Diabetes mellitus and insulin resistance · polyuria, polydipsia, pruritus, loss of weight and/or...
Transcript of Diabetes mellitus and insulin resistance · polyuria, polydipsia, pruritus, loss of weight and/or...
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Diabetes mellitus and insulin
resistance
A/prof. Barbara Ukropcova, MD, PhD
Institute of Pathological Physiology, Faculty of Medicine, CU
Biomedical Research Center, Slovak Academy of Sciences
04-2020
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• Epidemiology
• Summary of physiology of metabolic regulation by insulin
• Characteristics & klasification of diabetes mellitus
• Pathophysiology of diabetes mellitus; insulin
resistance
• Signs and symptoms
• Type 1 diabetes
• Type 2 diabetes
• Complications
• Therapy
• Metabolic syndrome
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Prevalence of type 2 diabetes and prediabetes(preclinical stage of T2D; IGT, Impaired glucose tolerance)
DeFronzo, R. A. et al. 2015
Type 2 diabetes, associated with obesity and sedentary lifestyle,
is the most common type of diabetes, representing >90% of all diabetics
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Global prevalence: Prediabetes
According to IDF, global prevalence of prediabetes is ~352 million (2017). According to
predictions, this number will increase up to 500 million (2045), and number of patients with
T2D will be surpass 400 million. (Hostalek 2019)
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Del Prato http://www.medscape.org/viewarticle/412864
The prevalence of disorders of glucose metabolism increases with age
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• Global prevalence of type 2 diabetes is 9,2%
• Diabetes mellitus is 4th leading cause of death
Diabetes mellitus
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Glucose homeostasis
• Insulin
Glucose-lowering
effect
• glucagon
• catecholamines
• cortisol
• growth hormoneCounter-regulatory
hormones, increase blood
glucose levels1.Fasting conditions:
glucose production (from lactate, aminoacids, glycerol)
in liver and kidney (gluconeogenesis)
2. Postprandial period (after meal):
glucose from ingested meal;
suppresion of glucose production by insulin
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Langerhans’s islets: The endocrine archipelago in an exocrine gland
• Discovered by Paul Langerhans in 1869
• One islet measures 0,5 mm
• ~ 1 million islets, total weight 1 gram
• Islets represent ~ 2 % of pancreas
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Changes of Langerhans’s islets in
diabetes
Healthy individual Atrophy in diabetes
B cellsA cells
In diabetes, there are
changes in the islets, with
the destruction of B-cells,
fibrosis and accumulation of
amyloid (in T2D), which
results in the islets’ atrophy.
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Cells of Langerhans’s islets
• A cells, glucagon (20 %)
• B cells, insulin (68 %)
• D cells, somatostatin (10 %)
• PP cells, pancreatic polypeptide (2 %)
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Human insulin
- Discovered by: dr.
Banting and medical
student Best
(Nobel price in 1923:
Banting & Mcleod)
- Administered for the
first time to a 14-year
old boy in diabetic
ketoacidosis, in Toronto
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Preproinsulin
Insulin
Proinsulin
mRNA
DNA
C-peptide
(connecting peptide),
orange:
Secreted from B-cells
in amounts equimolar to insulin,
a marker of endogenous
Secretory capacity
of B-cells
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Organ-specific effects of insulin
Liver
• stimulates glycolysis and glycogen synthesis• stimulates uptake of chylomicrones
and production of VLDL• stimulates synthesis of TAGs (triacylglycerols)
• inhibitsgluconeogenesis andglycogenolysis
Muscle
• stimulates glucose uptake(transporters GLUT-4) andglycogen synthesis
• stimulates aminoacids uptake andproteosynthesis
• inhibits glycogenolysis
Adipose tissue
• stimulates glucose transport (transporters GLUT-4) • increases activity of lipoprotein lipase,
which hydrolyzes circulating lipids
• inhibits intracellularTAGs breakdown
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• Antilypolitic effect
(adipose tissue)
• Suppression of glucose production
(liver)
• Uptake of glucose
(skeletal muscle, adipose tissue)
Major effects of insulin at a tissue level
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Insulin effects at a molecullar level
Apart from metabolic
effects, insulin also
exerts
mitogenic effects
(it stimulates
cellular proliferation).
