PROFESSIONAL REFERENCES:

1
LIST OF PUBLICATIONS
2
EXAMPLES OF CITATIONS:
TEXTBOOKS & PAPERS 3
INFORMATION ABOUT
SELECTED JOURNALS 4
Walter BorG, M.D.
Selected Publications
ORIGINAL PAPERS
5
CHAPTERS IN THE BOOKS
6
REVIEWS
7
ABSTRACTS
8
PATIENTS’ EDUCATION
9
ACTIVISM
10
PROFESSIONAL REFERENCES:
1
PROFESSIONAL REFERENCES:
ACADIANA REGION 2
CURRICULUM VITAE
3
LIST OF PUBLICATIONS
4
EXAMPLES OF CITATIONS:
TEXTBOOKS & PAPERS 5
INFORMATION ABOUT
SELECTED JOURNALS 6
ORIGINAL PAPERS
7
CHAPTERS IN THE BOOKS
8
REVIEWS
9
ABSTRACTS
10
 "" ~
=tIl.
Hospital of
Saint Raphael A4!1j or teaching D:tJiliare of
A member of the Saint Raphael Healthcare System Yale University School ofMedicin e

1450 Ch apel Streer interna l Medicine

New Haven. Connecticut 0651 1 Training Program
Phone: (203) 789 -3358
Fax: (203) 789-3222
November 10, 1998

Re: Walter Borg, M.D.

To Whom It May Concern:

It is, indeed, a pleasure for me to be able to recommend Walter Borg. Currently, I am in a

teaching position at the Hospital of Saint Raphael where I run the Endocrinology Clinic and
prepare and deliver most of the Endocrinology lectures. I am also, currently, the President of the
Connecticut Endocrine Society and a long-term member of the Endocrine Society. I was in active
subspecialty Endocrine practice for the past 32 years. I am a Clinical Professor of Medicine at
Yale and actively teach at Yale University on a weekly basis. I spend one month directing the
Endocrine section consultative service at Y ale-New Haven Hospital. I have also served as
Chairman of the Hospital of Saint Raphael, Department of Medicine on two separate occasions in
the past.

I had the privilege of observing Walter Borg as an Endocrinology fellow at Yale-New Haven
Hospital with one month's intensive observation as his preceptor. I also watched him weekly
during Endocrinology rounds. He is, indeed, a superb physician. He is able to obtain complete
histories and perform complete physical examinations on all of his patients. His clinical judgement
is excellent and is based on his avid reading ofthe Endocrine literature. His case presentations are
excellent and he is extremely well organized in his record keeping . He has a superb general
medicine knowledge to go along with his expertise in Endocrinology. He is more than capable to
teach medical students, residents, and fellows early in their training. His lectures and
presentations are extremely well organized and contain all of the pertinent literature data needed
to substantiate his views. He is extremely professional. I believe that Dr. Borg has shown a great
grasp of medicine and he performs at the highest level of competence.

Sincerely,

--Y--~JV\/-----·
, ~
Norman J. Marieb, M.D.

NJMlrr
 YilLE UNIVERSITY SCHOOL OF MEDICINE

GEltr.RI) N. 13uR~ow" MD
EClAt ADVISOI'\. TO TIlE PkESIl>£:-IT FOR HEALTH Af'FAHU;
DAV!" PAIGE SMITH PROfl:~OR or MH)!C1NE
PROH,,SSOR OF Ol:lST£TlUCS A~~) GYNECOL()(~Y

November 4, 1998

To Whom It May Concern:

I have been asked to write a letter of recommendation Dr. Walter Borg. I have related to him in my role
as a Professor of Medicine and a member of the section of endocrinology.

I have had close interaction with Dr. Borg seeing patients. He is an intelligent, committed physician with
good clinical judgment and an excellent ability to obtain history and perform physical examinations. He is
scrupulous in his case presentation and record keeping and has a broad knowledge in both general internal
-~<nedicine and endocrinology.

I have not seen him in a teaching situation but the quality of his lectures is such that they have been carefully
prepared and are inforrnative< His professional attimdes and behavior have been of high standard. Dr. Borg
is a clinically competent endocrinologist.

