Preeti Kishore

Pilot Study of Resveratrol in Older Adults With Impaired Glucose Tolerance

BACKGROUND Resveratrol, a plant-derived polyphenol, has shown promising effects on insulin sensitivity and glucose tolerance in animal models and is also reported to have cardioprotective properties, but human studies are limited. In a pilot study, we tested the hypothesis that resveratrol improves glucose metabolism and vascular function in older adults with impaired glucose tolerance (IGT). METHODS Ten subjects aged 72 ± 3 years (M ± SD) with IGT were enrolled in a 4-week open-label study of resveratrol (daily dose 1, 1.5, or 2 g). Following a standard mixed meal (110 g carbohydrate, 20 g protein, 20 g fat), we measured 3-hour glucose and insulin area under the curve (AUC), insulin sensitivity (Matsuda index), and secretion (corrected insulin response at 30 minutes). Endothelial function was assessed by reactive hyperemia peripheral arterial tonometry (reactive hyperemia index) before and 90 minutes postmeal. Results did not differ by dose, so data were combined for analysis. RESULTS At baseline, body mass index was 29 ± 5 kg/m(2), fasting plasma glucose 110 ± 13 mg/dL, and 2-hour glucose 183 ± 33 mg/dL. After 4 weeks of resveratrol, fasting plasma glucose was unchanged, but peak postmeal (185 ± 10 vs 166 ± 9 mg/dL, p = .003) and 3-hour glucose AUC (469 ± 23 vs 428 ± 19, p = .001) declined. Matsuda index improved (3.1 ± 0.5 vs 3.8 ± 0.5, p = .03), and corrected insulin response at 30 minutes was unchanged (0.6 ± 0.1 vs 0.5 ± 0.5, p = .49). There was a trend toward improved postmeal reactive hyperemia index (baseline vs resveratrol postmeal delta -0.4 ± 0.2 vs 0.2 ± 0.3, p = .06). Weight, blood pressure, and lipids were unchanged. CONCLUSIONS At doses between 1 and 2 g/day, resveratrol improves insulin sensitivity and postmeal plasma glucose in subjects with IGT. These preliminary findings support the conduct of larger studies to further investigate the effects of resveratrol on metabolism and vascular function.

Activation of KATP channels suppresses glucose production in humans

Increased endogenous glucose production (EGP) is a hallmark of type 2 diabetes mellitus. While there is evidence for central regulation of EGP by activation of hypothalamic ATP-sensitive potassium (K(ATP)) channels in rodents, whether these central pathways contribute to regulation of EGP in humans remains to be determined. Here we present evidence for central nervous system regulation of EGP in humans that is consistent with complementary rodent studies. Oral administration of the K(ATP) channel activator diazoxide under fixed hormonal conditions substantially decreased EGP in nondiabetic humans and Sprague Dawley rats. In rats, comparable doses of oral diazoxide attained appreciable concentrations in the cerebrospinal fluid, and the effects of oral diazoxide were abolished by i.c.v. administration of the K(ATP) channel blocker glibenclamide. These results suggest that activation of hypothalamic K(ATP) channels may be an important regulator of EGP in humans and that this pathway could be a target for treatment of hyperglycemia in type 2 diabetes mellitus.

The regulation of glucose effectiveness: how glucose modulates its own production.

Purpose of review‘Glucose effectiveness’ refers to the ability of glucose per se to suppress endogenous glucose production and stimulate glucose uptake. In addition to the inhibitory effects of insulin on endogenous glucose production, rising glucose levels have important direct effects on glucose homeostasis. The loss of glucose effectiveness in type 2 diabetes mellitus contributes importantly to hyperglycemia in those individuals. Given the rapidly increasing incidence and serious complications of type 2 diabetes mellitus, understanding the regulation of glucose effectiveness has great potential therapeutic benefits. Recent findingsThe loss of this important regulation appears to be secondary to the chronic ‘diabetic milieu’ in type 2 diabetes mellitus, which includes elevated plasma glucose and free fatty acid levels. Glucose effectiveness is completely restored by normalizing plasma free fatty acid levels. Increased free fatty acid availability stimulates gluconeogenesis and alters flux through key hepatic enzymes. It is likely that at least part of this regulation is through central pathways. In addition, hormones that may exert important effects on hepatic glucose effectiveness include cortisol, insulin and glucagon-like peptide 1. The effectiveness of glucose to stimulate glucose uptake is impaired by elevated free fatty acid levels and may be enhanced by glucagon-like peptide 1. SummaryThe regulation of glucose effectiveness involves a complex interplay of hormonal and metabolic factors, with free fatty acid and glucoregulatory hormones playing key roles. The loss of this regulation in type 2 diabetes mellitus contributes importantly to hyperglycemia, and may largely be caused by increased free fatty acid levels.