This effect can promote
carcinogenesis under
conditions
of chronic
hyperinsulinemia,
associated with obesity
and insulin resistance.
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Insu
lin
secre
tio
n
High blood glucose
time0 5 min
baseline
2. phase
1. phase
Dynamics of stimulated insulin secretion
Insulin secretion has two
components:
Baseline insulin secretion
(during 24 hours, independent
from food intake)
Stimulated insulin secretion
(secretion of insulin after the
meal)
First phase of glucose-
stimulated insulin secretion
lasts for 10 minutes, includes
exocytosis of secretory
granules in the close vicinity of
plasma membrane.
Second phase: synthesis of
new molecules of insulin, and
secretion of granules that are
not in the membrane vicinity.
Pickup and Williams, 2003
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What is diabetes mellitus?1. Diabetes mellitus is a syndrom with insulin deficit
• absolute; type 1 diabetes / T1D
• relative (defect of insulin effect); type 2 diabetes / T2D
2. Major characteristics
• a complex disorder of metabolism (lipids, sacharides, proteins)
• chronic hyperglycemia (decreased glucose uptake by skeletal
muscle, excessive glucose production in liver)
3. Typical signs and symptoms
polyuria, polydipsia, pruritus, loss of weight and/or
complications
4. T2D can be asymptomatic; diagnosis based on biochemical parameters
5. Disorder of glucose homeostasis can be present transiently
disorder of glucose metabolism in pregnancy (gestational diabetes
mellitus)
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Fasting glycemia
2-hours glycemia
NORMAL
< 7,8 mmol/l
PREDIABETES
7,8 - 11,0 mmol/l
DIABETES
> 11,0 mmol/l
NORMAL
< 5,6 mmol/l
PREDIABETES
5,6 - 6,9 mmol/l
DIABETES
> 6,9 mmol/l
Prediabetes – preclinical stage of type 2 diabetes:IGT: Impaired Glucose Tolerance
IFG: Impaired Fasting Glucose
American Diabetes Association / ADA criteria
• High risk of the development of type 2 diabetes
• IGT
• IFG
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Pathogenesis of DM symptoms
Insulin hyperglycemia → glycosuria (glucose
is osmotically active) → polyuria → dehydration
→ polydipsia
Tissue starvation → loss of muscle and lipid
tissue + loss of minerals and water → weight
loss despite increased food intake → cachexia
Excessive mobilisation of lipids (lipolysis) from the
adipose tissue → hyperlipidemia → increased oxidation
of FFA → high levels of acetylCoA, used for the ketones
synthesis in the liver → hyperketonemia → metabolic
acidosis, ketonuria
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Acute signs
and symptoms
of DM
kidney
glycosuria
aminoaciduria
polyuria
loss of electrolytes
dehydration
coma
acidosis
foetor
Kussmaul’s
breathing
aldosteron
ketone
bodies
osmolarity
fatty acids
lipolysisproteolysis
aminoacids
muscle
weakness
weight
loss
hyperglycemia
thirst
insulin deficit
glucose
production
glycogenolysis
liver
steatosis
decreased
glycolysis
in the cell
decreased glucose
uptake by skeletal muscle
& adipose tissue due to the
lack of insulin
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Signs & symptoms
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• Type 1 diabetes mellitus / T1D
• Type 2 diabetes / T2D
• Other specific types of diabetesgenetic defects of insulin secretion and action
diseases of exocrinne pancreas
diabetes induced by drugs – AIDS therapy, immunossupression after the organ transplantation
• Gestational diabetes mellitusdiagnosed during pregnancy (2nd or 3rd trimester)
6 months after the delivery - reclassification
Classification of diabetes mellitus
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I. Type 1 diabetesA. Autoimmune (over 90% of T1D cases)B. Idiopathic
I. Type 2 diabetes
I. Other specific types of diabetesA. Genetic defects of B cells1. Chromosom 12, HNF-1 (MODY3)2. Chromosom 7, glukokinase (MODY2)3. Chromosom 20, HNF-4 (MODY1)4. Mitochondrial DNA5. otherB. Genetic defects of insulin action
1. Type A insuline resistance2. Leprechaunism3. Rabson-Mendehall’s syndrom4. Lipoatrophic diabetes5. Other
Ethiopathogenetic classification of diabetes
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C. Diseases of exocrinne pancreas
1. Pancreatitis
2. Trauma/pancreatectomy
3. Tumors
4. Cystic fibrosis
5. Hemochromatosis
6. Fibrocalculos pancreopathy
7. Other
D. Endocrinopathies
1. Acromegaly 5. Hyperthyroidism
2. Cushing’s syndrom 6. Somatostatinoma
3. Glucagonoma 7. Aldosteronoma