Cordially,

~~~<-d?~ ~3~~
Gerard N. Burrow, MD

Special Advisor to the President for Health Affairs

Yale University School of Medicine

333 CEDAR STf<..EET, NEW HAVEN CT 0652{)-80,s5 L220 SHM 2\iJ.7HS J7HS PHONE 20J.7HSA693 FAX
 YALE UNIVERSITY
SCHOOL OF MEDICINE

SECrJON OF PEDIATRlC ENDOCRlNOLOGY WILLIA.}!. V TAMBORLANE, JR., M.D" Director

DEPARTMENT OF PEDIATRICS
P.O. BOX 208064
NEW HAVEN, CONNECTICUT 06520·8064
Sonia Caprio, M.D.
TELEPHONE: 203-785-4648 Thomas O. Carpenter, M.D.
FAX; 203-737-1998 Scott Rivkees, IvLD.
Myron Genel, M.D., Associate Dearl
JoAnn Ahern, M.S_N., R,N., cnE.
Apri14,2000 Nancy A. Held, i'vLS., R.n, c.nE.
Mary Savoye, R.D., CD/[\;
Patricia Gatcomb, R.N., cnE.
Elizabeth Boland, A.P.R.N.
Miranda Vincent, A.P.RN.

To Whom It May Concern

Dear Sirs:

It's a great pleasure to write this letter of recommendation for Dr. Walter Borg, as I have known
Walter ever since he arrived at Yale 10 years ago. It has been particularly gratifYing to observe
Dr. Borg's growth and development from a young person new to the US with only one year of
post-medical schoo] experience to a well-trained endocrinologist with a special knack for
research and scholarly activities.

--. Walter came to us on a special Juvenile Diabetes Foundation International fellowship, having
impressed the JDFI leadership by his interest, enthusiasm and intelligence at a JDFI workshop
for European medical students. Coming sight unseen, we didn't know what to expect and frankly
we did not expect that much. It quickly became apparent, however, that Walter had the potential
to be one of our most productive trainees. He was incredibly well organized, researched the
literature extensively and was able to prioritize! esearch questions in a focused and goal-directed
fashion.

Having been placed initially in a basic science laboratory, Walter recognized that this area of
research did not hold his interest. Instead, he shifted his area of study to the problem of
hypoglycemia counterregulation. This was a wise and productive move for Walter and for our
group. Dr. Borg has made important contributions to our clinical research projects and he has
had a leadership role in studies of the role of the VtvlH in regulating counterregulatory hormone
response to hypoglycemia. The results of Dr. Borg's studies have been published in top quality
journals. Walter's abilities to comprehensively search and organize published literature has
served him well in writing a variety of chapters and reviews, also.

Despite his many accomplishments, Dr. Borg had to suspend his research activities in order to
become Board certified in endocrinology. Most of the last 6 years have been spent in clinical
training in internal medicine and adult endocrinology. Although I have not had an opportunity to
observe Dr. Borg's performance in the clinical arena, I'm much impressed by the letters that he
has received from his clinical mentors They indicate that Walter has developed strong c1ihlcal
skills Those skills in combined with his abilities as an independent investigator make Walter an
outstanding candidate for any position that he

Sincerely, ; ; )

Ir~ 1/ Uv&'-­
William V. Tamborlane, M.D.
Professor of Pediatrics
Yale University
wolofMedicil1L' Rohert S. Sherwin, M.D.
Section of Endocrinology CN.H. Long Professor
333 Cedar Street, JIFlvfP of internal Medicine
P.o. Box 208020 Director, Di"betcs
New HlIVt:lI, Conl/celiell! 06520-H020 Elldocrinology Research
Center
Telephollu: 2()3~785-·4! 83
Fax: 203-737-5558
E-mail: robcn.shcrwill@yale.cdu
May 8,2000

Walter Borg, M.D.

Yale University School of Medicine

333 Cedar SI. TMP 532

New Haven, CT 06510

Dear Walter,
I would like to thank you very much for your active participation in our project. I should
emphasize that if not for your relentless effort and unique skills we would not be able to
successfully accomplish our goals. We are indeed fortunate, to have you as a member of
our team. since there are very few young physician-scientists with such a well-balanced
training in both research and clinical fields as yourself Due to this unique training you
are the great asset to the American Medical Community.
I am committed to be supponive in your future endeavors in any way I can. I
strongly believe that you have a bright future in the field of diabetes and endocrinology,
and your service in those areas will be of great value for the U S. Healthcare.

llook forward to our continuous future cooperation.

~,
, /

C,9rdiaP(l / / .
C-h't;'E~~;'-\jJ'~
Robert S Sherwin, M.D.

C N.H Long Professor of Medicine

Director, Endocrinology Fellowship Program

Director, Diabetes Endocrinology Research Center

 DEPARTMENT OF V;:TERANS AFFAIRS

Medical Center

555 Willard Avenue

Newington CT 06111

In Reply Refer To:

November 30, 1995

To whom it may concern,

I am writing in strong support of Dr. Walter Borgls application for a position in your fellowship
program. I have known Dr. Borg for more than one year and have observed him many times in the
general medicine clinic. I have also developed a research proposal with Dr. Borg evaluating the
effects of smoking cessation on diabetes control in diabetic smokers. Thus I feel qualified to
comment on his clinical skills and character, as weIl as his dedication to research.

Dr. Borg has outstanding clinical skills. Compared to other residents he is definitely in the top
10%. He accurately diagnoses conditions and devises appropriate treatment and follow-up plans
for his patients. He also has good common sense in his approach to diagnosing medical
conditions.

Dr. Borg's personal skills have also made him well liked by other residents, patients, and staff
~, members. He is extremely hard working, meticulous, and well organized. He devised an outpatient
history and physical exam checklist to better monitor his patients in' the general medicine clinic at
the Newington VA,

Dr. Borg is also a very dedicated scientist. He is very interested in diabetes and has published
many original articles on glycemic control. He has also shown great initiative in planning of a
project evaluating glycemic control after smoking cessation in subjects with NIDDM.

I enthusiastically support for Dr. Borg's application to your fellowship program. I hope you give
his application serious consideration.

soc' A---~
Ch~Jt:M.D'
Dir~e~en~ Medical Clinic

VA Medical Center, Newington

Assistant Professor of Medicine

University of Connecticut School of Medicine

CHCPhysicians
COMMUNITY HEALTH CARE PHYSICIANS

150 Sargent Drive Fax (203) 781-4383

New Haven, CT 06511 Physician Access Line (203) 781-4331

December 14, 1998

RE: Walter Borg, M.D.

To Whom It May Concern:

Dr. Walter Borg has asked me to write concerning my opinions about him as a physician that I
formed during a one month period when I was the endocrinology attending on the Yale inpatient
endocrine service. Dr. Borg was the fellow on service responsible for seeing all of the inpatient
endocrine consults and responsible for teaching both residents and medical students. Dr. Borg
overall is an excellent physician with solid clinical skills. His histories were thorough and his
physical exams complete and I found no deficiencies in these areas when cO!llpared to my own
history and physical examination of the same patients. His clinical judgment was excellent I
consider his clinical judgment to be excellent both in the area of endocrinology and in general
internal medicine. His case presentations were crisp and his notes in the medical record easily
read and logical in their order. He has sound knowledge of general internal medicine and far
greater knowledge in the field of endocrinology than I would have expected for a fellow at his
level. He excels in teaching medical students and residents and was well prepared with graphics
and pertinent photographs when he did didactic teaching, several sessions of which I observed in
person and learned a great deal myself. The area where I felt that he could be slightly faulted was
in the area of test ordering and I believe he tended to order a full panel of tests without regard to
cost. However, he was only led in this direction because of his intense intellectual curiosity. His
professional attitude and behavior toward patients is without fault and he behaved in an entirely
ethical manner. I would recommend him without reservation.

Sin~C2-JJ
Gordon Reid, M.D.
Assistant Professor of Medicine
Yale School of Medicine

GR/sah
 Jtmerican J'ederationfor Cfinica{!R...esearcfi

6900 Grove Road· Thorofare, NJ 08086-9447 • (609) 848-7072 • FAX (609) 384-6504
QE£K2~BS
E[~
ROY L. SILVERSTEIN
r~ell UnlVCr5l!y MedICal College
President-Eject
VERONICA M. CATANESE
New York University
Sil=~'ll
BRADLEY E. BRITIGAN
University 01 lowa
Iowa CIty VAMe
~~
BARBARA L. HEMPSTEAD
rneu University Medical College
~
June 17, 1994
JONATHAN C. WEISSLER
ltVerslty 01 Texas~Southwestern

E.xQCJJ1r~.~J:h,-e.ClQ[
Walter P. Borg, MD
JEAN M. HADDOCK
SLACK Incorporated
Yale University
Dept. of Medicine/Endocrinology
NA TIONAL COUNCIL 333 Cedar street LMP1
RICHARD M. ALLMAN
New Haven, CT 06511
"sny ot Alabama at B,rmingham
BirmIngham VAMC
IVOR J. BENJAMIN
Dear Dr. Borg:
"ver5Ity 01 Texas-Southwestern

~lve~slty 01
TIMOTHY D. BIGBY
California-San Diego
Congratulations on having been chosen to receive a
San Diego V AMC Trainee Investigator Award for your abstract
MATTHEW BRENNER
u;w..,en,.ly of Calilornla·trvlne
presentation at the Clinical Research Meeting in
HOWARD J. EISEN Baltimore, Maryland, April 29 - May 2, 1994.
" Temple University
Ptliladelphia VAMC
MONICA M. FARLEY In addition to your prize the AFCR also wishes to
Emory UniversIty
Atlanta VAMe
present to you a one year complimentary associate
ALAN M. GARBER
membership in the Federation. Your membership will
Stanford University
Palo Alto VAMC
begin on July 1, 1994. Please complete the enclosed
JOE G.N. GARCIA
form for our records and return it to the AFCR National
Indiana University
Inolanapoli~ VAMC
headquarters in the envelope provided. Please do not
ALISA E. KOCH
send a check.
Nortnwestern Universl'ty
VA LakeSIde
JENNIFER L. LARSEN
Your membership includes a subscription to the Journal
UnIverSity 01 Nebraska of Investigative Medicine and its supplements and the
FREDERICK P. OGNIBENE
r.. a!lor,Cj; Inslttutes ot HeatUl
AFCR newsletter. We hope that you will enjoy these and
MARK S. PALLER all benefits that membership in the AFCR provides.
JfW.i;'~5,ity 01 Minnesota
MONICA PEACOCKE
Er.;;iCor.O Medical Center
r,,€w We look forward to your participation in the activities
KEITH M. RAMSEY of the AFCR and if you have any questions please feel
DAVtD M. RODMAN
free to contact the National Office.
ot Colorado
U!;IIIf:!tSlty

• ••.!'ofIo
HARRY P. SELKER
E:19i.Jn'J MedlCal CU:1lef
Sincerely,

Z~.
ROBERT M. STRIETER
l,jr,,','\:"'Stty ot M1ctl!g2ln

GREGORY M VERCELLOTTI
;,;rH'It:ot~Jiy of MinnesOta

RONALD G. WASHBURN MD

~,-,w(·.;,r, C!ay SC',oul 01 Med,clnt;

AFCR President

PAMELA G. WILLIAMS-RUSSO
.(;1',.::: 0n~"'t(~.:. ~.~H1Ica! CO/if:Q€:

ALAN C. YEUNG

'IOALL YOUNG. JR.

'n ...,f:r'f.,. , "', j...<::-dlr.Q.Bl(m.(\\~nar;
p;;~;l\gl",a,~ "AM....

National MeetIng
May 5-8. 1995
San Diego. CA Official Publication.· Jo:.,·rr,al of Investigative Medicine
 .....=cr 7 t . I+T,b,'" H6t: t ( PSi

--------..;:;

rH~ CLINICAL /R~§lEIRCH ~~~-- ·-··-··-a·~-·p-",,-,:~,

/! ..'.... ' .... , ~... r'."·· ... ~.J ..';..~.
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M~~rING

/ ~ . .~~ .~~:;;.;.~;~~:..: ~:t-'4r\-'\.

TRAINEEhtrvEStlOA~qR AWARD
for Excelleq<;~,i~n\:~Gie~~i~c Research
I._._. __ :::::..~ ~"""' .. 1 ............ J- .

Presented_:to_~

~al±tr ,+ IhllirB, 4ffiIJEl

~p:;df~ ~~~ President ASCI .

~W~
President AFCR

MAY 2, 1994

Baltimore, MD

~ nW-"-"'"'+fH~..,.,e!." mi,) w XI : ;_-.-.~-~ ..... -"~--'~'. - •• ----.".-.­

 Page 1 of 1

SUbj: Nomination of Walter Borg for election to AACE BOD

Date: 10/8/20073:28:24 P.M. Central Daylight Time

From: MHARRI;:J.I,.@OIolIV!ardhe.!aJth.Qrg

To: oqa!y@a?lce.com

Dear Betty et al:

I would like to nominate Dr. Walter Borg for election to the AACE BOD for 2008. Dr. Borg is an active and influential member of my
Socioeconomic and Coding Committee and have devoted countless hours to AACE affairs over the past 2 years. He will be a leader in our
organizations for years to come. Sincerely, R. Mack Harrell, MD, FACP ,FACE

IMPORTANT: The contents of this email and any attachments are confidential. They are intended for the named recipient(s) only.

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Monday, October 08,2007 America Online: Guest

:::..... ~.;~ :
.....

FRANK R. BACQUE, M.D.

" UROLOGIST

• (Professional Medical Corporation)

602 ST. LANDRY STREET

LAFAYETTE. LOUISIANA 70506-4698

Telephone (337) 235-1200

September 10} 2007

Dr. Walter Borg

501 W. St. Mary} Suite 120
Lafayette, LA 70506

Re

Dear Dr. Borg,

Mr. is a wonderful man who came to see me two years ago about a hernia
and some ED. In his follow up visits we found that a co-worker of his, who had similar
problems, was found to be hypogonadat with a very low testosterone. $0, we studied him
and found a similar situation with a 121 testosterone, and then we did a CT scan of his head
and found suspicious pituitary area. We did the MRI, and Dr. Wojak thought it did go along
with the pituitary adenoma, and then we sent him to Dr. Todd Baquet. At the time I did not
know that you were available, and the patient wants a second opinion, and I have heard
such good things about you that I am looking forward to his seeing you.
".
Endosed are his records and I sure appreciate your help.

Respectfully yours,

Frank R. Bacque, M.D.

FRB/el

Enclosure
 Page 10f1

Subj: RE: Baton Rouge Meeting

Date: 11/2/20067:52:15 AM. Central Daylight Time
- -~rom: andyblalock@CQx.net
0: DrWBo(g@caol.com

Dr. Borg,
Thcank you very much for your service to the society and for your kind words. We are also lucky to have members
like you that are willing to dedicate themselves to the improvement of healthcare in the state of Louisiana. If you are
interested, I would like you to consider serving on the Executive Committee for the Lafayette Parish Medical Society­
which also carries with it an automatic position on the LSMS delegation.

Thank you again for your service and interest.

Sincerely,
Andy Blalock

From: DrWBorg@aol.com [mailto: DrWBorg@aol.com]

sent: Sunday, October 29, 2006 5:01 PM
To: andyblalock@cox.net
Cc: staff@lpms.org
Subject: Baton Rouge Meeting

Dear Dr. Blalock,

It was a real pleasure to meet you in Baton Rouge. Lafayette Parish Medical Society is very fortunate to have you

as a leader.

I am looking forward to serve our Society for many years to come.

--" !Viii keep in touch. Please let me know if I can be of any assistance in the meantime.

Sincerely,

Walter Borg, M.D.

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Friday, August 10,2007 America Online: DrWBorg

 Dear Dr. Borg,

I am writing to,"Thank You". You are the finest doctor I have ever known. As far
as I am concerned, you are the best in several states for sure. I have been to
many doctors in different states, in the last several years and had never found one
who was interested or cared about my health, like you did.l appreciate the time,
interest and care you gave to me and my health issues. With you as my doctor I
felt safe. I wonder if I will ever find another doctor like you.
I don't mind telling you, that I am so disappointed with my new doctor and will
be looking for another one.
I had signed all the necessary papers with your office and his office to have my
medical records sent to him. I waited over two months for an appointment with him
and had hoped I would find him to be the kind of doctor you are. On the day of my
appointment, when he walked into the room, he didn't even give me the time of
day. He dropped into his chair and said, what can I do for you?He did not have my
medical records from your office, his nurse had not given him the copy of my
medical history and medications that I had given to her. I gave him my copy and
went over what had been going on. He appeared not to know anything about my
condition and really didn't seem to be interested. He asked very few questions
and said he wanted some test run and walked out of the room. This visit was
approximately ten minutes. When he walked out I didn't see him again. He hacJn't
said, nice to meet you, see you later or even good-bye. I'm not anyone special,
_.l!~ a little common courtesy would have gone a long way. His nurse came in and
said for .me to go to the lab and call them in ten days for the results. On the tenth
and eleventh days I called and left messages and sent an email. On the third day I
received the results in the mail. I didn't understand them and had questions, so I
called again and sent another email, with two phone numbers where they could
reach me and asked to schedule an appointment with the doctor because I have
not been feeling well. Also that I had questions about the test and any orders he
had that I should follow and that J n~ new prescriptions. The nurse finally
called me late on the third day and said, the doctor doesn't know why you're not
feeling well and there is nothing on the results that concerns him. She'said, you
don't need to cOme back until the end of October. Oh, and your thyroid level is too
high, so reduce your Cytomel to one a day. I told her one of my other doctors had
alreacJy Iower~ my Synthroid by 25 mg. the week before. She just brushed that
aside and said, he wants you to take one Cytomel. So for a couple of weeks now I
have been on .075 mg and one Cytomel daily. I really don't feel well, I have
gained around thirty pounds in the last three months, my back has been hurting a
lot and I have broken a toe. My Pulmonary doctor has put me on fluid pills,
 Page2of2

because I have swelled up so much. I'm always bloated and move very slowly. My
stomach is always hurting and J just feel like a wreck. I feel like and look like, I did
the first time I went to see you. It's really discouraging for me.
Anyway, t don't even know if you remember me or if my records are still with
you. I thought I'd take the chance that you would. I wanted to let you know how
things were going and to ask if you would possibly recommend a doctor that I
could see, that would live up to your standards. After having the best, it's hard to
Medicare
settle for less. Of c;ourse I can only go to a doctor that will accept and
PPO PLUS. 00 you think you will ever accept Medicare again? If you did, I would
certainly be back in your office.
Dr. Borg, I would really appreciate any help you could give me in selecting another
doctor.
Again I want to thank you, for three years of the best health care I have ever
had from a doctor. You are a good human being and a nice person. Oh and did I
mention the best of doctors.
Thank you Dr. Borg.
I also hope all is well with you. Have a blessed week!

PS My email address
 PaseI of I

Subj: Letter of Recommendation

Date: 111112009 8:00:33A.M.CentralStandard
Time
From: WILIIAMCONWAY
To: DrWBorg

To Whomit mayConcern,

I haveknownDr Borgas a colleague for severalyears.He and I havebothbeenon a nationalcommitee for

American Association (AACE).Hiscontribution
of Endocrinologists io the committeehasalwaysbeenpositiveand
On a personalnote,Dr. Borghasbeenexceeding
subtantial. generous withhistimein assisting mewithlearning
the processof publication, in my groupsuccessfully
resulting obtaining two publications