Reduced Adipose Tissue Macrophage Content Is Associated With Improved Insulin Sensitivity in Thiazolidinedione-Treated Diabetic Humans

Obesity is associated with increased adipose tissue macrophage (ATM) infiltration, and rodent studies suggest that inflammatory factors produced by ATMs contribute to insulin resistance and type 2 diabetes. However, a relationship between ATM content and insulin resistance has not been clearly established in humans. Since thiazolidinediones attenuate adipose tissue inflammation and improve insulin sensitivity, we examined the temporal relationship of the effects of pioglitazone on these two parameters. The effect of 10 and 21 days of pioglitazone treatment on insulin sensitivity in 26 diabetic subjects was assessed by hyperinsulinemic-euglycemic clamp studies. Because chemoattractant factors, cytokines, and immune cells have been implicated in regulating the recruitment of ATMs, we studied their temporal relationship to changes in ATM content. Improved hepatic and peripheral insulin sensitivity was seen after 21 days of pioglitazone. We found early reductions in macrophage chemoattractant factors after only 10 days of pioglitazone, followed by a 69% reduction in ATM content at 21 days and reduced ATM activation at both time points. Although markers for dendritic cells and neutrophils were reduced at both time points, there were no significant changes in regulatory T cells. These results are consistent with an association between adipose macrophage content and systemic insulin resistance in humans.

Adipocyte-Derived Factors Potentiate Nutrient-Induced Production of Plasminogen Activator Inhibitor–1 by Macrophages

In response to free fatty acids and factors from fat cells, macrophages within the fat tissue of obese individuals release a hormone that contributes to atherosclerosis and insulin resistance. Deleterious Cytokines from Adipose Tissue Obesity is bad for your metabolism. One possible contributor to obesity-induced diabetes and atherosclerosis is plasminogen activator inhibitor-1 or PAI-1, a hormone secreted from fat cells. PAI-1, a protease inhibitor and hemostatic agent, is correlated with cardiovascular events and atherosclerosis, and mice engineered without this hormone are protected from these diseases. Free fatty acids in blood, which are derived from the diet, are also correlated with PAI-1, with higher fatty acid concentrations resulting in more blood PAI-1. Kishore et al. tested whether diet-derived free fatty acids cause increased PAI-1 production in human adipose tissue, focusing on macrophages, immune cells resident in fat that secrete PAI-1. By delivering free fatty acids directly to the bloodstream of their subjects, the authors elicited increased serum PAI-1 concentrations, as well as decreased glucose uptake into tissues. This increased PAI-1 in blood was accompanied by PAI-1 gene expression in macrophages from adipose tissue, although similar cells in the bloodstream did not respond in this way to the fatty acids. Suspecting that the fat cells surrounding the adipose tissue macrophages were somehow sensitizing the macrophages, the authors added adipocyte-conditioned medium to macrophages. This treatment augmented the response of the macrophages to fatty acids, boosting their production of PAI-1. Thus the adipose-tissue macrophages seemed to be uniquely stimulated by their surrounding environment to respond to free fatty acids by secreting the undesirable hormone PAI-1, which can increase propensity to cardiovascular disease. Adipose tissue is gaining a reputation for being more than an inert fat depot. The results from this study by Kishore et al. reinforce this idea, suggesting that in humans adipose tissue delivers elevated concentrations of PAI-1 by creating a unique, local paracrine environment to promote its synthesis. Macrophages are more abundant in adipose tissue from obese individuals than from those of normal weight and may contribute to the metabolic consequences of obesity by producing various circulating factors. One of these factors is plasminogen activator inhibitor–1 (PAI-1), which contributes to both atherosclerosis and insulin resistance. Because nutritional factors appear to regulate PAI-1 expression, we hypothesized that exposure to fatty acids and adipocyte secretory products could stimulate production of PAI-1 by adipose macrophages. Increased free fatty acid (FFA) concentrations in blood for 5 hours in nondiabetic, overweight subjects markedly suppressed insulin-stimulated glucose uptake and raised circulating PAI-1 concentrations, with a concomitant increase in the expression of the PAI-1 gene in adipose tissue. FFAs also rapidly increased PAI-1 gene expression in adipose macrophages and PAI-1 protein immunofluorescence surrounding these cells. By contrast, PAI-1 expression in circulating monocytes was very low and was not affected by raising the concentration of FFAs. Medium from cultured adipocytes stimulated PAI-1 expression in cultured macrophages and potentiated the increase in PAI-1 messenger RNA expression in response to FFAs. Together, our data suggest that adipocyte-derived factors prime adipose macrophages so that they respond to nutritional signals (FFAs) by releasing a key inflammatory adipokine, PAI-1.