4. Feochromocytoma 8. Other
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E. Drugs and chemicals
1. Vacor 7. ß-adrenergic antagonists
2. Pentamidine 8. Thiazides
3. Nicotinic acid 9. Dilantine
4. Glucocorticoids 10. Α-interpheron
5. Thyroid hormones 11. Other
6. Diazoxide
F. Infections1. Congenital rubeola
2. Cytomegalovirus
3. Other
G. Less common forms of immune-based diabetes1. „Stiff-man“ syndrom
2. Antibodies against insulin receptors
3. Other
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H. Other genetic syndroms sometimes associated with
diabetes
1. Down’s syndrom 7. Lauren-Moon-Biedel’s sy
. 2. Klinefelter’s sy 8. Myotonic dystrophy
3. Turner’s syndrom 9. Porphyria
4. Wolframov syndróm 10. Prader-Willi’s syndrom
5. Friedreichova ataxia 11. Iné
6. Huntingtonova chorea
IV. Gestational diabetes mellitus
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• glycemia ≥11.1 mmol/l, with symptoms of diabetes
• FPG ≥7 mmol/l (after minimum 8h fasting)
• 2-hour glycemia in oGTT ≥11.1 mmol/l
PrediabetesIFG - Impaired Fasting Glucose 5.6 – 6.9 mmol/l
IGT - Impaired Glucose Tolerance 7.8 – 11.0 mmol/l
(after 2 hours of oGTT)
Diagnostic criteria for diabetes mellitus according to American Diabetes Association, ADA
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Diagnostic criteria for diabetes mellitus according to ADA
Glycated hemoglobin (HbA1c) ≥6.5 mmol / l
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Type 2 diabetes
• diagnosis depends on the confirmation of hyperglycemia
• initial test: fasting glucose in blood or plasma
• if fasting glycemia is lower → oral glucosetolerance test (oGTT) can be indicated, which confirms or excludes T2D or IGT
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Diagnosis of type 2 diabetes
• based on the confirmation of hyperglycemia
• the initial test: fasting glycemia (or HbA1c)
• in pregnancy: oGTT (oral glucose tolerance test)
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oGTT – 2 hour glycemia
1. Normal glucose tolerance – NGT:
less than 7.8 mmol / l
1. Impaired glucose tolerance - IGT:
7.8 – 11.0 mmol / l
1. Type 2 Diabetes mellitus
≥11.1 mmol / l
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Diagnosis of diabetes mellitus
• Signs and symptoms of complications –
target organs
• Parameters of metabolic syndrome
• Family history of diabetes
Therapy:
• Lifestyle modification / intervention, weight loss
• Pharmacotherapy
• Metabolic surgery (reversal of diabetes in early
stages, obesity management)
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Type 1 diabetes
• destruction of B cells, insulin, absolute insulin
deficit(to a smaller extent, defects in insulin action)
• hyperglycemia and its symptoms: polydypsia,
polyuria, hunger, polyphagia, weight loss
• deteriorated regulation of lipolysis( keton bodies → ketosis and ketonuria → metabolic acidosis, coma, exitus)
• insulinotherapy: inevitable to achieve the control of
glycemia and as a prevention of ketoacidosis
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Type 1 diabetes
• the most common type of diabetes in children
and adolescents (though the proportion of T2D in this age
category increases, due to increasing incidence of obesity)
incidence in North Europeans
• incidence with age till adolescence & then
• it affects people of all age groups
• it represents around 10 % of all types of DM
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Ethiological classification of T1D
A. Autoimmune destruction of B cells
B. Typ II polyglandular autoimmune syndroms Schmidt’s sy
C. Viral infection with destruction of B cellscongenital rubella, coxsackie virus B, cytomegalovirus
A. Loss of pancreatic tissueacute and chronic recurrent pancreatitis, carcinoma, congenital hypoplasia, pancreatectomy
A. Chemical compounds affecting pancreasN-3 pyridymethyl-N-p-nitrophenylurea
A. Genetic syndromsDIDMOAD sy*, Friedreich’s ataxia
A. Idiopathic__________________________________________*diabetes insipidus, diabetes mellitus, atrophy of nervus opticus, deafness
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Type 1 diabetes
• autoimmune destruction of B cells
evidence: antibodies against cells of islets (ICA)
antibodies against insulin (IAA)
antibodies against decarboxylase of
glutamate (GAD)
• autoimmune destruction of B cells is most common in
patients with certain HLA types ( DR4, DQw8)
• initiation of autoimmune reaction: triggered by viruses?