in the InsulinJournal.
I am a generalinternistanda diabetologist who provides criticalservicesin an underserved
ruralTennessee. I
providecriticalserviceto chronicallyill patients,one thirdwho do not haveinsurance.My practicepatternsreflect
what is medicallynecessary,in the bestinterests,and affordableto my patients.I am not a fellowhiptrained
endocrinologist.My patientsrountinely havediabetes, thecomplications of diabetes,depression,
anxiety,copd,
and rheumatoidarthritis.My practicepatternsare shapedby the povertyof thoseI serve.I am currentlytrainingin
psychiatryto betterservemy chronicallyill patients.

Dr. Borgaskedto reviewchartslastyear underinvestigation by the statemedicalboardof Lousiana.I invested

severalhoursin the reviewof thoseiharts. Hischartsclearlvstatethatthe scoDeof his oracticeis timrteO-'O--
@ewasemphaticinhiSchartsthatni'spatientihaveaprimarycare
physician.
Hischarts,as wellhiswritingin theendocrine community, clearlystatethatDr. Borgdoesnot manage
psychiatric
or psychosocialaspectsof chronicillness..

Dr. Borq'schartsclearlvreflecta practicepatternwhlchis consistentwithconsultantendocrinoloqists who have

beentrainedin elitelnstituions.Histhinkingpatternis consistent withconsultativeendocrinologiists
who havebeen
trbinedin eliteinstututions.
Manyof theopinionsexpressed by Dr,Borgare heldfellowendocrinologists on our
AACEcommitee,lf Dr. Borgwas in my area,and if my patients couldaffordDr. Borg,I woulduseDr. Borgas a
consultan.. Or. Borg'scharts,in my opinion,do not fall belowthe levelof carerequiredfor actionby a state
medicalboard.

Dr.,Borgis b!'illiant,
unusqallv
welltrained,andwillcontinue
to makean academiccontributjonto endocrinologv
andan ongoing,substantial contribution
to theworkof AACE. I respectfully
requeston the behalfof endocrinology
thatDr.Borgbe continued to be licensed.

Sincerely,

WlliamF. Conway,MD,FACP

A Good Credit Score is 700 or Above. Seeyours in just 2 easy steps!

Mondav.January12.2009AmericaOnline
 Pase1 of I

Subj. IMPORTANTTimothy S. Bailey,MD, CPI - OPINIONLETTER

Date: 1 1 1 2 1 2 0 0192 : 3 9 : 1 3
A . M . C e n t r aS
l t a n d a r dT i m e
From: DrWBorg
To: mwa@judice-adley.com

From:tbailey@amcri nstitute. com

To: DrWBorg@aol.com
S e n t .1 1 1 1 1 2 0 079: 5 8 : 5 1P . M .C e n t r aS
l t a n d a r dT i m e
Subj:The Conundrumof StateMedicalBoards

To Whom lt May Concern:

I have reviewedthe medicalrecordsin questionof Dr Borg.

evaluationsthat I have ever encounteredin my past 20 yearsas a practicingspecialist

- in endocrinology
aTd rnelab-oiism Ev€try ie6t"o rAeied vibi mdileul-ously Aocurnenied-and-justmtd.

Sincerely,

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PROFESSIONAL REFERENCES:
YALE UNIVERSITY 1
LIST OF PUBLICATIONS
2
CURRICULUM VITAE
3
LIST OF PUBLICATIONS
4
EXAMPLES OF CITATIONS:
TEXTBOOKS & PAPERS 5
INFORMATION ABOUT
SELECTED JOURNALS 6
ORIGINAL PAPERS
7
CHAPTERS IN THE BOOKS
8
REVIEWS
9
ABSTRACTS
10
 Walter P. Borg, M.D.

List of selected publications

2009

Borg, W.P.: Case Against Bioidentical Hormones. JPANDS, 2008. 13(2): 47-51.

Borg, W.P.: Need for Objective Approach. The First Messenger. American
Association of Clinical Endocrinologists, 2006. 15(5): 1,7.

Borg, W.P.: AMA Calls for Reality Check on Bioidentical Hormone. The First
Messenger. American Association of Clinical Endocrinologists., 2007.

Borg, W.P.: Reproductive Endocrinopathies and Psychopathology

Common misconceptions. The First Messenger. American Association of Clinical
Endocrinologists., 2007. 16(6): 9-10.

R. Sherwin, W.P. Borg, Boulware, S.D:: Metabolic effects of IGF-1: Implication for
the therapy of Diabetes Mellitus. In: Blackman, M.R., Harman, S.M., Roth J.,
Shapiro J.R. (Ed.): GH and IGF-1: Basic and Clinical Advances.1993 Raven Press.

W.P. Borg, M.J. During, R.S. Sherwin, M.A. Borg, M.L. Brines, G.I. Shulman:
Ventromedial hypothalamic lesions in rats suppress counterregulatory responses
to hypoglycemia. J Clin Invest. 93:1677-1682; 1994.

WP Borg, and WV Tamborlane, Summary and Commentary: Mechanism of

Awareness of Hypoglycemia: Perception of Neurogenic (Predominantly
Cholinergic) Rather Than Neuroglycopenic Symptoms by Dwight A. Towler, et al.
From Research to Practice. Diabetes Spectrum 7:249-250; 1994.

R. Sherwin, W.P. Borg, S.D. Boulware: Metabolic effects of insulin like growth
factor 1 (IGF-1) in normal humans. Horm Res 41(Supp.2):97-102; 1994.
 Walter Borg, M.D. -2-

WP Borg, MJ During, RS Sherwin, MA Borg, GI Shulman: Ventromedial

hypothalamus plays a critical role in triggering counterregulatory responses to
hypoglycemia. Abstract. Clinical Research 42:213A; 1994.

W.P. Borg, MA Borg, GI Shulman: Local Ventromedial Hypothalamus Glucopenia

Triggers Counterregulatory Hormones Release. Abstract. Diabetes
43(Suppl.:1):446; 1994.

MA Borg, RS Sherwin, MJ During, WP Borg, GI Shulman: Local Ventromedial

hypothalamus glucose perfusion blocks counterregulation during systemic
hypoglycemia. Abstract. Diabetes 44(Suppl.:1):2; 1994.

T. W. Jones, WP Borg, S. D. Boulware, G. McCarthy, R. S. Sherwin, and W. V.

Tamborlane: Enhanced adrenomedullary responses and increased susceptibility to
neuroglycopenia: mechanisms underlying adverse effects of sugar ingestion in
healthy children. J Pediatr 126:171-177; 1995.

Borg W.P. and Sherwin R.S.: Metabolic effects and potential clinical applications of
insulin-like growth factor 1. Diabetes Annuals. 1995 Elsevier Science B.V.

R. Sherwin, W.V. Tamborlane, and W.P Borg: Carbohydrate, Lipid, and Amino
Acid Metabolism in the Nonpregnant Patient. In Diabetes Mellitus in Pregnancy.
Principles and Practice. Second Edition. E.A. Reece, D.R. Coustan. Eds New
York, Churchill Livingstone 1995.

W.P. Borg, R.S. Sherwin, M. During, M.A. Borg, and G.I. Shulman: Local
Ventromedial Hypothalamus glucopenia triggers counterregulatory hormone
release. Diabetes 44:180-184, 1995.
 Walter Borg, M.D. -3-

W.P. Borg, CHL Shackleton, SL Pahuja, and RB Hochberg. Long lived

testosterone esters in the rat. Proc. Natl. Acad. Sci. USA 92:1545-1549; 1995.

D.G. Maggs, Borg W.P., During M.J., Sherwin R.S. Microdialysis techniques in
the study of brain and skeletal muscle. JDFI/EASD Meeting 1995.

D.G. Maggs, Borg W.P., Sherwin R.S. Microdialysis techniques in the study of
brain and skeletal muscle. Diabetologia 40:S75-82; 1997.

MA Borg, RS Sherwin, MJ During, WP Borg, GI Shulman: Local Ventromedial

hypothalamus glucose perfusion blocks counterregulation during systemic
hypoglycemia. Diabetes 44(Suppl.:1):2; 1995.

MA Borg, RS Sherwin, WP Borg, WV Tamborlane, GI Shulman: Lactate perfused

locally into the ventromedial hypothalamus suppresses counterregulation during
systemic hypoglycemia. Diabetes 45(Suppl.:1):195; 1996.

MA Borg, RS Sherwin, WP Borg, WV Tamborlane, and GI Shulman: Local

Ventromedial hypothalamus glucose perfusion blocks counterregulation during
systemic hypoglycemia in awake rats. J Clin Invest. 99:361-365; 1997.

MA Borg, GI Shulman, WP Borg, WV Tamborlane, RS Sherwin: Recurrent

iatrogenic hypoglycemia and IDDM suppress counterregulation caused by
localized 2-DG perfusion of the ventromedial hypothalamus. Diabetes
46(Suppl.:1):159; 1997.

TW Jones, WP Borg, MA Borg, SD Boulware, G McCarthy, D Silver, WV

Tamborlane, and RS Sherwin: Resistance to neuroglycopenia: An adaptative
response during intensive insulin treatment of diabetes. J Clin Endocrin & Metab.
82:1713-1718; 1997.
 Walter Borg, M.D. -4-

WP Borg, MA Borg, and WV Tamborlane. The brain and hypoglycemic

counterregulation: Insights from hypoglycemic clamp studies. Diabetes Spectrum
10:33-38; 1997.

MA Borg, WP Borg, WV Tamborlane, ML Brines, GI Shulman, RS Sherwin:

Recurrent hypoglycemia and diabetes mellitus impair counterregulation induced by
localized 2-deoxy-glucose perfusion of the ventromedial hypothalamus in rats.
Diabetes 48:584-587, 1999.

WP Borg, MA Borg, WV Tamborlane, RS Sherwin: Local VMH Alpha-Adrenergic

Blockade Impairs the Epinephrine Response to VMH Glucopenia. Diabetes
48(Suppl.:1):239; 1999.

WP Borg, RS Sherwin: Classification of Diabetes Mellitus Including MODY. In

Advances in Internal Medicine, Volume 45. Mosby 2000.
PROFESSIONAL REFERENCES:
YALE UNIVERSITY 1
PROFESSIONAL REFERENCES:
ACADIANA REGION 2
EXAMPLES OF CITATIONS:
TEXTBOOKS & PAPERS 3
LIST OF PUBLICATIONS
4
EXAMPLES OF CITATIONS:
TEXTBOOKS & PAPERS 5
INFORMATION ABOUT
SELECTED JOURNALS 6
ORIGINAL PAPERS
7
CHAPTERS IN THE BOOKS
8
REVIEWS
9
ABSTRACTS
10
 14TH
EDITIO

Harrison's

p C P ES f

EDITORS

Anthony S. Fauci, MD Joseph B. Martin, MD, PhD,

Chief, Laboratory of Immunoregulation; Director, PRep (c), MA (Bon)
National Institute of Allergy and Infectious Dean of the Faculty of Medicine;

Diseases, National Institutes of Health, Bethesda Caroline Shields Walker Professor of

Neurobiology and Clinical Neuroscience,

Eugene Braunwald, AB, MD, Harvard Medical School, Boston

MA (Hon), MD (Hon), ScD (Hon)

Distinguished Hersey Professor of Medicine. Dennis L. Kasper, MD, MA ( Hon)

Faculty Dean for Academic Programs at Brigham William Ellery Channing Professor of

and Women's Hospital and Massachusetts General Medicine, Harvard Medical School;

Hospital, Harvard Medical School; Vice-President Director, Channing Laboratory; Co-Director,

for Academic Programs, Partners HealthCare Division of Infectious Diseases; Executive

System. Boston Vice-Chainnan, Department of Medicine,

Brigham and Women's Hospital, Boston

Kurt J. Isselbacher, AB, MD

Mallinckrodt Professor of Medicine, Harvard Stephen L. Hauser, MD
Medical School ; Physician and Director, Chainnan and Betty Anker Fife Professor,
Massachusetts General Hospital Cancer Center, Department of Neurology, University of
Boston California San Francisco, San Francisco

Jean D. Wilson, MD Dan L. Longo, AB, MD, FACP

Charles Cameron Sprague Distinguished Chair Scientific Director, National Institute on

and Clinical Professor of Internal Medicine, The Aging, National Institutes of Health,

University of Texas Southwestern Medical Center, Gerontology Research Center.

Dallas Bethesda and Baltimore

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 PART THIRTEEN
2080
Endocrinology and Metabolism
The -insulin r~sistance is severe, and ketoacidosis may occur despite
high endogenous insl}lin levels. The Alstrom syndrome is a rare autoso­
mal recessive disease"cfiaracterized by childhood blindness due to
retinal degeneration, nerve deafness, vasopressin-resistant diabetes in­
sipidus, and, in males, hypogonadism with high plasma gonadotropin
levels. The patients thus appear to have end organ resistance to multiple
hormones. Other features include baldness, hyperuricemia, hypertri­
glyceridemia, and aminoaciduria. Superficially, the patients may re­
semble subjects with the Laurence-Moon-Biedl syndrome but can be
differentiated on initial examination by the absence of polydactyly
and · mental deficiency. Insulin resistance in the Alstrom syndrome
is mild. Ataxia-telangiectasia is characterized by cerebellar ataxia,
telangieclasia;apredispositicmto breast cancer, and a variety.ofabnor­
malities in the immune system in addition to insulin resistance. The
Rabson-Mendenhall syndrome consists of dental dysplasia, dystrophic
nails, premature. puberty,. and acantbosis. nigticans. The insulin resis­
tance is probably due to an insulin receptor abnormality. Lepre­
chaunism is characterized by an elfin appearance of the face, hirsutism,
absence of subcutaneous fat, thickened skin, and insulin resistance.
Defects are found in both the 0. and the f3 subunits of the insulin
receptor, causing expression in plasma membranes to be markedly
diminished. Not listed in Table 334-12 is insulin resistance due to
hormone excess (acromegaly, Cushing's syndrome), myotonic dystro­
phy, and thalassemia major. The insulin resistance in these conditions
usually is not clinically significant.
·INSULIN ALLERGY Insulin allergy is due to 19E antibodies
to insulin. Manifestations include immediate reactions with local sting­
ing or itching, delayed local reactions with brawny swelling lasting
up to 30 h, and generalized urticaria or frank anaphylaxis. Systemic
reactions are usually seen in patients who have stopped insulin therapy
for one reason or another and have then resumed treatment. The allergic
reaction may occur as early as the second injection on resumption of
therapy. Mild reactions can be treated with antihistamines. If the
problem is severe, desensitization procedures are required. A I-day
insulin desensitization procedure is shown in Table 334-13. Once the
patient is desensitized, insulin therapy should not be interrupted .
THE EMOTIONAL RESPONSE TO DIABETES It is diffi­
cult to accept that one has a chronic disease that requires a change in
life-style. This is particularly true in the case of diabetes, since patients
are usually aware that they are vulnerable to late complications and
that their life expectancy is shortened. It is not surprising that the
emotional response to diabetes often hampers treatment. The primary
reaction can range from denial with an accompanying refusal to cooper­
ate to excessive preoccupation with the illness. The physician should
make every effort to bring the patient to a middle ground of acknowl­
edging the disease and responding prudently without becoming ob­
sessed. The goal is to live with diabetes, not for it. Patients with
diabetes are no different from other patients, in that they may use
their disease manipulatively with both family and physician. These
problems are particularly acute with children and adolescents. While
'fable 334-13
Insulin J)cscnsitization ':'
Time, h Dose, U Route Time, h Dose, U Route
0 0.001 Intradennal 3.5 0.2 Subcut.
0.5 0.002 Intradermal 4 0.5 Subcut.
I 0.004 Subcut. 4.5 I Subcut.
1.5 0.01 Subcut. 5 2 Subcut.
~
2 0.02 Subcut. 5.5 4 Subcut.
2.5 0.04 Subcut. 6 8 Subcut.
3 0.1 Subcut.
* Following desensitization, use 2 to 10 U of regular insulin every 4 to 6 h for 24 to 36 h
after the 6-h injection before switching to intermediate-acting insulin.
SOURCE: Schedule ofJA Galloway. For detailed information see JA Galloway, R Bressler,
Med Clin North Am 62:663 . 1978.
the psychiatric aspects of diabetes are not discussed here, most prob­
lems can be anticipated and handled if common sense is coupled with
sympathy and finnness. It is also appropriate to offer cautious hope
that the disease will be handled better in the future than is possible now.
Please refer to Chap. 60, Insulin, oral hypoglycemic agents, and
the pharmacology of the endocrine pancreas, in Goodman &
Gilman's The Pharmacological Basis of Therapeutics, 9th ed. , New
York, McGraw-Hill.
BfBLIOGRAPHY
G ENERAL REVIEW
UNGER RH, FOSTER DW: Diabetes mellitus, in Williams ' Textbook ofEndocri­
nology, 9th ed, JD Wilson, DW Foster (eds). Philadelphia, Saunders, 1997
(in press)
GENETICS AND PATHOGENESIS
ATKINSON MA, MACLAREN NK: The pathogenesis of insulin-dependent diabe­
tes mellitus. N Engl J Med 331: 1428, 1994
BINGLY PJ et al: Can we really predict IDDM? Diabetes 42:213, 1993
COUSTAN DR et al: Gestational diabetes: Predictnrs of subsequent disordered
glucose metabolism. Am J Obstet Gynecol 168: 1139, 1993
GHOSH S, SCHORK NJ: Genetic analysis of NIDDM. The study of quantitative
traits. Diabetes 45: I, 1996
HAGOPIAN WA et al : Glutamate decarboxylase-, insulin-, and islet cell-antibod­
ies and HLA typing to detect diabetes in a general population-based study
of Swedish children. J Clin Invest 95:1505, 1995
HARRISON LC et al: MHC molecules and f3-cell destructive immune and nonim­
mune mechanisms. Diabetes 38:815, 1989
HYOTY H et ill: A prospective smdy of the role of coxsackie B and other
enterovirus infections in the pathogenesis ofIDDM. Diabetes 44:652, 1995
PALMER JP, McCuLLOCH DK: Prediction and prevention of IDDM-1991.
Diabetes 40:943, 1991
I'ERMUTT MA et al: Glucokinase and NIDDM: A candidate gene that paid off.
Diabetes 41 :1367, 1992
POLONSKY KS et al: Non-insulin-dependent diabetes mellitus-a genetically
programmed failure of the beta cell to compensate for insulin resistance.
N Engl J Med 334:777, 1996
PuGLIESE A et al: HLA-DQBl*0602 is associated with dorrtinant protection
from diabetes even among islet cell antibody-positive first-degree relatives
of patients with lODM. Diabetes 44:608, 1995
THAI AC, EISENBARTH GS: Natural history of lODM. Diabetes Rev 1:1 , 1993
UMPIERREZ GE et al: Diabetic ketoacidosis in obese African-Americans. Diabe­
tes 44:790, 1995
DIABETIC COMPLlCATIONS
AIELLO LP et ai: Vascular endothelial growth factor in ocular fluid of patients
with diabetic retinopathy and other retinal disorders. N Engl J Med
331:1480, 1994
BEISSWENGER PJ et al: Formation of immunochemical advanced glycosylation
end products precedes and correlates with early manifestations of renal
and retinal disease in diabetes. Diabetes 44:824, 1994
BORG WP et ai: Local ventromedial hypothalamus glucopenia triggers counter­
regulatory hormone release. Diabetes 44: 180, 1995
BOYLE PJ et ai: Brain glucose uptake and unawareness of hypoglycerrtia in
patients with insulin-dependent diabetes mellitus. N Engl J Med
333:1726, 1995
BROWNLEE M: Glycation products and the pathogenesis of diabetic complica­
tions. Diabetes Cart: 15: 1835, J 992
FOSTER DW, McGARRY JD: The metabolic derangements and treatment of
diabetic ketoacidesis.N Engl J Med 309:159; 1983
KROLEWSKl AS et al: Glycosylated hemoglobin and the risk of microalbumin­
uria in patients with insulin·dependent diabetes mellims. N Engl J Med
332:1251, 1995
LEURS PB et al: Tissue factor pathway inhibiror activilY in patients with lODM.
Diabetes 44:80, 1995
PARTANEN J et"al: Natural history of peripheral neuropathy in patients with
non-insulin-dependent diabetes mellitus. N Engl J Med 333:89, 1995
SEQUIST ER et al: Familial clustering of diabetic renal disease: Evidence for
genetic susceptibility and diabetic nephropathy. N Engl J Med
320:1161 , 1989
SIPERSTEIN MD: Diabetic ketoacidosis and hyperosmolar coma. Endocrinol
Metab Clin North Am 21 :915,1992 . .
TOWLER' DA et ai: Mechanism of awareness of hypoglycemia. Perception
of neurogenic (predominantly cholinergic) rather than neuroglycopenic
symptoms. Diabetes 42: 1791, 1993
 J

I WILLIAMS TEXTBOOK OF

I ENDOCRINOLOGY , ,

9th Edition

Jean D. Wilson, M.D.

1 Charles Cameron Sprague Distinguished Chair
j and Clinical Professor of Internal Medicine
The University of Texas Southwestern Medical Center
Dallas, Texas
j Daniel W. Foster, M.D.
Donald W. Seldin Distinguished Chair
and Chairman of Internal Medicine
The University of Texas Southwestern Medical Center
Dallas, Texas
)
j Henry M. Kronenberg, M.D.
Professor of Medicine
Harvard Medical School
Chief, Endocrine Unit
Massachusetts General Hospital
Boston, Massachusetts

1 P. Reed Larsen, M.D.

Professor of Medicine

I Harvard Medical School

Chief, Thyroid Division
and Senior Physician, Brigham and Women's Hospital
Boston, Massachusetts
J
J

W.B. SAUNDERS COMPANY

1 A Harcourt Health Sciences Company
Philadelphia London New York St. Louis Sydney Toronto

1

10'12. Roy H. Chou MeV. Field .lB. Tilne-acrion characteristics of regular and
NI)H insulin in inSl1irtHfe;:{lt:ri diabetics. j Clin Endocrinol Metab 1980~
50:475-47'1.
1O~:1. 1\oltc MS, Poon V, (;rod,k; C \1. d al. Reduced solubility of short-acting
solubk insuliuK wht~n mixed \<ilth Iongf'r~ac(ing insulin. Dlabeles 1983~
:1:0>:1 177-1 I Ill.
JO:!4. Skykr.JS. Insulin pharmacology. M('d Clin :-iorth Am 1988; 72:1337-1354.
iO~S Zinman B. The physjologic replacement of in~Hlin: an elusIve goal. N
f.nglJ Med 1989; 321:363-:>70.
