereas ∼30% and ∼25% of the basal Gln disappearance is due to removal by these tissues; 2) extending the fast to 42 h does not affect basal arterial Gln flux or the contribution of the gut to arterial Gln fluxes but decreases hepatic Gln release, causing a greater retention of gluconeogenic carbon by the liver; 3) moderate-intensity exercise increases hepatic Gln removal from the blood regardless of fast duration but does not affect the hepatic release of Gln; and 4) Gln plays an important role in channeling nitrogen into the ureagenic pathway in the basal state, and this role is increased by ∼80% in response to exercise. These studies illustrate the quantitative importance of the splanchnic bed contribution to arterial Gln flux during exercise and the ability of the liver to acutely adapt to changes in metabolic requirements induced by the combined effects of fasting and exercise.