chemicals?
• other causes of type 1 diabetes are less common
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Gillespie, K. M. CMAJ 2006;175:165-170
Presentation of antigen(peptides of proinsulin) to CD4 T lymphocytes
via HLA II molecules on antigen presenting cell
Antibodies in type 1 diabetes
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Environmental influences on the T1D
• viral infections
• other factors:
• lower risk of T1D in brestfed children
(bovine albumin from cow milk more antigenic)
• risk of T1D correlates with average year temperature and
the distance from the equator
(more T1 diabetics have light skin and eyes and higher
sensitivity to UV radiation)
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Autoantibodies and prediction of T1D
• high ICA signals the risk of type 1 diabetes in
patient’s relatives (8-10 % will be type 1 diabetics)
• combination of high ICA and IAA constitute even
higher risk
• ADA recommends screening of autoantibodies in
first degree relatives as a prevention of diabetes
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Gillespie, K. M. CMAJ 2006;175:165-170
Potential targets of therapeutic intervention in type 1 diabetes
PREVENTION
Identification and
abolishment of the
environmental factor
REVERSAL OF DISEASE
PROGRESSION
Islet transplantation
Gen therapy
• anti-T lymfocyte
strategies
• induction of tolerance
• regulation of T-lymfocytes
• Regeneration
of B cells
• Resources of
islets
Diagnosis of type 1 diabetes (less
than 20% islets)
Antibodies against
islets
Genetic predisposition
Environmental
influences
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Immunosupression in therapy of T1D
Hypothesis
Immunosupression will prevent progressive
deterioration of B cell function
• cyklosporin A:
plus: remission of diabetes up to 2 years
minuses: acute and chronic nephrotoxicity
• azathioprine with prednisone: 1 year remission
• nicotinamide: remission 1-2 years
Future: safe immunosupression before clinical
manifestation of T1D in individuals with positive
autoantibodies
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Immunomodulation in therapy of T1D
• Monoclonal anti-CD3 antibodies: induction of
immune regulation by monoclonal antibodies
• Effective in maintaining insulin secretion during first
two years of disease
• the aim: to keep and improve the function / quantity
of B cells
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Summary T1D
• absolute insulin deficit
• autoimmune disease
• genetic predisposition + environmental factors
• preclinical phase (autoantibodies)
• clinical manifestation of type 1 diabetes is associated
with the death of majority of B cells (over 80%)
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Summary II
Viral infection Autoimmune disease
B cells (pancreas)
Type I
10%
diabetics
Absolute insulin
deficit
Lipolysis Hyperglycemia Proteolysis
Destruction of B cells
Genetic
predisposition
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Type 2 diabetes
• defects of insulin action, dysfunction of B cells
• T2D represents ~90 % of all diabetics
• obesity increases the risk of T2D 4x
• long asymptomatic period
• positive family history of diabetes
• up to 90% T2D are obese
• heterogenous syndrom → pathogenesis is not clear
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The link between BMI, age and type 2 diabetes
DeFronzo, R. A. et al. (2015) Type 2 diabetes mellitus
Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.19
T2D and BMI T2D and age
IDF Global Fact sheets, 2019
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Type 2 diabetes
• manifestation: 1. classical signs & symptoms
2. complications
3. asymptomatic
• ketoacidosis is very rare (usually linked to stress, such
as serious infection, surgery, trauma… )
• the risk of hyperosmolar hyperglycemic coma
• insulin is not necessary (to prevent ketoacidosis…)
• insulin might be important for the control of
glycemia
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Type 2 diabetes • Insuline resistance
skeletal muscle: lower glucose uptake, lower oxidative and nonoxidativeglucose utilisation
adipose tissue: lower antilipolytic effect of insulin (increase in FFA)
lower uptake of glucose
liver: lower suppression gluconeogenesis = higher endogenous glucose production
Metabolic inflexibility
skeletal muscle: lower ability to switch fat oxidation to glucose oxidation during insulin stimulation
- uptake of glucose stimulated by insulin is 60 % lower!