iO~6 Sonnenberg GEt Chanteiau E. Sundermann S. et at Human and porcine
regular insulins art: c<ruaUy effective in !'ulx:utaneous replacement ther­
apy: resultS of a double-blind crQ.'i-'iover .study in type 1 diabetic patients
with continuous subcutaneous insulin luftLSioll. Diabetes 1982; 31:600­
tiM.
1O~7. Home PD, Malisi-Bened~"i M. Shepherd f;.AA. et aL A comparison of the
activity and disposal of S(':rni·s~lHhetic hum;tn insulIn and pordne insulin
in normal man by 'he glutose clamp technique. Diabetologia 1982;
22:11-45.' _.
JO;!i\. Heding LG, Marshall :.to. Persson B. c, a!. Immunogenici,,, of monocom·
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hypoglycemia associated wiuI deficiencies in the release of counter-regula.
tory hormones. N EnglJ Med 1981; 305:1200-1205. .
1070. Cryer PE. Decreased sympalhochromaffin activity in IDDM. Diabetes
1989; 38:405-409.
1071. Dagogo-Jack S, Rattera;;arn C, Cryer PE, et aL Reversal of h}poglycemia
unawareness, but not defective glucose counterregulation, in IDDM. Dia­
betes 1994; 43:1426-1434.
1072. Boyle PJ, Kempers SF, O'Conn"r 'AM, et al. Brain glucose uptake and
unawareness of hypoglycemia in 'patients with insulin-<lependent diabetes
mellitus. N En I Med 1995; 333:1726-173L
Borg ViP, Sherwin RS, During MJ, et at Local ventromedial hypothalamus
glucopenia triggers counterregulatory hormone release. Diabetes 1995;
44:180-184.
nawareness 0 ypog ycem.a.
l075. Somog); M. Exacerbation of diabetes by excess insulin action. Am J Men
1959; 26:169-191.
1076. Wilson DE. Excessive insulin therapy: biochemical effects and clinical
repercussions. Current concepts of counterregulation in type I diabetes.
Ann Intern Med 1983; 98:219-227.
1077. Tordjnan Klvl, Havlin CE, Levandoski LA, et a!. Failure of nocturnal
hypoglycemia to cause fasting hyperglycemia in patients with insulin­
dependent diabetes mellitus. N EnglJ Med 1987; 317:1552-1559.
1078. Winter RJ Profiles of metabolic contrnl in db.hetlc chtldren- fre-quency
of asymptomatic nocturnal hypoglycemia. Metabolism 1981; 30:66&-672.
1079. Kahn CR. Rosenthal AS. Immunologic reactions to insulin: insulin ai!('rgy,
insulin resiSlanCt\ and the autoinlmune insulin syndrome. Diabetes Care
1979; 2:283-295.
1080. Kahn CR, Mann 0, Rosenthal AS, et aL The immune response to illSulin
in mall: interaction of HLA alloantigens and the development of the
immune response. Diabetes 1982; 31:716-723.
1081. Galloway .lA, Bressler R, Insulin treaunent in diabetes. Med Clio North
Am 1978; 62:663-680.
1

sO ~ffi\JY ~©
1
1
1
0
!

ocrlno ogy
1
Mark A. Sperling, M.D.
1 Vrra I. Heinz Professor and Chainnan

Department of Pediatrics

University of Pittsburgh School of Medicine

1
Pediatrician-in-Chief

Children's Hospital of Pittsburgh

Pittsburgh, Pennsylvania

w.s. Saunders Company

A Divisioll of Hmcmut Brace &: CO"'JlO1I1
Philadelphia London Thronto Montreal Sydney 1bkyo

hyperinsulinemia is present and demands further evaluation
and treatment. In children, an adenoma is more likely than
f)-cell hyperplasia. Treatment shou~d .~e best directed toward
the likelihood of surgery. If the inItial sample reveals an
insulin concentration of more than 100 J.LU/mL, a tumor is
possible, but factitious h.yperinsuli~emia must .be. e~clu~ed.
At this stage, a C-pepude level IS helpful; If It IS high,
indicating endogenous hyperinsulinemia, a tumor or ade­
noma secreting insulin is most likely. If it is low, factitious
hyperinsulinemia with exogenous administration of insulin
must be suspected, and further eva1l!ation is indicated. If the
initial cortisol concentration is less ~han 10 J.LgldL and/or the
"fowth hormone concentration'iS less than 5 nglmL at the
'"time of documented hypoglycemia, adrenal insufficiency
and/or pituitary insufficiency must be suspected, and a full
endocrine evaluation, including appropriate imaging studies,
should be performed.
'If the history is suggestive of hypoglycemia but the
physician is not present at the time of acute symptoms, a
careful history and physical examination may provide im­
portant diagnostic clues. A history of salt craving, a change
in growth velocity, access to insulin, and the relationship of
symptoms to time elapsed since the last meal are clearly
relevant. During physical examination, the presence of hepa­
tomegaly, hyperpigmentation, or neurological findings of
raised intracranial pressure provides clear direction for fur­
ther investigation. Ultimately, however, suggestive history
even in the absence of findings requires a 24-hour fast
under careful observation. If symptoms of hypoglycemia are
provoked, the steps are those described in Figure 11-5. An
algorithmic approach to hypoglycemia has been described98
and is detailed in Chapter 5. Rarely, an oral glucose tolerance
test may be helpful in suspected reactive hypoglycemia.
Treatment
The treatment of each major cause of hypoglycemia has
been discussed in its relevant section.
References
I. Cryer PE: Glucose homeostasis and hypoglycemia. In Wilson lD,
inherited in an autosomal dominant (AD) form differs clinically and
Foster DW (eds): Williams Textbook of Endocrinology, 8th cd.
genetically from the more common autosomal recessive form. Pediatr
Philadelphia, W.E. Saunders. 1992, pp. 1233-1253.
Res 37:587, 1995. Abstract
2. Gerich JE: Glucose counterregulation and its impact on diabetes
28. Stanley CA. Baker L: Hyperinsulinism in infancy: diagnosis by
mellitus. Diabetes 37:1608, 1988.
demonstration of abnormal response to fasting hypoglycemia.
3. Dinneen S, Gerich 1, Rizza R: Carbohydrate metabolism in non·
Pediatrics 57:702, 1976.
insulin dependent diabetes mellitus. N Engl J Med 327:707, 1992.
29. Finegold DN, Stanley CA. Baker L: Glycemic response to glucagon
4. Haymond MW: Hypoglycemia in infants and children. Endocrinol
during fasting hypoglycemia: an aid in the diagnosis of
Metab Clin North Am 18:211, 1989.
hyperinsulinism. J Pedialr 96:257, 1980.
5. Bier DM. Leake RD. Haymond MW, et al: Measurement of "true"
30. Levitt-Katz LE. Satin-Smith MS, Stanley CA, Cohen P: Insulin-like
glucose production rates in infancy and childhood with 6,6~
growth factor binding protein-I levels in the diagnosis of
dideuteroglucose. Diabetes 26:1016. 1977.
hypoglycemia due to hyperinsulinism. Pedlatr Res 37:538. 1995.
6. Chaussain JL: Glycemic response to 24 hour fast in nonnal children
Abstract.
and children with ketotic hypoglycemia. J Pedialr 82:438. 1973.
31. Gottschalk ME. Geffner ME. Yasuda PM, Shields WD: Reversal of
7. Chaussain JL, Georges P, Olive G, Job JC: Glycemic response to 24­
hour fast in normal children and children with ketotic hypoglycemia,
II: hormonal and metabolic changes. J Pediatr 85:776. 1974.
8. Seltergren G, Lindblad BS, Persson B: Cerebral blood flow and
factitious hypoglycemic coma. Gen Hosp Psych 8:291, 1986.
exchange of oxygen, glucose, ketone bodies, lactate, pyruvate and
33, Editorial: Meadow's and Munchausen. Lancel 1:456, 1983.
amino acids in infants. Acta Pediatr Scand 65:343. 1976.
34: Sperling MA: Insulin biosynthesis and C-peptide: practical application
9. Haymond MW, Ben·Galim E. Strobel KE: Glucose and alanine
Hypoglycemia in the Child 271
metabolism in children with maple syrup urine disease. J Clin Invest
62:398, 1978.
10. Pagliara AS. Karl IE, DeVivo DC, et al: Hypoalaninemia: a
concomitant of ketotic hypog.lycemia. J Clin Invest 51:1440. 1972.
[I. Pagliara AS, Karl IE. Haymond M, Kipnis DM: Hypoglycemia in
infancy and childhood. J Pediatr 82:365 (pt n, 558 (pt 2).
/973.
[2. Stanley CA. Baker L: Hypcrinsulinemia in infants and children:
diagnosis and therapy. Ad,' Pediatr 23:315, 1976.
13. Arnie! SA. Simonson DC, Sherwin RS, et al: Exaggerated epinephrine
responses to hypoglycemia in normal and insulin·dependent diabetic
children. J Pediatr 110:832, 1987.
14. Jones TW. Boulware SD, Kraemer DT. et a[: Independent effects of
youth and poor diabetes control on responses to hypoglycemia in
chi ia
5. Jones TW, Borg WP. Boulware SD, et al: Enhanced adrenomedullary
response and increased susceptibility to neuroglycopenia: mechanisms
underlying the adverse effects of sugar ingestion in healthy children. J
Pedialr 126: 171 f 995.
DeFeo P, Gallai V, Mazzotta G, et al: Modest decrements in plasma
glucose concentration cause early impairment in cognitive function
and later activation of glucose countelTegu[ation in the absence of
hypoglycemic symptoms in normal man. J Clin Invest 82:436,
1988.
17. Schwartz NS, Clutter WE, Shah SD. Cryer PE: Glycemic thresholds
for activation of glucose counterregulatory systems are higher than
the threshold for symptoms. J elin Invest 79:777, 1987.
18. KelT D, Diamond MP. Tamborlane WV, et al: Influence of
counterregulatory hormones. independently of hypoglycemia on
cognitive function, warning symptoms and glucose kinetics. Clin Sci
85:197, 1993.
19. Bloch CA. Clemons P, Sperling MA: PubertY;decreases insulin
sensitivity. J Pedialr [10:481. 1987, .'
20. Amiel SA. Caprio S, Sherwin RS, et aJ: Insulin resistance of puberty:
a defect restricted to peripheral glucose metabolism, J Clin
Endocrinol Merab 72:277, [991.
21. Thornton PS, Alter CA, Katz LE, et a1: Short- and long-term use of
octreotide in the treatment of congenital hyperinsulinism, 1- ~e.diatr
123:637, 1993.
22. Thomas PM, Cote GJ, Hallman DM, Mathew PM: Homozygo'Sity
mapping, to chromosome I I p, of the gene for familial persistent
hyperinsulinemic hypoglycemia of infancy. Am J Hum'Genet 56:416,
1995.
23. Glaser B. Chui KC, Anker R, et al: Familial hyperinsulinism maps to
chromosome II p 14-15.1. 30cM centromeric to the insulin gene.
Nature Genet 7:185, 1994.
24. Augilar-Bryan L, Nichols CG, WechSler SW. et a1: Cloning of the ~
cell high-affinity sulfonylurea receptor: a regulator of insulin
secretion. Science 268:423, 1995.
25. Thomas PM, Cote GJ, Wohlik N, et al: Mutations in the sulfonylurea
receptor gene in familial persistent hyperinsulinemic hypoglycemia of
infancy. Science 268:426, 1995.
26. Steiner DF, Philipson LH: Pas de deux or more: the sulfonylurea
receptor and K' channels. Science 268:372, 1995.
27. Thornton PS. Glaser B, Herold K, et al: Familial hyperinsulinism (HI)
microcephaly and developmental delay after cure of hyperinsulinemic
hypoglycemia. J Pedialr 117:432, 1990.
32. Price W A. Zimmer B. Conway R, Szekely B: Insulin-induced
from basic research. Am J Dis Child 134:1119, 1980. "

 The ~el\' En
IMPAIRED COUNTERREGULATION
OF GLUCOSE IN, A PATIENT
reF0rt erl5udes of [lintnc55 thJ.t la>ted one to [\\0 hours- ~lnd 0(­
WITH HYPOTHALAMIC SARCOIDOSIS
dlrn:d .lbout once a week. These cpisoJC5 wert' unn:brc-d to eat­
FRAN(,:OISE FERY, MD" PH.D., LAURENCE PLAT, M,D.,
PHILIPPE VAN DE BORNE, M.D., PH.D.,
EUE COGAN, M,D., PHD., AND JEAN MOCKEl, M.D., PH.D.
YPOGLYCEMIA stimulates rapid increases
H in the secn:tion of several hormones, in­
cluding cJteclmLmlines, glucagon, cortisol,
and growth hormone, th,lt act in concert to increase
the plasma glucose concentration. The chief role of
the central nervous system in triggering the release
of such coumerregulatory hormones during hypo­
glycemia is well recognized. The specific region of
the hypothabmus responsible for this process is
probably the ventromedial region, because bilateral
lesions or perfusion of f)-glucose into this region re­
duces the increases in plasma glucagon and catechol­
amines in response to h\'pogJycemia in rats.1.2 vVe
describe a patient \\ith a Iwpothalamic sarcoid infIl­
trate who had complete loss of the counterregula­
tory response to hvpogln:emia.
CASE REPORT
A 31-year-old \\'onlJll in whom ,arcoidosis had been diagnosed
ar the age of 27 ye,lfs Iud an IS-month history of secondary
amenorrhea, a I2-1l1()l1th hisron' ofm:ight gain orabout 20 kg,
and polydipsia and polyuri." ApJ.rt from. the presence: of obesitr
(weight, 86 kg; height, 171 em) ~nd J tendency toward hvporher·
ntia) the resnIts of the ph~'sicJl cxanlin<ltion were norn1aL .:\ W'lter~
deprintion test confirmed the ctL.1gnosis of central diabetes insip­
idus. Measurement' of pl.1Sma allLi uriDar), hormones disclosed
partial pituitar), insufiicienc,', with low pbsn1.l concentrations of
free thyroxine and corti"o! .md hvperprolactinemia. Pbsma lute­
inizing hormone .lnd ti,liide'"rill1uiating honl1one concentrations
were l1ornlai, but the rc~ponSC$ to gonadotropin-releasing hor­
fil0ne were: snpranonn.1L ;\l.lgnctic n:sonance 1:Hlaging ren::;.1kd ',1
nonnal pirnitltv gland bur multiple intiltrates in the brain,
inclnding one in tht: hypoth~tblIl1il,..- reglon. The diagnosis of sar­
coidosis was contirmed h)' the: findings of a high pbsma ;111­
giotemin~con\Trting (nZ,'m\! cOBeemration, bilateral hll~r lvm­
phadenopathy with r(ticul.lr interstitial intiirrates on computed
tOlllography of the el1'''t, ;lnd typical tindings on transbrunchiJl
biopsy, Treatment was inmated with 32 mg of methvlpredn;so­
lone per day, 100 p.g of len ,thYroxine per cta\', 30 JLg of dcsmo­
pressin acetate p~r day~ .Hltl :1 dHnbin~ltion of 30 j1.g of ethin~:l t':S~
From the Dcpanrnenb of Elldncrinolog.y (FE. LP,~ I.i\!J :.lnd Inrl:!'rnJ.j
Medicine (E.c.) and 11K Ttn'C[[CnSil)f1 Cliilic (PIl.t Hopit,l ErJ5n1c, Uni·
versite Lion: de Rntxdk.,>" Hru:>~\:b. Hdgimn. Addrc:>~ reprim n:qucs{!), to
Dr. FerY;.l[ tht: DcpJIu)1(,;l1t u-t' En,-iocrinolog:r~ H()pit~ll ErJSnh:-, 80~ routt:
de Lellnik~ B-l070 Brussels, Hdgium, or;u ftery@mt'd.ulb ...1c.be.
© 1999, Nbss~1ChI!$t:tts. l\-lcdtl';l! Sonety.
852 March 18, 1999
nd Jotllll.lI "f .\!cdicinc
~r_hE~~i J.lhJ 75 j.Lg of gestoden~ gin:n 011 tby~ 1 [() 21 of dH:­
men'trlul Llde ,'-ttcr one month of medll'lprcdni\"lol1c therapy,
pttlHun: m.lgneric resonance iJl1Jging showed compkrc IT\olu­
nun of .,11 the intiltr;w.:s except the one in the !l\'poth"I,lJllm, and
H rcmJHH.:d unchanged thereafter.
Dunn\! the next two vcars, the do,\~ of Jw.:tl1\·I{)n:dni~(Jlonc \\".1.s.
,"I ,khl.lll,- reduced to 6 ~lg per d"y "nd then repl~ce:d bv (orti,one
J":CLitl" t 37.5 Jng per d~}r). Shorr Iv thcrt:;'lfrcr~ the p~1tit.:fH h(:g.'Ul to
!n~ or and were nor accompanied by other symp[ool.\. -Jl1C
p~ttt,:nl',,, other syrnptorns were freqLlcnt cpi\odl",\ of hypcr­
l,,,trC[l\l,l r",ulting from i11lp"ired thirst perception, the cle\~dop'
fI1Lnr (;f cushingoid teatures, and progressive \\Tight lo:.~ of 10 kg.
Sh!..' \\"a' hO$pitalized for asseSSJ11t:nt of t:lintne~s. ()n adrnls~,on,
her bluod pressure and heart rate were normal but she still had
h'pothermi,L Laboratory tests were norm;:" except te'r ;1 plasma
glucos,' "uncentration (measured while she was LIsting) of ,,5 mg
pcr deciliter (3J mIllol per liter), which prompted tllrrher e,'alu·
,Ition uf ,e,eral aspects of glucose homeostasis, Dttring the c,·alna·
tion dl\.' pJ[ient continued to receive her usual tn:~urnent ti)[ hV'­
popituttJ.ri~ln, except that her n10rning dose of 25 n-lg of corti\)ol~e
.>Cerate "<.1$ ddayed until the end of testing on each studv li:ly,
METHODS
The ,tudies were approved by the ethics committee of the Fac·
ulty of \Iedicine of the University of Brussels, and the p"tient
gaw oral int()rmed consent,
l'bsnu glucose was measured by " glucose oxichse method
,Bochri'lger Mannheim, Mannheim, German),), and glycosvlated
hemoglobin 'Y:'S measured by affinity high· pressure liquid chroma­
tograph,' (Bio· Rad LaboratOries, Hercules, Calif.); the normal
r'.mge is ,LO to 6,5 percent. Plasma instllin, growth hormone, cor·
rislll, giuc"son, and pancreatic polypeptide were measured by
fadioll1u11unoa5sJ.y>i-5 Plasma and urinary c;]techobrnines \ven:
mc,lsurcd by high-pressure liquid chrom~tograph)' with dectro·
chen1icl! detection. 6
RESULTS
Base-line Hormonal Status
Plasma growth hormone concentrations were unde­
tectab!.::, and plasma cortisol concentrations, measured
apprminutdy 14 hours after the evening dose ofl2.5
mg of cortisone acetate, averaged 1.5 f-Lg per deciliter
HI I1mol per liter), whereas plasma glucagon .md
catecholamine concentrations and urinarv catechol­
amine excretion were within the normal ~ange,
Glucose Homeostasis
Blood glucose was measured at least eight times
per d;l\' throughom the 33-day hospitalization, and no
hypoglrcemia was detected. The lowest values oc­
cnrred on waking; the mean (±SD) of these "alnes
\\'as 51->::'::8 mg per deciliter (3,2::'::0.5 m11101 per li­
ter). The mean blood glucose concentrations twO
hOllr~ and four hours after a meal were 11 0::'::45 and
90::'::3;1 mg per deciliter (6.1::'::2.5 and 5.0::'::1.9 mmol
per liler), respectively. The mean value at 3 a.m. was
85:!:28 mg per deciliter (4]::'::1.6 mmo! per liter).
The glycosylated hemoglobin value was 5.3 percent.
During a three-day fast, the patient'S plasma glu­
cose concentration fell from 66 mg per deciliter (3]
1111nol per liter) to 50 mg per deciliter (2.8 111mol per
liter), and the plasma insulin concentration fell from
 BRIEF REPORT

Insulin injection Insulin injection

100
t t

200
80 c
(l)
160 o::=::
u'" g'E.
0
60
:::l 120 urn
20.
a a
80
:20 40

20
2500
15 2000
o::=::
.-
trn--­
"'-0
10
1500
o::t, 1000
u­
5 500
0
0

50
l]) 800 l])
c
0 40 c:
.;:
§ 30
600 ..r:::­
0.-
0 l]) E
::c c-'"

-e
..r:::
:;:
20
10
•••••••• •
400

200
._
~-
0
z
rn
0.0.

a 0 -~
0
~30 0 30 60 90 120 -30 0 30 60 90 120
Minutes Minutes
Figure 1. Changes in Plasma Glucose and Counterregulatory Hormone Concentrations Induced by the
Intravenous Administration of Insulin in the Patient (Solid Circles) and in 16 Patients with Panhypopi­
tuitarism (Open Circles).
The values in the patients with hypopituitarism are means (:!eSE), and the stippled areas are the mean
(:!eSE) values in normal subjectsJ The patient received 10 9 of glucose intravenously at minute 30. To
convert values for glucose to millimoles per liter, multiply by 0.0556; to convert values for cortisol to
nanomoles per liter, multiply by 27.59; 10 convert values for epinephrine to picomoles per liter, mUltiply
by 5.458; and to convert values for norepinephrine to nanomoles per liter, multiply by 0.0059.

12 fLU per milliliter (72 pmol per liter) to 5 fLU
millilirer (30 pmol per liter). No ketones were
recred in urine during the fast.
The response to the ingestion of 100 g of glucose
was abnormal and delayed, with peak plasma glucose
and insulin concentrations of 181 mg per deciliter
(10.1 m11101 per liter) and 120 fLU per milliliter (720
pmo! per liter), respectively, at 120 minutes. The
plasma glucose concentration was 42 mg per decili­
ter (2.3 mmol per liter) at 240 minutes and 38 mg
per deciliter (2.1 mmol per liter) at 300 minutes; the
corresponding plasma insulin concemrariorlS were
16 and 11 fLU per milliliter (96 and 66 plUol per li­
ter). The patient had no sympathoadrenal symptoms
during the hypoglycemia.
Effect of Acute Hypoglycemia on the Release
of Counterregulatory Hormones
After the intravenous injection ofO.IS U of human
insulin per kilogram of body weight, the plasma glu­
cose concentration decreased from 54 mg per deci­
liter (3.0 mmol per liter) to 29 mg per deciliter (1.6
mmol per liter) in a 3D-minute period. The patient
was then given 10 g of glucose intravenously. Despite
this injection, the plasm;} glucose concentration re­
mained low for the next 60 minutes, when she re­
ceived another lO-g injection of glucose and drank a
cola. This experimentally indw.:ed hypoglycemia did
not activate any hormonal counterregulatory response.
To be able to distinguish between deficiencies of
growth hormone and cortisol and a deficiency ofoth-

Volume 340 Number 11 853

-.
 The New and Journal of .vledicine

--- Insulin infusion-­ -- Insulin infusion -­

180
140

~
, ,
100
. , 60