Insulin sensitizing and anti-inflammatory effects of thiazolidinediones are heightened in obese patients.

Objective The American Diabetes Association has called for further research on how patients’ demographics should determine drug choices for individuals with type 2 diabetes mellitus (T2DM). Here, using in-depth physiology studies, we investigate whether obese patients with T2DM are likely to benefit from thiazolidinediones, medications with a known adverse effect of weight gain. Materials and Methods Eleven obese and 7 nonobese individuals with T2DM participated in this randomized, placebo-controlled, double-blind, crossover study. Each subject underwent a pair of “stepped” pancreatic clamp studies with subcutaneous adipose tissue biopsies after 21 days of pioglitazone (45 mg) or placebo. Results Obese subjects demonstrated significant decreases in insulin resistance and many adipose inflammatory parameters with pioglitazone relative to placebo. Specifically, significant improvements in glucose infusion rates, suppression of hepatic glucose production, and whole fat expression of certain inflammatory markers (IL-6, IL-1B, and inducible nitric oxide synthase) were observed in the obese subjects but not in the nonobese subjects. Additionally, adipose tissue from the obese subjects demonstrated reduced infiltration of macrophages, dendritic cells, and neutrophils as well as increased expression of factors associated with fat “browning” (peroxisome proliferator–activated receptor gamma coactivator-1α and uncoupling protein-1). Conclusions These findings support the efficacy of pioglitazone to improve insulin resistance and reduce adipose tissue inflammation in obese patients with T2DM.

Glycemic Control and Cardiovascular Disease: What’s a Doctor to Do?

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in individuals with diabetes mellitus. Moreover, rates of CVD mortality are two to four times higher in diabetes than in those without diabetes. It was conventional thinking that achieving near-normoglycemia would help reduce CVD risk and overall mortality in type 2 diabetes mellitus. Several recent large trials attempted to answer this question using a randomized control trial design with a conventional therapy and an intensive control arm. Surprisingly, these trials did not demonstrate neither mortality nor a CVD advantage with intensive glycemic control. Moreover, some studies (e.g., the ACCORD [Action to Control Cardiovascular Risk in Diabetes] study) showed increased mortality in the intensive control arm. In this review, our goal is to summarize the findings of the major trials in this field and to explore the potential reasons for why these trials had largely negative results. We conclude with some lessons that may be applied to the clinical management of patients with diabetes.

Time-Dependent Effects of Free Fatty Acids on Glucose Effectiveness in Type 2 Diabetes