- 80% more fats in insulin resistant celle
• Defects of secretory capacity of B cells
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Insulin resistance
Obesity, T2D, systemic diseases COPD, tumors, cachexia, connective tissue diseases, sepsis, cardiac
insufficiency, cirrhosis…
also in otherwise healthy individuals immobilisation, high fat diet, stress (trauma, injury, infection…), pregnancy, aging…
Prereceptor
• immunity, metabolism, genetics
• in the past: antibodies against exogenous insulin
Receptor
• a decrease in tyrosinkinase activity, increased degradation…
• rarely – mutation of the receptor genes...
Postreceptor (the most common cause, induced by chronic low-gradeinflammation and lipotoxicity)
• Signaling pathways, glucose transport, enzymes of glycolysis,protein synthesis
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Effects of 2 weeks of physical inactivity on insulin
sensitivity in young lean healthy adults
Krogh-Madsen R et al. J Appl Physiol 2010;108:1034-1040
• reduced VO2max (aerobic
physical fitness) by 7%
• reduced muscle mass and
strength
• increased visceral fat
by 7%
Two weeks of inactivity
can reduce your insulin
sensitivity by 20%
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Knudsen S H et al. J Appl Physiol 2012;113:7-15
Effects of 2 weeks of physical inactivity AND
overeating in healthy young individuals on:insuline sensitivity visceral adipose tissue
Two weeks of physical inactivity and overeating can increase your
visceral fat by ~30% and reduce your insulin sensitivity by 30-40% (!!)
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Progression of B-cell dysfunction in the
development of T2D
Prentki a Nolan, 2006
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The association between B-cell mass and their
function
DeFronzo, R. A. et al. (2015) Type 2 diabetes mellitus
Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.19
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The ominous octet: 8 principial components of
T2D pathomechanisms
DeFronzo, Diabetes 2009; DeFronzo et al, review 2018
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Principal pathomechanisms in T2D:
complex pathogenesis of type 2 diabetes
DeFronzo, Diabetes 2009; DeFronzo et al, review 2018
• 2x pancreas (reduced insulin secretion, increased secretion of glucagon)
• GIT (dysregulation of incretins, hormones from the small intestine, which
potentiate glucose-induced insulin secretion; changes in microbiome)
• adipose tissue (dysregulation / increased lipolysis)
• kidneys (increased reabsorption of glucose)
• skeletal muscle (reduced glucose uptake)
• liver (increased gluconeogenesis)
• brain (dysfunction of neurotransmiters)
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Pathophysiology of T2D: the implications for therapy
DeFronzo et al, 2015
GIT:
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The effect of thiazolidindions
Redistribution of adipose tissue: reduction of visceral /
ectopic fat, an increased differentiation capacity of
subcutaneous fat to store lipids – metabolic health
DeFronzo review 2009
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type 2
diabetes
Genes„Thrifty“ genotype–
Energy storage
EpigeneticsEnvironmental imprinting of the genome,
which influences the gene expression patters,
and which is transferable between cellular
populations and/or from parents to offspring; it
is also a tool of early reprogramming, with an
impact on the risk of diseases in the adulthood
(in utero, early childhood)
Lifestyle(caloric excess,
Reduced physical
activity)
Interaction of genes with the environment
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Pima Indians Arizona
1885 present
http://optimalhealthsource.blogspot.sk/2011/04/are-genes-responsible-for-modern.html
http://www.earlypics.com/2012/05/pimo-indians-arizona-elias-bonine-1875.html
Genetic predisposition
for diabetes in Pima
Indians
is translated into diabetic
phenotype when
confronted with obesity /
caloric excess / sedentary
lifestyle
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Types of obesityAndroid / abdominal & gynoid / gluteofemoral
• intraabdominal
adipose tissue
• high risk of
T2D and CVD
• subcutaneous
adipose tissue
• low risk of
T2D and CVD
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Nature. 2008 July 24; 454(7203): 463–469.