~~~~~~~L-L-7r1000

800
o(/) 4 ,,
,, 600
-
U
~

o
3
2
1~
'
400
200
,
~~~~~+l-o
,
O~-r-r-r-r-.-..-~

0.6 ~--~--~~--L---+T300
.~
0.4 250 ro
200 ~
0.2
0.0
-30
•
• • , • • • • • •,,
~~~---'r---r---+L100
150
u
c
0)
CL

0 30 60 90 -30 0 30 60 90
Minutes Minutes
Figure 2. Plasma Glucose, Counter regulatory Hormone, and Pancreatic Polypeptide Concentrations
during a Hypoglycemic-Clamp Study in the Patient.

To convert values for glucose to millimoles per liter, multiply by 0.0556; to convert values for cortisol

to nanornoles per liter, mUltiply by 27.59; to convert values for epinephrine to picomoles per liter, mul­

tiply by 5.458; to convert values for norepinephrine to nanomoles per liter, multiply by 0.0059; and to

convert values for pancreatic polypeptide to picomoles per liter, multiply by 0239.

er cOlillterregulaton' hormones, we compared the pa­
tient's responses to hypoglycemia with those ob­
served under similar experimental conditions in 16
patients \vith p~mh\'popitllitarism (mean age, 42±10
years; body-mass index [the weight in kilograms
divided the square of the height in meters),
(Fig. l). In these patients the hypoglyce­
mia was corrected JS dl1ciently as in normal subjects,
despite deticiencies of cortisol and growth hormone
biu presum::tblv normal secretion of glucagon and
catechobmines.1{
Effect of a Hypoglycemic Clamp on the Release
of Counterregulatory Hormones
We performed ;1 In:poglycemic-damp study in the
patient to assess the response of counterregulatory
hormones. During a primed constant intravenous in­
fusion ofimulil1, ,lLiministcn.:d at a rate of 4.5 mU per
kilogram per milllHt: tt)[ 90 minutes, the plasma glu­
cose concentration decreJsed ti'om 59 per decili­
ter (3.3 I11mol per liter) to a mean of ±2 mg per
deciliter (l.7±O.1 rmnol pn liter) between minutes
30 and 90 (Fig. 2). There were no changes in plasma
cortisol, growth hormone, or glucagon concentra­
tions at any rime. Plasma epinephrine and norepineph­
rine concentrations did not change during the first
hour and then increased slightly, averaging 185 pg per
milliliter (1009 pmol per liter) and 178 pg per mil­
liliter (l.05 nmol per liter), respectively, during the
last 30 minutes of the clamp study. These values 'are
60 to 80 percent lower than those reported for nor­
mal subjects in whom hypoglycemia of a similar
magnitude was induced. 9 · 12 The plasma pancreatic
polypeptide concentration rose, reaching a maximal
value of 281 pg per milliliter (67 pmol per liter) at
90 minutes. Throughout the test, the patient had
moderate symptoms ofneuroglycopeni::t (slow speech
and drowsiness) but no sympathoadrenal symptoms.
Changes in Muscle Sympathetic-Nerve Activity
in Response to Hypoglycemia, Chemoreceptor-Reflex
Activation, and Baroreflex Deactivation
The patient's muscle sympathetic-nerve activity was
recorded continuously from the peroneal nave pos­
terior to the fibular head with a nerve-tramc analyzer
(Bioengineering Department, University of Iowa,
Iowa City) during the hypoglycemic-clamp study and
several other experimental conditions. Sympathetic
bursts were identified by inspection of the neurogram.
The sympathetic-nerve activity and heart rate tend­
ed to decrease during hypoglycemia (from 42 bursts
per minute to 30 bursts per minute and from 68 beats
per minllte to 63 beats per minute, respectively) (Fig.
3). In contrast, sympathetic-nerve activity increased
(to 50 bmsts per minute) during activation of the
chemoreceptor reflex by maximal end-expiratory ap­

854 . March 10, 1999

 BRIEF REPORT

Electrocardiographic Activity

Respiratory Activity

10 seconds

Sympathetic-Nerve Activity

Base Line Hypoglycemia Apnea Nitroprusside Infusion

Figure 3. Electrocardiographic, Respiratory, and Muscle Sympathetic-Nerve Activity in the Patient at Base Une and during Hypo­
glycemia, Maximal End-Expiratory Apnea, and an Infusion of Sodium Nitroprusside.
The plasma glucose concentration was 30 mg per deciliter 0.7 mmol per liter! during hypoglycemia. Sodium nitroprusside (0.4 f.L9 '
per kllogram per minute) was infused intravenously for 10 minutes.

nea, especially at the end of the period of apnea,
when stimulation of the chemoreceptor renex is
maximaL Barordlex deactivation bv an intravenous
infusion of SOdilll1 nitroprusside (0.4 /-Lg per kilogram
per minute) for 10 minutes also markedlv increased
the heart rate, to 94 beats per minute, and muscle
svmpathetic-nerve activity, to 84 bursts per minute.
Release of Counterregulatory Hormones
in Response to Other Stimuli
To determine whether the defect in the release of
counterregulatory hormone was specific tor hypo­
glvcemia, we evaluated the secretory capacity of the
pancreatic alpha cells and the response of the auto­
nomic nervous system to other stimuli_ A 30-minLite
intravenous intusion of arginine induced a 7.5-told
rise in tht: plasma glucagon concentration and a 10­
f(Jld rise in the plasma insulin concentration, The plas­
ma norepinephrine concentration increased sixtold,
and the heart rate increased trom 60 beats per min­
ute to 92 beats per minute once the patient stood
up after having been Iving down for 10 minutes.
Other Tests
The rectal temperature, monitored contiilllously
with a calibrated themnc probe, averaged 36.0±0.5°C.
Resting energy expenditure, determined by indirect
calorimetry, was 65 percent of the predicted value
adjusted tor sex, age) and lean body mass. I3
DISCUSSION
Sarcoid granulomas have a predilection for the hy­
pothaLm1lls, and patients with neurosarcoidosis fre­
quentlv present with panhypopituitarism resulting
from the loss of the ability of the hypothalamus to
release certain hormones. H These patients also com­
monly have central diabetes insipidus, impairment of
thirst, and alterations in body temperature associated
with a low metabolic rate_lS In addition to these symp­
toms, our patient had selective loss of the counter­
regulatory response to hypoglycemia.
The tact that our patient did not have hypoglyce­
mia during a three-day [;1st is not surprising, because
in normal subjects a selective, drug-induced deficien­
cy of any counterregulatory hormone lowers plasma
glucose concentrations aher three days of fasting but
does not calise hypoglycemiaY· On the other hand,
the patient'S late, persistent hypoglycemia after the
.ingestion of glucose is similar to that in patients with
a combined deficiency of epinephrine and g1ucagonF
Glucagon and epinephrine have a crucial role in