Impaired effectiveness of glucose to suppress endogenous glucose production (EGP) is an important cause of worsening hyperglycemia in type 2 diabetes. Elevated free fatty acids (FFAs) may impair glucose effectiveness via several mechanisms, including rapid changes in metabolic fluxes and/or more gradual changes in gene expression of key enzymes or other proteins. Thus, we examined the magnitude and time course of effects of FFAs on glucose effectiveness in type 2 diabetes and whether glucose effectiveness can be restored by lowering FFAs. Glucose fluxes ([3-3H]-glucose) were measured during 6-h pancreatic clamp studies, at euglycemia (5 mmol/l glucose, t = 0–240 min), and hyperglycemia (10 mmol/l, t = 240–360 min). We studied 19 poorly controlled subjects with type 2 diabetes (HbA1c 10.9 ± 0.4%, age 50 ± 3 years, BMI 30 ± 2 kg/m2) on at least two occasions with saline (NA− group) or nicotinic acid (NA group) infusions for 3, 6, or 16 h (NA3h, NA6h, and NA16h groups, respectively) to lower FFAs to nondiabetic levels. As a reference group, glucose effectiveness was also assessed in 15 nondiabetic subjects. There was rapid improvement in hepatic glucose effectiveness following only 3 h of NA infusion (NA3h = 31 ± 6% suppression of EGP with hyperglycemia vs. NA− = 8 ± 7%; P < 0.01) and complete restoration of glucose effectiveness after 6 h of NA (NA6h = 41 ± 8% suppression of EGP; P = NS vs. nondiabetic subjects). Importantly, the loss of hepatic glucose effectiveness in type 2 diabetes is completely reversible upon correcting the increased FFA concentrations. A longer duration of FFA lowering may be required to overcome the chronic effects of increased FFAs on hepatic glucose effectiveness.

Inhibiting gluconeogenesis prevents fatty acid-induced increases in endogenous glucose production.

Glucose effectiveness, the ability of glucose per se to suppress endogenous glucose production (EGP), is lost in type 2 diabetes mellitus (T2DM). Free fatty acids (FFA) may contribute to this loss of glucose effectiveness in T2DM by increasing gluconeogenesis (GNG) and impairing the response to hyperglycemia. Thus, we first examined the effects of increasing plasma FFA levels for 3, 6, or 16 h on glucose effectiveness in nondiabetic subjects. Under fixed hormonal conditions, hyperglycemia suppressed EGP by 61% in nondiabetic subjects. Raising FFA levels with Liposyn infusion for > or =3 h reduced the normal suppressive effect of glucose by one-half. Second, we hypothesized that inhibiting GNG would prevent the negative impact of FFA on glucose effectiveness. Raising plasma FFA levels increased gluconeogenesis by approximately 52% during euglycemia and blunted the suppression of EGP by hyperglycemia. Infusion of ethanol rapidly inhibited GNG and doubled the suppression of EGP by hyperglycemia, thereby restoring glucose effectiveness. In conclusion, elevated FFA levels rapidly increased GNG and impaired hepatic glucose effectiveness in nondiabetic subjects. Inhibiting GNG could have therapeutic potential in restoring the regulation of glucose production in type 2 diabetes mellitus.

Fatty Acid-Induced Production of Plasminogen Activator Inhibitor-1 by Adipose Macrophages Is Greater in Middle-Aged Versus Younger Adult Participants

BACKGROUND Human aging is associated with heightened risk of diabetes and cardiovascular disease. Increased fat mass may contribute to age-related diseases by harboring inflammatory macrophages that produce metabolically important proteins such as plasminogen activator inhibitor-1 (PAI-1). Elevated PAI-1 concentrations have been implicated in the pathogenesis of such aging-related conditions as insulin resistance, obesity, and atherosclerosis. We have previously reported that increased plasma free fatty acid (FFA) concentrations augment both circulating PAI-1 concentrations and PAI-1 production by adipose tissue macrophages (ATMs). METHODS Because increasing age is associated with increased infiltration and reactivity of adipose macrophages, we performed euglycemic-hyperinsulinemic clamp studies and adipose tissue biopsies with and without elevated FFA concentrations in 31 nondiabetic participants stratified by age, to determine whether middle-aged individuals manifest heightened insulin resistance and PAI-1 production by ATMs in response to elevated nutrient signals relative to their young adult peers. RESULTS We observed that elevating FFA concentrations under euglycemic-hyperinsulinemic clamp conditions induced the same degree of insulin resistance in both middle-aged and younger body mass index-matched adults, whereas systemic PAI-1 concentrations were significantly increased in the middle-aged group. Likewise, elevated FFA and insulin concentrations induced larger increases in PAI-1 gene expression in the whole fat and ATMs of middle-aged compared with younger adult participants. CONCLUSIONS These studies reveal a heightened adipose inflammatory response to increased FFA and insulin availability in middle-aged individuals relative to younger adults, suggesting that increased susceptibility to the effects of fatty acid excess may contribute to the pathogenesis of age-related diseases.