„Gluttony and Sloth“(Unger, Scherer, 2010)
65% global mortalityBlair SN, Archer E et al, 2012
Visceral obesity
Dysfunctional adipose tissue
Lipotoxicity
Chronic systemic inflammation
Insulin resistance
Metabolic
syndrome
Despres, Lumieaux, Nature 2006
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Adipose tissue
• subcutaneous
• visceral
(intraabdominal)
Adapted from Després JP a Lemieux I, 2006.
Positive Energy
Balance
Normal adiposity
Subcutaneous obesity
“Healthy” adipose tissue
Visceral obesity
Adipose tissue dysfunction
Normal metabolic
profile
Altered metabolic
profile
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Where is the fat stored? …lipid spill-over into other organs, after surpassing the
capacity of the subcutaneous adipose tissue to store
excessive calories as lipids (TG, triglycerides)
Unger RH, et al., Lipid homeostasis, lipotoxicity and the metabolic syndrome Biochim Biophys Acta. 2010; 1801:209-14
*Foster DJ, et al., Fatty diabetic lung: altered alveolar structure and surfactant protein expression. Am J Physiol. 2010; 298:L392-403
Lipotoxicity: storage of lipids in the form of ectopic
adipose tissue (in the organs)
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Lipotoxicity: mediated by intermediate metabolites of
lipid metabolism, such as (diacylglycerols, long-chain Acyl-CoAs,
ceramides...); it contributes to the chronic systemic low grade
inflammation, insulin resistance, mitochondrial dysfunction
Schenk S, et al., Journal of Clinical Investigation. 2008
LPC, AA
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Dysfunctional, „pathogenic“ adipose tissue
inflammatory infiltration of the adipose tissue
Hypertrophic
Hyperplastic
Big adipocytes: insulin-resistant, inflammation in the adipose tissue, which contributes
to the systemic inflammation
Small adipocytes: insulin-sensitive, absence of inflammation in the adipose tissue,
better differentiation capacity and the capacity to store lipids
No inflammation
Metabolic
health
Inflammation
Metabolic
disease
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Kadowaki et al., 2006
The insulin resistant phenotype of liver & skeletal
muscle is associated with adipose tissue qualities
obese adipose tissue
lean adipose tissue
Glucose utilization
Glucose production
CRP, SAA,
Insulin secretion
Beta cell
TYPE 2 DM
FFA TNF-a, resistin
IL-6, IL-18, PAI-1
adiponectin
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Mechanisms of insulin resistance
DeFronzo, R. A. et al. (2015) Type 2 diabetes mellitus
Nat. Rev. Dis. Primers doi:10.1038/nrdp.2015.19
- Change in the secretory
profile of the hypertrophic
adipocyte
- Activation of
inflammatory
pathways (TLR4, TNFR)
- Lipotoxicity
- Oxidative stress
(accumulation of ROS)
- ER stress
- Postreceptor
insulin resistance
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Insulin
Glucose
Dyslipidemia
Inflammation
Hypertension
Smoking
Obesity
Physical inactivity
Sleep disorders
Stress
...
Type 2. diabetes
Cardiovascular disease
Oncologic disease
Neurodegenerative disease...
brain, liver, B cells
Skeletal muscle...
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Genetic predisposition
Environmental factors
insulin secretion insulin resistance
liver glucose production
transport of glucose to tissues
antilipolytic effect
HYPERGLYCEMIA
FREE FATTY ACIDS
glucotoxicity, lipotoxicity
defects of
B cells
basal
hyperinsulinism
“down”-regulation of
insuline receptors
defects of skeletal
muscle
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Summary – T2D
Genetic
predisposition
Insulin resistance
Type II
~90%
diabetics
Insulin
Lipolysis
Energy intake /
energy expenditure
Obesity
Target
cell
Ketone bodies
Free fatty acids
Relative insulin
deficit
Hyperglycemia
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Summary: comparison of T1D & T2D
Genetic
predisposition
Insulin resistance
Type II
~ 90%
diabetics
Insulin
Lipolysis
Energy intake /
energy expenditure
ObesityTarget
cell
Ketone bodies
Free fatty acids
Relative insulin
deficit
Hyperglycemia
Viral infection Autoimmune disease
B cells (pancreas)
Type I
~10%
diabetics
Absolute insulin
deficit
Lipolysis Hyperglycemia Proteolysis
Destruction of B cells
Genetic
predisposition
Type 1 DM - typically
young, lean individuals
Type 2 DM - typically
older, obese individuals
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When is your patient
at a higher risk of
developing T2D
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InsulinResistance
(common denominator)
Prediabetes,
IR
Visceral
obesity
Dyslipidemia(higher TAG, lower
HDL-chol)Hypertension
Metabolic syndrome: ≥3 out of 5 parameter(in red rectangles, changes in lipid profile represent two independent
parameters)
Low physical
fitness (not
officialy)
Low adiponectineInflammation
HyperuricemiaNAFLD / Steatosis
Metabolic sy increases the risk
of cardiometabolic, but also neurodegenerative and specific oncologic diseases.