Volume 340 Number 11 855

 The New England Journ;ll of Medicine
the rccon:ry Irom imulin-induccd hypoglyccmi.l,
whereas cortisol and growth homlone Me of minor
importance.. I'.I~ The normal pattern of glucose re­
covery that we found in the patients with pituitary
insufficiency but presumably normal responses of
other countcrregulatory hormones8 further illustrates
this concept .md points to ddcctivc cltcchohmine
and g!uc.lgon responscs as rhe !"3.crors responsible for
the persisrcm hypoglycemia. after intravenous injec­
tion of insulin in our patient.
Besides stimulating the release of pituitary hor­
mones, the hypoglycemia-mediated activation ofhy­
pothalamic ccntcrs incrcases the activity ofperipheral
cholinergic and symp.lthetic neurons, which in nom1al
subjects m.lrkedly increase the heart rate and muscle
sympathetie-nen'e .lCtiviry.!U In our patient, both dle
heart rate and sympathetic-nerve activity decreased
during hypoglycemia, possibly as a consequence of
unopposed parasympathetic activation. The fact that
sympathetic retlexes involving brain-stem neurons
(activation of the chemoreceptor reflex and deactiv;l­
tion of the barordlex) were preserved suggests that
the defective counterregul.ltion was related to the hy­
pothalamic lesion. The findings of normal increases
in plasma norepinephrine and the heart rate during
the postural tcst provide further evidence of the in­
tegrity of the srmpathetic nervous system.
Although the role of the autonomic nervous sys­
tem in ll1edi;lting the secretion of glucagon during
hypoglycemia in humans is cOllIToversial,11,22 the com­
plete abrogation of glucagon release in our patient
during hypoglycemia, rogether with the large increase
induced by arginine, supports the concept that the
autonomic nervous system has a major role in the
alpha-cell response to hypoglycemia.
The glycemic threshold tor the ;lctivation of coun­
terregulation is about 65 mg per deciliter (3.6 mmol
per liter) in nonl1al subjecrs,"·12 but it is lower in
patients with intensively rreated diabetes mellitus
who have recurrent hypogiycemia,13 in patients with
insulinomas,lO and in normal subjects in whom hypo­
glycemia is induced 12 ro 24 hours before test­
ing.t I ,l1 Therefore, the possibility that the low plasm;l
glucose concentrations in our patient lowered the
drreshold for sympathOJdrenal activation CMillot be
mled out. However, this possibility is lullikely, be­
cause in normal subjects, after the plasma glucose
concenrration has been maintained at 52 mg per dec­
iliter (2.9 mmol per liter) fOl: 56 hours, stepwise low­
ering of the plasma glucose conccntr.lbOn to 45 mg
per deciliter (2.5 mnlol per liter) induces an increase
in the secretion of catecholamines and glucagon.24
A defect in rhe defense against hypoglycemia like
that fOlmd in our patient 111;1\' not be rare, but it is
ditlicult to diagnose because of the absence of sym­
parhoadrenal symptoms of hypoglycemia.
856 March 18, 1999
at' an indchlt'd £/) Dr. J:
lh·ters for the "'amm:menU off/fIrma
~iflurl!lJf.m
<,,,d pn"rrmry: po/ypfptide. til I};: EO. fttrLass, "",d Dr S.
RL"fetnjfji>r YI'l'iewmg the mn.ntucript all4 far hdp};,' fUMtstWns,
~nd to r.
Stokes arid M. Drqp'$ for editarial assistance.
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6. G..dn fA. SC\,''Lm. C. Urinary and. pla....ma catt:choumim:s and urin.uy
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D.M. The rok of <ldrc.ncrgi~ mcchanisms in the substrate ;and hormonal r('­
sp<>nS< til ilJ>ulin-induceu hypoglycCUll;, in man. J Clin In,·c.t 1976;58:7­
15.
S. targ A. t;rialc WE, K:lruil PC, Stabler TV, Roots LR. CouJl(cr
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popi'Ulrary p.1ti<n.s. Horm Mcub Res 1994;26:276·82.
9. Dagogo· jJCk 5E, CraJi: $, Cryer PI:. Hypoglycemia·associated amo­
I nomlt:: tailure in iIl.~ll1in -dependent dhlbete5 mellitus: recent anre.("cdcnt
hypogly'(cmia reduces <luronomic R"Sponscs to.. symptoms of; .mu defense
against subse'luent hvpogl!"cnria. J Clm In,"",,! 1993;91:819·28.
10~ Mirr.llcou A~ ~A.ndli C, Veneman >r~ et at Re"'crsibl1iry ofunawArencss
of h\,><:>gIyccm.ia in plticnts with insulino=. .N Engl J Med 1993;329,
834-9.
11. 1)a"5 SN, Shavers C~ flavis R~ Costa H Prcvemioll or an increase 10
pl.l$nu (ortisoI during hypoglycemia preserves subsequent countcr.n.::gub· ~
"'{" ["'1',,0"'_'. ) Clin In,,"'t 1997;100:429-38.
12_ Vcnc:mJ:n T~ Mitrak.ou .0\" Mobn 1\1, Cryer P, Gcri~h J. rnuuc(lon of
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Dialx"" 1993;42:1233··7.
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17. Tsc TI', ClutTer WE, $hah SD, Cryer PI'. Mechanisms of postprandial
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litus. Di"""[c, 1988;37:1608,lZ
19. Cryer PI::. Glucose COUDtcrregulmon: prevention and com..'Crion of
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nerves iOCR""" durin!,- hrpoglyccmi,. DUhctL'S1986;35:1124·9.
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in..';.ulin-itlliucco h~1X)g1yt:cmi.a in women. Diabetes 1997~46:801-7.
22. Hil~ted J~ r:r.wJseo H, Holst H", ChrisI:C:nsen NJ, ~idscn SL. Pl.t<:,ma
glUClgOQ ,:md glucose recovery mer hypoglyL"Cmia: the effect of tool ';1U­
t<~l"mi<:: bl<x:k.ldc. ,\era Eudocriuol (Cnpcnh) 1991;125:460·9,
23. "'-mid $.\. Sherwin RS, Simonson DC, Tambo,l.n.: W\'. Effi:cr of
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24. Bayk Pl. o.:.lgy Rl, O'Connor AM, Kempers SI'. Yeo it.>" QU.llls C
fu.Upurion in br:llu glucose Hptake following n.:",-urn:n( hrp()gl~·ccm.ia. Pmc
Natl ACdd $,; l! <; A 1994;91:9352·6.
OOZI·972XJO II$O:UIOlO
Tht: .Jnumal ofCIiOltaJ Endoa1mlliJg}- & Metabolism
CnpynJ?:ht © 20m by Thl" EndocnnE.> Soc!ety
Oral Glucose Augments the Counterregulatory
Hormone Response during Insulin-Induced
Hypoglycemia in Humans*
RUBINA A HEfYfULIA, WILLIAM V. TAMBORLANE, TONY Y-Z. MA, FRAN RIFE,
ANDROBERT S. SHERWlN~
Department of Pediatrics, Internal Medicine and the General Clinical Research Center, Yale University
Ekhool of Medicine, New Haven, Connecticut 06520; and Department of Pediatrics Baystate Medical
Center, Springfielt.i. MaEsachusetts 01199
ABSTRACT
It has been suggested that the counterregulatory hormone (eRH)
response to acute hypoglycemia is triggered via glucose sensors sit­
uated in either the hypothalamus or the portohepatic area. If the
latter were critical during hypoglycemia, one would anticipate that
ingestion ofglucose, by rdising glucose levels in the portal circulation,
should attenuate CRH responses previously described in animal stud­
ies. To evaluate the effect ofraising portal, but not peripheral, glucose
levels during insulin-induced hypoglycemia, we performed hypogly­
cemic clamp studies in five healthy adult males on two occasions. On
one occasion, subjects received oral glucose lOG) (25 g) during hypo·
glycemia; and on one occasion, noncarbohydrate-containing drink of
equal volume, while maintaining plasma glucose at 55 :!: 2 mgldL
(3.08 mmolfL).
As a result, there were no sigoificant differences in systemic plasma
I NSULIN-INDUCED HYPOGLYCEMIA RESULTS in a
prompt and coordinated counterregulatory hormone
(CRH) response resulting from hormonal and neural acti­
vation (1). Although CRH responses to hypoglycemia have
been extensively studied (2), the putative mechanisms of
hypoglycemia detection have not been fully elucidated. In­
deed, studies in animal models have provided conflicting
results as to whether the preeminent locus of hypoglycemia
detection resides in the brain (3-5) or in the portohepatic
area (6-8).
A variety of experiments in rats suggest that the ventro­
medial hypothalamtLs (VMH) plays the central role in stim­
ulating catecholamine and glucagon responses to hypo­
glycemia (9-12). On the other hand, epinephrine and
norepinephrine responses were reduced in studies in dogs in
which systemic hypoglycemia was induced by insulin while
euglycemia was maintained within the portal vein by direct
intraportal infusion of exogenous glucose (6). The suppres­
sion of antiinsulin hormones by entry of glucose into the
portal system might facilitate the switch from the fasted to
Received July 20, 2000. Revision received October 16, 2000. Accepted
October 25, 2000.
Address all correspondence and requests for reprints to: Rubina A.
Heptulla, M.D., Department of Pediatrics, Division of Endocrinology,
Baystate Medical Center, 3300 Main Street, Springfield, Massachusetts
011'1'1. E-mail: rheptul!d@yahoo.com.
~Supported by NIH Grants DK-20495, HD-30671. RR-06022, and
RR-125.
645
Vol H6. No.2
Prilitt'd til U,S.A
glucose levels between the two hypoglycemic clamp studies, and basal
CRH concentrations were alS() similar. As expected, there was a brisk
rise in all CRH during the control (hypoglycemia+noncarbohydrate
drink) study. ill the experimental study, administration of OG
(hypoglycemia +OG), to raise intraportal glucose levels during systemic
hypoglycemia, did not attenuate CRH responses. illdeed, OG enhanced
the rise in epinephrine, glucagon, and GIl.
Increases in cortisol and norepinephrine did not differ between the
two studies.
Therefore, our data suggest that increasing the level of glucose in
the portal vein above that in the systemic circulation, during hypo­
glycemia, enhances (rather than suppresses) eRH responses. Thus,
ingestion of glucose may reverse hypoglycemia directly by provision
of substrate, as well as indirectly by stimulating countereguiatory
mechanisms. (J Clin Endocrinol Metab B6: 645-648, 2001)
fed state and serve to limit postprandial hyperglycemia (13).
However, during hypoglycemia, it might have the adverse
effect of reducing the capacity of oral glucose (OG} feeding
to promote glucose recovery.
In comparison with animal models, there is paucity of data
available regarding the locus of hypoglycemia detection in
human subjects. In an experiment in nature, it has been
recently shown that the counterregulatory response to hy­
poglycemia was markedly attenuated in a patient with hy­
pothalamic sarcoidosis (14). Experiments examining the in­
fluence ofportal vein glucose sensors in human subjects have
been impeded by practical difficulties in trying to prevent
reductions in glucose in the portal system while lowering
plasma glucose systemically. In the current study, we have
attempted to overcome this obstacle by introducing glucose
into the portal vein via the oral route, while a stable and
reproducible hypoglycemic stimulus was induced systemi­
cally using the hypoglycemic damp technique (15). Surpris­
ingly, CRH to hypoglycemia tended to be increased rather
than diminished by ex; administration, in compariSon with
control hypoglycemia studies without OG.
Materials and Methods
Subjects
We studied five healthy, nondiabetic, lean (body mass index, 24 + 1
kg/m') altult males (age, 26 + 1 yr) on two occasions. All subjects were
seen in the outpatient department of Yale General Oinical Research
Center, in the morning, after a 10- to 12-h overnight fast. A detailed
646 HEPrULLA ET AL. .JCF: & M • 2001
Vol 86. ~o. 2

10)
·400
a>
9-J c ·200
.-.-- Hypo - non-<:arbohydralB drink E0.. :000
8') --0- Hypo + oral glucose
a>~

70 ­
.£E
0..___ 800

:!2 wO>
0..
600
OJ &J !1!~

E 400
E
ID
SG 200
~ C1l
(/)
0 40
a:: a
0
.2
CJ 30
30.-----------------------------------------,
20
25 ~ Hypo + non-carbohydrate drink
*
a> - 0 - Hypo .. oral glucose
10 c 20
o
0 r- --,-----[ I r--,-----r--~-,---
E ·.5
o 20 40 60 80 100 120 140 160 180 0::1
.co,
Time (min) .c::l '0
~~
FIt;. 1. Data are expressed as means::':: SE for plasma glucose con­ o
centrations. Shaded circles represent the hypoglycemia study along ~ o
",-jth noncarbohydrate drink, and open circles represent data of the
hypoglycemia and OG study where patients received 25 g OG at 80 t25 g of oral glucose
m..in. To convert plasma glucose values to millimoles per liter, multiply
200
by 0.056.
ISO
medical history and physical examination were obtained for each sub­ 160 *
ject. All subjects were in good health and taking no medications. The c 140
0_
nature and purpose of the study was explained to them, and written CJLJ 120 *
0--..
voluntary consent to participate in the study was obtained. The Human 00> 100
Investigation Committee of Yale University School of Medicine ap­ ~.3
C) 80
proved the study protocols.
60
40
Procedures
20
To produce a standardized hypoglycemic stimulus, we performed a 0
one-step hypoglycemic clamp procedure, as described by Simonson IT 20 40 60 80 100 120 140 160 180
af. (16), in all the subjects. Two cannulas were inserted, one in an an­ Time (min)
tecubital vein for infusion of insulin and glucose and the other in the
dorsal hand vein for blood sampling. The hand was placed in a heated FIG. 2. Data are expressed as means::':: SE for plasma epinephrine,
(65 degree C) box to arterialize the venous blood sampling (17). The GR, and glucagon concentrations. Shaded circles represent the hy­
subjects were given continuous iv infusions of insulin (120 mU per poglycemia study along with noncarbohydrate drink, and open circles
square meter of body-surface area per nUnute), and target plasma glu­ represent data of the hypoglycemia and, OG study where patients
cose values were achieved by varying the rate of infusion of 20% glumse received 25 g OG at 80 min. To convert plasma epinephrine values to
in water. Plasma glucose was measured, at the bedside, at 5-min inter­ picomoles per liter, multiply by 5.458.
vals (Beckrn.an Coulter, Inc. glucose analyzer, Beckman Coulter, Inc.,
Fullerton, CAl. In all the subjects, plasma glucose concentrations were 4.2% (at 11.1 ng/mL); glucagon, 8.3%; and cortisol, 8.6%. For epineph­
stabilized between 90 and 108 mg/ dL (5.0 and 6.0 mmol/L) before the rine and norepinephrine, the interassay variability levels were 17% and
induction of hypoglycemia. The length of the euglycemic phase was 60 16%, respectively. The intraassay variability values were 6% for epi­
min in all subjects, the plasma glucose concentration was reduced to nephrine and 4% for norepinephrine.
approximately SO-55 mg/dL (2.8-3.1 mmol/L), over a period of ap­
proximately 10 min, by reducing the rate of glucose infusion. Plasma
Statistical analysis
glucose concentrations were then maintained at that level for a further
100 min. The plasma glucose concentra tions and hormone responses in the two
During one hypoglycemic clamp study, a load of 25 g glucose studies were compared by ANOVA with repeated-measures design.
was given orally as a cola-flavored drink at 80 min, the time when When there was a statistically significant group-time effect, two-tailed
plasma glucose concentration had reached approximately 50 mg/dL paired t tests were used to localize the effects. Differences were regarded
(2.8 mmol/L). During the other clamp, patients were given a caffeine­ as statistically significant if P values were less than 0.05.
free diet cola equal in volume and color to the OGdrink at 80 min
of the study (0-60 min euglycemia, 60-180 min hypoglycemia, 80 min Results
administration of the oral drink)
Plasma insulin concentrations in the basal state 18 ::':: 1 vs.
M eas urements 7::':: I/LU/mL (57 ::':: 7 vs. 50 ::':: 7 pmol/L)] and during the
Blood samples were taken at 10-to 20-min intervals for measurements insulin infusion [178::':: 8 vs. 190::':: 10 /LU/mL (1277::':: 57 vs.
of plasma insulin, epinephrine, norepinephrine, cortisol, glucagon, 1363 ::':: 70 pmol/L)] did not differ between the studies, re­
and GH. gardless of whether or not OG was given during hypogly­
Plasma catecholamines were measured by high-performance liquid cemia. As shown in Fig. 1, there were also no significant
chromatography using an electrochemical detector; and plasma insulin,
differences (P < 0.8) between the two studies, with respect
GH, cortisol, and glucagon were measured by double-antibody RlAs. All
the samples from each subject were analyzed in a single assay, and all to basal glucose concentrations or in the fall in plasma glu­
tests were run in duplicate. The intraassay variations for the GH were cose levels during both hypoglycemic clamps. Thus, virtu­
 OG AND COUNTERREGULATORY HORMONE ACTION 647