MSy is present in ~30% of adult population (higher in older age groups)
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Complications of diabetes
1. Acute• Hyperglycemic coma
– with ketoacidosis (T1D)
– without ketoacidosis (T2D)
• Hypoglycemic coma (insulin or PAD, intensive physical
activity...)
2. Chronic• Microangiopathy, macroangiopathy
• Neuropathy, nephropathy
• Infections, gingivitis, cataract...
• Impaired immune functions
• Impaired wound healing
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Del Prato http://www.medscape.org/viewarticle/418580_2
Sustained elevated
blood glucose
levels, or even
glucose levels that
wax and wane,
cause toxic effects
to tissues.
Controlling both
postprandial and
fasting blood
glucose levels is
essential for
efficient prevention
of chronic
complications.
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Chronic complications of diabetes
retinopathy nephropathy neuropathy
https://en.wikipedia.org/wiki/Diabetes#/media/File:Diabetes_complications.jpg
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Diabetic complications – target organsDiabetes mellitus is the most common cause of
blindness, kidney failure, lower limb amputation
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Diabetic foot
Combination of diabetic
• microangiopathy
• macroangiopathy (ischemia of tissues)
• neuropathy (reduced sensory perception…)
&
• impaired immune functions, edema of tissue
(impaired wound healing)
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Pathogenesis of complications
Ketones
Sorbitol
Advanced Glycation End products (AGEs)
Reactive Oxygen Species (ROS)
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Pathogenesis of diabetes complicationsSorbitol (activation of polyol pathway in non-insulin dependent tissues with high
activity of aldosoreduktase; pericytes of capillaries, lens, neurons), pseudohypoxia
Advanced Glycation End products (AGEs)
(non-enzymatic glycation of proteins; plasma, cells, tissues; accumulation in the artery wall, in mesangium of glomerulus, in basal membranes...); it exerts effect upon functional qualities of proteins
Reactive oxygen species (ROS), (mitochondria, chronic hyperglycemia,...); damage of cell membranes by lipoperoxidation; activation of NFkB signaling
Activation of proteinkinase C (proliferation and fibrotisation, inflammation, oxidative stress)
Hexosamine pathway (sensor of energy sufficiency, glucosamine-6-phosphate, insulin resistance in adipose tissue and skeletal muscle)
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MicroangiopathyComplex functional and structural changes
Capillary wall Extravascular tissue
Early changes
• Endothelial dysfunction(increased permeability, adhesion, production of inflamm. cytokines, growth factors....)
• Apoptosis of pericytes
Early functional changes
• activation of mesangial cells and fibroblasts (rastové faktory, väzivo)
• activation of macrophages(zápalové cytokíny)
Late changes
• Angiogenesis (proliferation of
capillaries, neovascularisation)
Late structural changes
• thickening of basalmembranes
• fibrous tissue proliferation
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Del Prato
Postprandial elevation of
glucose may exert both
short-term and long-term
effects on the vasculature.
The hyperglycemic wave can
trigger events ultimately
contributing to vessel wall
oxidative stress and
atherosclerosis. Tight control
of hyperglycemia can
minimize these vascular
effects and reduce the risk of
cardiovascular complications
in patients with diabetes.
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The aim of therapy
• Metabolic
compensation of
diabetes
• Lifestyle modification
• peroral antidiabetics
metformin, sulfonylurea
incretin analogs, DPP4
inhibitors...
• Insulin (when endogenous
secretory capacity is substantially
reduced)
• Chronic complications
Control of other risk
factors:
• Hypertension
• Dyslipidemia
• Smoking
• Management of chronic
inflammation
• Dental hygiene
• …
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„Walking is the best medicine.“
„Sport is the health protector.“
Hippocrates
Prescription of exercise as an essential component of
complex lifestyle modification in the prevention and treatment
of type 2 diabetes:
Evidence based medicine
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Diabetes Prevention Program, USA
(Knowler et al, NEJM 2002)
Finish Diabetes Prevention Study
(Tuomilehto et al, NEJM 2001)
Da Qing Study (Pan et al, Diabetes
Care,1997)
Indian Diabetes Prevention Program
(Ramachandran et al, 2006)
Prevention of T2D by lifestyle, Japan
(Kosaka, 2005)
Intervention studies in prediabetics, aimed at the
prevention of type 2 diabetes
DPP Research Group, 2015 Lancet
Cum
ula
tive
incid
ence
of ty
pe 2
dia
bete
s
Li et al, 2008 Lancet
58%
31%
0
20
40
60
80
100
Ris
kre
du
ctio
n(%
)
- exercise with medium
intensity 150 min/week - low caloric, low fat diet - education
Lifestyle Intervention
Metformin
>3200 patients with prediabetes, ~2,8 year follow-up
Clinical studies with the complex lifestyle
modification document efficiency and
long-term sustainability of lifestyle
interventions
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PREVIEW: PREVention throught lifestyle intervention…
• Multinational study to prevent type 2 diabetes in prediabetic individuals with
BMI >25kg/m2, all age groups
• Fixed LED for 8 weeks (Cambridge Weight Plan), the aim: weight loss of at
least 8%
• n=2224 at baseline, 2020 after 8 weeks (>90%)
• Average weight loss after 8 weeks: ~11%
• 35% of patients reverted into normoglycemia after 8 weeks
• 3-year follow-up, weight maintenance (diet + physical activity + CBT)
• 96% did not progress into T2D during 3-y FU (DPP – 91%)
• weight loss of 10% was sustained in those who remained in the study (43%
vs. 92% in DPS)
EASD Berlin 2018
Christensen, Raben et al, DOM 2018
Swindell, Stratton et al, Diabetes Care 2018
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Intervention study DiRECT: weight loss with the aim to induce
remission of T2D, coaching by the general practitioners
• intensive weight management
within routine primary care to
achieve remission of T2D
• 306 individuals from 49
(intervention and control)
general practices;
• patients with T2D, 20-65 years,
BMI 27-45 kg/m2, w/o insulin.
• at 12 months, weight loss of 15
kg or more in 36 (24%)
participants in the intervention
group and no participants in
the control group (p<0·0001).
• Diabetes remission in 68 (46%)
participants in the intervention
group and six (4%) participants
in the control group (at 12-
month).
Wweight loss at 12 months [kg]
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PrescriptionPatient‘sID
number
Nameandsurname
Residence
Dateofbirth
Code
AA0972203HealthInsuranceGroup
Rp.
Dg.
ü 10 000 steps daily
ü 30 minutes moderate-intensity physical activity
5 times weekly
ü 60 minutes high-intensity physical activity
3 times weekly
ü 60 minutes of strength exercise 2 times weekly
acceptedby preparedby date
………………………………………………….Stampandsignature
Code
• 8 000 steps / day
• ≥ 30min medium intensity
aerobic activity, ≥ 5 days / week
• 2-3x / week strength exercise
• Interruptions of sedentary
behavior
• psychiatric diseases (depression, anxiety, stress,
schizophrenia);
• neurological diseases (dementia, Parkinson's
disease, multiple sclerosis);
• metabolic diseases (obesity, hyperlipidemia, MS,
PCOS, T2D, T1D);
• CVD (hypertension, coronary heart disease, heart
failure, cerebral apoplexy, claudication intermittent);
• pulmonary diseases (COPD, asthma, cystic
fibrosis);
• musculo-skeletal disorders (osteoarthritis,
osteoporosis, back pain, rheumatoid arthritis);
• cancer
Exercise prescription in clinical practice
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Learn more about diabetes and obesity
www.diabetes.org/home.jsp
www.idf.org
www.iaso.org/