ally an identical hvpoglycemic stimulus was achieved,
whether or not the subject ingested OG.
As shown in Fig. 2, basal concentrations and the early
(60-80 min) rise in plasma epinephrine, GH, and glucagon
levels were similar in both studies. However, during the last
60 min of the hypoglycemic clamp with OG, the plasma
concentrations of epinephrine 11212 ::':: 145 pg/mL (6605 ::'::
790 pmol/L)J, GIl (23 ::':: 3 Jl.g/L), and glucagon (134 ::':: 23
ng/L) rose to values that were .signifiGmtly higher than
plasma epinephrine [824::':: 181 pg/mL (4490::':: 986 pmol/L),
P < 0.015], GH (14 ::':: 3 fJ.g/L,.P < 0.015), and glucagon (86
20 pg/mL, P < 0.(5) levels observed during the hypoglyce­
mic clamp without ex:; (Table 1 ).In contrast, as shown in Fig.
3, administration of OG did not significantly affect plasma
cortisol (P < 0.08) or plasma norepinephrine (P < 0.16) re­
sponses to hypoglycemia.
Discussion
The present investigation was undertaken to examine the
role of glucose sensors within the portal venous system in
regulating CRH responses to hypoglycemia in human sub­
nisms underlying alterations in CRH responses induced by
ex:;. However, with respect to GH, it is noteworthy that
ghrelin (a GH-releasing acetylated peptide from the stom­
ach) has been shown to stimulate GH release independent of
regulation by hypothalamic GHRl-I (21). Previous studies by
Donovan et al. (7, 8) did not examine changes in GH levels
during their hypoglycemia and portal euglycemia experi­
ments. The increased glucagon responses with OG could be
mediated by neural connections linking the portal venous
system with the YMH (22). There may be other mediators of
glucagon secretion (like endothelin-1) that may account for
the increased glucagon response (23). In addition, the study
design with hyperinsulinemic euglycemia before hypogly­
40
35
- - - Hypo + non-carbohydrate alnk
30 -0-- Hypo + oral glucose
tEc 25

jects. Animal experiments from our own laboratory have '0 20

suggested the YMH is responsible for detection of hypogly­ Jl
(5 15
cemia (9-12); whereas other studies have shown that main­ 0
tenance of euglycemia in the portal vein suppresses the CRH 10
response to systemic hypoglycemia (6). In this study, we
attempted to produce similar experimental conditions in hu­ 5
man subjects by using the glucose clamp teclmique to cause
0
an identical reduction in systemic plasma glucose concen­
trations during two studies: one with and one without in­ 600
gestion of OG. Relatively large iv doses of insulin were used
in both studies so that precise control of systemic glucose =E 500
- - - Hypo + non-carbohydrate drink
concentrations could be achieved in the face of ingestion of
OG in amounts (25 g) within the range that might be used
~ -0-- Hypo + oral glucose
<l>
c:: 400
clinically to treat hypoglycemia. ~
Oral glucose wa<; ingested during the experimental study 0.
<I>
after mild hypoglycemia was induced and CRH responses c:: 300
a.
were initiated. Practical considerations precluded measure­ e0
ments of glucose concentrations in the portal vein in these z 200
subjects. However, in animal studies, ingestion of 40g OG
leads to a rapid rise in glucose concentration and appearance
'en"
E
en 100
of approximately 27 g glucose intraportally within 15--30 min 0::
of glucose ingestion (18-20). Under these conditions, one
might estimate that we would have observed a detectable 0
o 20 40 60 so 100 120 140 160 180
reduction in plaSJIla epinephrine concentration vs. control
TIme (min)
experiments if a portal glucose sensor was operative in hu­
mans. However, ingestion of OG enhanced, rather than re­ fIG. 3. Data are expressed as means ± SE for plasma cortisol and
duced, the adrenomedullary responses to hypoglycemia. norepinephrine concentrations. Shaded circles represent the hypo­
glycemia study along with noncarbohydrate drink, and open circles
Moreover, the ingestion of ex:; also increased GH and glu­ represent data of the hypoglycemia and OG study where patients
cagon responses to hypoglycemia. received 25 g OG at 80 min. To convert plasma norepinephrine values
This study was not designed to investigate the mecha­ to picomoles per liter, multiply by 5.458.

TABLE 1. Counterregulatory honnone response to hypoglycemia with and without oral glucose

Basal Peak Basal Peak

Hypo + 824 :!:: 181 0.7 0.1 14.5 ± 3.
Hypo + OG 27 ± 7 12.12± 14.5 0.7 ± 0.1 22.6:!:: 3.
Pvalue NS 0.015 NS 0.015
NS. Not significant.
648 HEPI'ULLA ET AL.
cemia induction may have also contributed to the reduction
in glucagon response (24).
Regardless of the mechanisms involved, the data support
the contention that the increased CRH responses were the
result of absorption of glucose into the portal system We
controlled for nonmetabolic effects of volume and taste by
having the subjects, during the control study, ingest a de­
caffeinated drink of the same taste and volume as they in­
gested during theexperiroental'stu<;ly. Moreover, the pattern
of a 4O-min delay in response for all·three hormones is more
consistent with the time requi:r~l:to absorb ing~'Sted glucose
into the portal circulation than what might be expected from
a more immediate neural response. It is also noteworthy that
these rt.'Sponses were very consistent and selective, so that
statistical significance was readily observed with a relatively
small number of subjects. Ingestion of ex:; did not seem to
alter plasma cortisol and norepinephrine responses to hy­
poglycemia, but further studies in larger numbers of subjects
are needed to evaluate these responses more definitively.
In conclusion, although the results of the present study
were surprising, the implications regarding clinical manage­
ment of hypoglycemia are potentially important. Further
studies are needed to determine whether similar effects are
observed in patients with type 1 diabetes with or without
autonomic neuropathy. If so, provision of ex:; to patients
with diabetes during hypoglycemic events may have benefits
that go beyond the simple provision of substrate.
References
1, Gerich JE. Campbell PJ. 1988 Overview of counterregulation and its abnor­
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'.

 TABLE OF CONTENTS

,
.Diabetes. Vol 48. Issue 3 584-587. CopHight
. t !999 by American Diabetes Association
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l'ubMcd Citation
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Chronic hypoglycemia and diabetes impair Alert me when:
'counterregulation induced by localized
2-deoxy-glucose perfusion of ~he ventromedial
hypothalamus in rats
MA Borg, WP Borg, WV Tamborfane, ML Brines, GI Shubnan and RS Sherwin

Department oflntemal Medicine, Howard Hughes Mcdicallnstitule, Yale University School of Medicine, New Haven, Connecticut

06520-8020, USA

Previous studies have demonstrated that the ventromedial hypothalamus (VMH) plays a critical role in sensing and
responding to systemic hypoglycemia. To evaluate the mechanisms of defective counterregulation caused by
.iatrogenic hypoglycemia and diabetes per se, we delivered 2-deoxy-glucose (2-DG) via microdialysis into the VMH to
produce localized cellular glucopenia in the absence ofsystemic hypoglycemia. Three groups of awake chronically
catheterized rats were studied: I) nondiabetic (with a mean daily glucose [MDG] of 6.9 mmolll) BB control rats (n =
5); 2) chronically hypoglycemic nondiabetic (3-4 weeks, with an MDG of2.7 mmol/I) BB rats (n = 5); and 3)
moderately hyperglycemic insulin-treated diabetic (with an MDG of 12.4 mmolll) BB rats (n 8). In hypoglycemic
'rats, both glucagon and catecholamine responses to VMH glucopenia were markedly (77-93%) suppressed. In
diabetic rats, VMH 2-DG perfusion was totally ineffective in stimulating glucagon release. The epinephrine response,
'but not the norepinephrine response, was also diminished by 38% in the diabetic group. We conclude that impaired
:counterregulation after chronic hypoglycemia may result from alterations ofthe VMH or its efferent pathways. In
diabetes, the capacity ofVMH glucopenia to activate the sympathoadrenal system is only modestly diminished;

however, the communication between the VMH and the alpha-cell is totally interrupted.

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~~9strl!C11I£l.1UJ):;\tJ
• Cryer, P. E. (2001). Hypoglycemia-associated autonomic failure in diabetes. Am. J. Physiol. 281: Ell1S-1I21
fAb::;tractl [Full Tc.:Ql
• Shu.m, K:, Inouye, K., Chan, 0., Mathoo, J., Bilinski, D., Matthews, S. G., Vranic, M (2001). Effects of
antecedent hypoglycemia, hyperinsulinemia, and excess corticosterone on hypoglycemic counterregulation. Am.
J. Physiol. 281: E455-465 {,i\b,;tractllF!llL!S;ill
• Segel, S. A, Fanelli, C. G, Dence, C. S., MarkhaIfi, Videen, T. 0., Paramore, 0. S., Powers, W ..J"Cryer,
P. E. (2001). Blood-to-Brain Glucose Transport, Cerebral Glueose MetabolisII1, and Cerebral Blood Flow Are
Not Increased After Hypoglycemia. Diabetes 50: 1911-191716bst!actJ IFull Text} ..
• Heptulla, R A, Tamborlane, W. V., Ma, T. Y.-Z., Rife, E, Sherwin., R S. (2001). Oral Glucose Augments the
Counterregulatory Honnone Response during Insulin-Induced Hypoglycemia in Humans. J Clin Endocrinol
Metab 86: 645-648 [Abst!.'!£U LEL1lI Text!
• Santizo, R A, Koenig, H. M, Pelligrino, D. A (2001). {beta}-Adrenoceptor and nNOS-derived NO

interactions modulate hypoglycemic pial arteriolar dilation in rats. Am. J. Physiol. 280: 562H -568

 - ..'''.''''lltL, 1 . J " 1 <:;1<:;1',- V llldHIJl, D , l'd\\.:W, jL, IVIOlilLaHil, IC, VilUCJ\), .Vl. (":U!J!-'1. j"anereallc JJoITIt;odornam
TmDScription Factor IDXllIPF I Expressed in Developing Brain Regulates Somatostatin Gene Tmnscription in
Embryonic Neural Cells. J Biol. Chern. 275: 19106-19114 [i\hHLW::t] lrull. c"ll
• Fantin, V. R, Wang, Q., Lienhard, G, E" Keller, S. R (2000), Mice lacking insulin receptor substrate 4 exhibit
mild defects in growth, reproduction, and glucose homeostasis. Am. J Physiol. 278: 127E-133
L6bstructj !Ill!1 Text)

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• Search Medl ine for articles by:
Perfusion Blocks Counterregulation during Borg.:"!, A. Ii ;>h.u!l!ia11.Ji.L
j>-';ystemic Hypoglycemia in Awake Rats • Alert me when:
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• f)ownlnad t() (itatlQl1:Vl;1!l;tg<";[
Monica A. Borg·, Robert S_ Sherwin·, Walter P. 8?rg*, William V.

Tamborlanet , and C.erald I. Shulman *

* +
Yale Univenity School of Medicine, Department of Internal Medicine and - Department of Pediatrics., New Haven,
Connecticut 06520

The ventromedial hypothalamic nucleus (VMH} is necessary for the integrated hormonal response to hypoglycemia. To
determine the role of the VMH as a glucose sensor, we performed experiments designed to specifically prevent glucopenia in
the VMH, while producing hypoglycemia elsewhere. We used awake chronically catheterized rats, in which local VMH
glucose perfusion (100 mM or IS mM ofD-glucose) was combined with a sequential euglycemic- hypoglycemic clamp. In
twO control groups the VMH was perfused either with (a) an iso-osmotic solution lacking glucose, or with (b)
.nonmetabolizable L-glucose (100 mM). During systemic hypoglycemia glucagon and catecholamine concentrations
promptly increased in the control animals perfused with either 100 mM L-glucose or the iso-osmotic solution lacking
glucose. In contrast, glucagon, epinephrine and norepinephrine release was inhibited in the animals in which the VMH was
'perfused with D-glucose; hormonal secretion was partially suppressed by the VMH perfusion with 15 mM D-glucose and
'suppressed by - 85% when the VMH was perfused with 100 rnM D-glucose, as compared with the control groups. We
'conclude that the VMH must sense hypoglycemia for full activation of catecholamine and glucagon seeretion and that it is a
key glucose sensor for hypoglycemic counterregulation. (J Clin. Invest. 1997.99:361-365.)

~Key words: VMH; microdialysis; hypog~vcemia; glucagon; epinephrine

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'J
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l 86: 645-648 [1\~st@~J ffiJll Tt!tl
• Beverly, 1. L, De Vries, M. G., Bouman, S. D., Arseneau, L M. (2001). Noradrenergic and GABAergic systems in
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1 doundy, V. A., Cincotta, A. H. (2000). Hypothalamic adrenergic receptor changes in the metabolic syndrome of
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• Levin, B. E., Dunn-MeynelJ, A. A., Routh, V. H. (1999). Brain glucose sensing and body energy homeostasis: role in
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;Dial'>etes. Vol 44, Issuc 2 180·1 R4, Copyright © 1995 by American Diabetes Association t. Similar articles found in:
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JLocal ventromedial hypothalamus glucopenia triggers

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,. Alert me when:
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,counterregulatory hormone release ,. Download to (i!"tilmM;lI1ager
1

;WP Bo.-g, RS Sherwin, MJ During, MA Borg and GI Shulman

[)epanmcnt of Inlemal Medicine, Yale University School 0f,Medicine, New Haven, Connecticut 06520·8020.

To lest the hypothesis that nuclei of the ventromedial hypothalamus (VMH) playa key role in the detection of
20unterregulatory responses to hypoglycemia, we'delivered the glucopenic agent 2-deoxyglucose via bilaterally placed
microdialysis probes into the VMH of conscious, chronically catheterized rats. The goal was to produce cellular glucopenia
localized to the VMH. The volume of brain tissue exposed to 2-deoxygJucose was determined by adding
[3HJ2-deoxyglucose to the dialysate; its distribution in cerebral tissue was almost exclusively limited to the VMH. Rats with
microdialysis probes placed into the frontal lobes served as a control group. Local perfusion of2-deoxyglucose (but not
glucose) into the. VMH caused a prompt twofold increase in plasma glucose in association with a striking elevation of
plasma glucagon (3.5-fold), epinephrine (30-fold), and norepinephrine (3.5-fold), No effect was seen when 2-deoxyglucose
,was delivered into the frontal Jobes. We conclude that glucopenia localized to the VMH triggers the release of
counterregulatory hormones that defend against hypoglycemia. Thus, the neurons that sense glucopenia may be simated in
theVMH.

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[£\bs!@£!] [full IJ:.hll
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86: 645-6481Abstract] [Full Textl
• Beverly, 1. L., De Vries, M. G., Bouman, S. D., Arseneau, L. M. (2001). Noradrenergic and GABAergic systems in
the medial hypothalamus are activated during hypoglycemia. Am. J. PhysiOl. 280: 563R-569 [Abstract) [Full Text)
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"
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Soriano, L. R., Strack, A. M., Viall, V. (1999). Starvation: Early Signals, Sensors, and Sequelae. Endocrinology 140:
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Oetenninant of the Impaired (beta}-Cell Secretol)' Response after Protein-Energy Restriction in the Rat.
Endocrinology 139: 3382-3389 L-il?ma~tl U'll[j Jex,!}
• Beverly, J. L, de Vries, M. G., Beverly, M. F., Arseneau, L M. (2000). Norepinephrine mediates glucoprivic-induced
increase in GABA in the ventromedial hypothalamus of rats. Am. J. Physiol. 279: 990R-996 It\bst@f!l [Full Text)
• Boundy, V. A., Cincotta, A. H. (2000). Hypothalamic adrenergic receptor changes in the metabolic syndrome of
genetically obese (ob/ob) mice. Am. J. Physiol. 279: 505R-514 [Abstract] [Ful! Text]
• Levin, B. E., Dmm-Meynell, A. A., Routh, V. H. (1999). Brain glucose sensing and body energy homeostasis: role in
obesity and diabetes. Am. J. Physiol. 276: 1223"&-1231 filll§tract] [Fuil Text}
• Jackson, P. A., Pagliassotti, M. J., Shiota, M., Neal, D. W., Cardin, S., Cherringtol4 A. D. {I 997). Effects of vagal
blockade on the counterregulatol)' response to insulin-induced hypoglycemia in the dog. Am. J. Physiol. 273:
1 178E-1 188 filllstract] [Full Text}
• Borg, M. A., She:rwin, R. S., Borg, W. P., Tamborlane, W. V., Shulman, G.1. (1997). Local Ventromedial
Hypothalamus Glucose Perfusion Blocks Counterregulation during Systemic Hypoglycemia in Awake Rats. J. Clin.
Invest. 99: 361-365 [Abst@ill [Full Text]

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publication. A footnote indicating that the data have been
deposited will he added to the paper.
Protein and Nucleic Acid Sequences: Authors should submit
manuscripts containing nucleotide sequences to GenBank/
EMBL/DNA Data Bank of Japan (DDBJ) at GenBank, National
Center for Biotechnology Information, 8600 Rockville Pike,
Builamg 38A., Room 8N-803, Bethesda, MD 20894 USA Phone:
(301) 496-2475. E-mail (submissions):gh-sub@;.mc!)i.nJm.nih.gov.
E-mail (information):info@ncbi.nlm.nih.gov.An ·accession num­
ber must be obtained before the manuscript is printed.
Structures of Oligonucleotides: Authors must deposit
these data directly with the Nucleic Acid Database at
deposit@ndbserver.rutgers.edu.
ture determinations must submit to the Protein Data Bank at
Brookhaven National Laboratory all structural data required
to validate the discussion, including x-ray amplitudes and the
derived atomic coordinates. For nuclear magnetic resonance
stlUctures, data deposited should include resonance assign·
ments and all restraints used in structure determination and
the derived atomic coordinates for both an individual Structure
and a family of acceptable structures.
Corresponding Author. The name, address, telephone and
"fax numbers, and e·mail add.ess of the author .esponsible fo.
.eviewing the page proofs should be provided on the title page
of the manuscript. Manuscripts should be sent to PROCEED·
INGS OF THE NATJONAL ACADEMY OF SCfENCES, 21Of-Consti­
tuHon Avenue, N.W., Washington, DC 20418 USA. or by
courier or express mail to 1055 Thomas Jefferson Street. N. W ..
 The Editoria1 Policies and Practices of The Journal of Clinical Investigation
The Journal ofClinicallnvesligation is published monthly by
the American Society for Clinical Investigation. The editorial
i policies and practices of The Journal are established by the
editorial board under authority of the Society Council. The
editor is nominated by the Council and elected by the Society.
The associate editors are appointed by the editor in consulta­
tion with the Council. The editor and associate editors form the
editorial board. which meets weekly to consider manuscript
decisions and general editorial policies. The editorial board is
aided in these tasks by a board of consulting editors, which
includes members of the editonaf committee of the Society.
and other scientists with appropriate interests. A complete list­
ing of members of the Editorial Board and Board of Consulting
Editors can be found in each issue of The Journal.
Scope oIpllblications. The JOllrnal strives to publish origi­
nal articles of the highest quality pertaining to all aspects of the
biology and physiology of the human organism, in health and
disease. The terms "biology" and "physiology" in this context
are to be interpreted in the broadest possible sense, to be inclu­
sive of all types ofresearch on humans. Studies in animals or in
vitro systems are also considered if they are directly relevant to
normal or abnormal human biology. While recognizing that
studies on humans can be limited by ethical, moral, and practi­
cal considerations, The Journal wishes to publish work that is
rigorous enough to have a high likelihood ofstanding the test of
time, i.e., studies whose conclusions are likely to remain valid.
Apart from general quality and scientific rigor, the other im­
portant criteria for manuscript acceptance are originality and
interest to the broadly based readership of The Journal. Thus,
certain articles that are otherwise scientifically sound may be
rejected because they are felt to lack novelty and/or breadth of
appeal. While iss).les such as novelty and interest can be matters
of subjective opinion, the board relies upon the reviewers, and
on its own broadly based expertise to render such priority judg­
ments in the fairest possible manner.
Types ofarticles. Apart from specially solicited "Perspec­
tives" and Editorials, The Journal considers original manu­
scripts in "Regular" and "Rapid" categories. The latter are
distinguished by definitive and exceptional scientific content
and by size limitations (five printed pages or less). During ini­
tial review, both types of papers are handled similarly, although
relative priority is given to Rapid manuscripts. In addition,
Rapid manuscripts receive expedited publication after accep­
tance, thus cutting short the time from original submission to
final publication.
Rilles ofsubmission. Manuscripts may be submitted from
any country, and must be in clear, concise, readable English.
All submissions should report original research that has not
been published or submitted for publication elsewhere, in any
form other than a simple abstract of 400 words or less. The
format should follow that indicated in the ""Instructions to Au­
thors" from the most recent January or July issue, and be ac­
companied by the manuscript submission form from the same
issue. All listed authors should have seen and approved at least
a prefinal version of the manuscript, all personal communica-
J. C1in. Invest.
into the following categories are unlikely to be accepted. unless
© The American Society for Clinical Investigation. Inc.
there are exceptional reasons:
0021-9738/94/01/v/03 $2.00
I. Purely methodological reports, or development of as­
Volume 93, January 1994, v-vii
says, with no application to a specific question.
tions and unpublished observations should have been ap­
proved by the individuals cited, and one copy of all "in press"
manuscripts cited must accompany the submission.
Rcviell' process. Soon after a manuscript is received, the
editor assigns it to an associate editor whose expertise is appro­
priate. In a small proportion of cases, papers deemed to be of
poor quality or inappropriate content. or showing scrious defi­
ciencies. may be rejected outright after initial review by the
editors. A few others may be rejected outright because it is
evident from their content that the likelihood of the eventual
acceptance is essentially nil. In all such cases. the manuscript is
evaluated by two or more of the editors before the decision is
made. For the rest of the manuscripts, the associate editor pro­
vides a list of potential expert reviewers, which may include
some suggested by the authors. Requests by authors to exclude
certain potential reviewers are also honored. if the reasons for
the request appear reasonable. However, in fields with a limited
number of experts, a request for exclusion based solely on
Ucompetition" may be difficult to honor. Two expert reviewers
who agree to review the manuscript are identified, and copies
are sent to them by overnight express mail. Reviewers are asked
to screen the manuscript immediately, assign a priority based
on content, originality, quality, relevance, and interest, and
promptly fax back their opinion. Meanwhile, the associate edi­
tor will have formed an independent opinion. If at least two of
the three individuals involved feel that the manuscript is highly
unlikely to achieve a publishable priority, it will be returned to
the author with some basic reasons for the negative decision.
However, if at least two of the three feel that it does merit
further consideration, the review will proceed without preju­
dice regarding the initial screening decision. If it is fell to be
appropriate, a third review may be obtained. It is important to
note that this modified review process is not very much differ­
ent from the traditional one. It simply allows the reviewer to
make an early judgment as to whether the overall content and
conclusions of an article make it highly unlikely that he or she
will eventually recommend acceptance. In such an instance,
the reviewer is permitted to provide a short-form review which
may (but will not necessarily) result in a rapid rejection of the
article. The detailed rationale behind this screening process has
been described elsewhere (I), and is aimed at providing an
expedited review process that is fair, and in the best interests of
both authors and reviewers.
Final decision process and criteria. Manuscripts that pasS
initial screening will receive a complete review, with additional
reviewers being sought if necessary. When complete reviews
are received, the manuscript is discussed at the weekly editorial
board meeting. Discussions are based upon the reviewers' com­
ments to the authors, confidential comments from the re­
viewers to the editors, additional opinions of consulting edi­
tors, and the opinions of the editor who handled the manu­
script. Authors are informed of the final decision by mail. and
appropriate comments from the reviewers and the editors are
appended (note that reviewers and editors do not always pro­
vide comments meant for transmission to the authors). Final
decisions are made mainly on the basis ofscientific merit, nov­
elty, and mechanistic insights. In general, manuscripts that fall
Editorial v
] 2. Simple descriptive surveys, with no specific question
and no substantial discovery.
3. Reports of new reagents, clones, or antibodies, without
characterization and/or application to specific questions.
i 4. Single case reports, unless they provide thoroughly docu­
mented and important mechanistic insights, or illuminate a
novel principle.
5. Findings that are largely repetitive of previously pub­
lished information.
6. Findings that represent a minor incremental advance
over previous information.
7. Descriptions of a humal1l)omologue of a gene or cDNA
that has been previously cloned in another animal system, with
no unique or unusual features.
8. Development or use of a new drug closely related to a
previously described one, wiih no remarkably different feat1.Jres
or advantages.
9. A genetic abnormality or polymorphic variation in the
DNA sequence of a gene with many previously well character­
ized mutations, and no new biological insights arising from the
study.
Revisions, rejections, and reblillals. Occasionally, manu­
scripts may be accepted with no changes. Others (the top 10­
15%) are provisionally accepted, pending minor revisions. The
remainder are rejected. In some cases (LO-20%) the authors of
rejected manuscripts are invited to resubmit, if they can ad­
dress the major criticisms by revision and/ or additional experi­
mentation. However, such revised manuscripts are subjected
to careful reexamination, and no guarantee is made about their
ultimate acceptability. To avoid long-drawn-out negotiations
that can be counterproductive for all concerned, only one ma­
jor revision of each manuscript is permitted. Revised manu­
scripts must be accompanied by a formal statement signed by
all authors, indicating that they have seen and approved of the
contents, and that no substantial part of the manuscript is
under consideration or already published elsewhere.
A decision for rejection is final, and a rejected manuscript
cannot be simply revised and resubmitted for consideration.
unless a revision was specifically invited. However, if the au­
thors believe that a serious scientific error has occurred during
the review, a letter of rebuttal may be sent, explaining the rea­
sons why the board should reconsider the decision. All such
rebuttals are taken very seriously and their handling typically
takes several week:;.lfappropriate, the matter may be taken up
with the initial and/ or additional reviewers, and with consult­
ing editors. Final decisions regarding rebuttals are made after
discussions at the editorial board meeting. In general, rebuttals
that challenge rejections based upon priority alone are rarely
successful, since the assignment ofsuch priority is necessarily a
matter of opinion. In 1992, approximately 5% of rebuttals were
successful in reversing the original decision. It should also be
noted that disposition of rebuttals cannot take precedence over
the timely handling of regular manuscripts.
As indicated above, a rejected manuscript cannot be simply
revised according to reviewer comments and resubmitted for
consideration. However, if authors choose not to submit the
work elsewhere and make major new advances that go far
beyond the original submission, they may consider submitting
a new manuscript for complete de novo review. In such a cir­
cumstance, a new submission form and fee will be required,
and the manuscript will be assigned a new submission number.
If the authors wish, they may refer to the prior submission,
vi .4. P. J 'ark;
particularly to indicate how the present version is different.
The editors handling the manuscript wiJl make a preliminary
determination if the work is indeed substantially advanced
beyond the original submission. 1fso, a complete review cycle
will proceed, as described for a new manuscript. If not, the
manuscript may be subject to early rejection after discussions
with the editorial board.
Time from submission to decision and publication. The edi­
torial office strives to minimize the time from submission to
decision, which currently averages approximately 40 days.
However, this time period varies widely between individual
manuscripts, and delays can occur for many unforeseen rea­
sons. The most common type of delay occurs when many of
the reviewers who are initially contacted refuse the opportunity
to review the manuscript. In other cases, one of the reviewers
who had originally agreed to review the manuscript may take
an inordinately long time to do so, or even change his/her
mind about doing the review at alL The Journal makes every
effort to avoid these situations. However, authors must recog­
nize that the reviewers do a completely voluntary service for
The Journal. Thus, the editorial office can do no more than
request the reviewers to be prompt, and remind them when
they are tardy. However, if a reviewer does not respond after
three clear reminders. the possibility exists that he/she may be
deliberately holding back the manuscript for improper reasons.
In this case, a third review will be solicited as soon as possible.
or a decision may be rendered with a single review. Once a
paper is accepted, every effort is made to publish it as soon as
possible.
Manllscripts sllbmilledftom the host institution or by edi­
tors. The weekly editorial board meeting is possible only be­
cause all of the editors are geographically clustered in one area..
This, along with the number of consulting editors from the
same area, could raise concerns of provincialism or bias. To
avoid any possible appearance of favoritism, manuscripts sub­
mitted from the host institution (including those from
members of the editorial board), are handled by guest editors
from outside the institution. The editorial office staff work with
the guest editors to ensure that these manuscripts are handled
in a similar fashion to those from outside the institution.
Reviewer anonymity. Except in very unusual circum­
stances, the identity of the associate editors and reviewers in­
volved is kept confidential. Although cogent arguments for an
"open" review process can be made, the board believes that, on
balance. the anonymous review process has merits that justify
its continuation. The same is true of subsequent interactions
between the authors and the editorial board. Since The Journal
is a written medium. such interactions are required to be
carried out in writing. Verbal communications (except for sim­
ple questions to the office staff concerning manuscript status)
are kept to a minimum because past experience indicates that
written communications provide more logical. clearly thought
out, and well-documented interactions.
Polic)' regarding telephone calls. Questions by authors con­
cerning the status of manuscripts are handled by the JCI office
staff. In the interests of keeping the office functioning
smoothly. The Journal requests that authors keep such calls to
the minimum possible. To avoid the possibility ofmisinterpre­
tation and/or errors in verbal communication, the office staff
does not provide extensive details about manuscript status
(e.g., exact number of reviewers, exact status of reviews., the
names of the handling editors, or a predicted time to final deci­
sion). In case of complex problems with manuscript handling,
the matter is referred to the Managing Editor or the Assistant
Managing Editor.
The Associate Editors do not take calls from the authors
concerning decisions or other matters directly related to manu­
scripts. All such enquiries should be addressed to the Editor in
the form of a written communication, which will be forwarded
with the complete file to the appropriate Associate Editor. The
Associate Editor and/or the editorial staff will then communi­
cate with the authors by letter or by teJephone, as appropriate.
The following are the major reasons [or the policy of not ac­
cepting phone calls. . corporate entities to gain access to confidential work under
1. The Journal is a written medium, and all communica­
tions concerning its activities must be recorded in written form.
This is important not only for uniformity and fairness, but also
because it provides a written record for other editors and/or
office'staffwho may handle the manuscript in the future.
2. The Journal receives manuscripts from all over the world.
At present approximately 40% of submissions are from foreign
countries, The Editorial Board feels that it would be unfair if
only authors in certain time zones and with low costs ofcalling
have direct access to the editors to discuss their manuscripts.
3. For fair and proper handling of enquiries the Associate
Editor must have access to the entire manuscript file at the time
of making the assessment. However, the individual editors do
not keep set office hours at the main Jeloffice, where the files
are kept. A written enquiry allows the entire file to be pulled
and sent to the Associate Editor for a proper evaluation.
4. Manuscript decisions are made during the weekly meet­
ing of the Editorial Board. Enquiries and rebuttals are also
discussed at the meeting. Thus, communication with the au­
thors is most useful after an initial evaluation of the written
material has been made by the Associate Editor, and the matter
has been discussed by the Editorial Board.
"Preapproval" ofpapers and selective 'rast-track pllblish­
ing. .. With increasing competitiveness in science, some jour­
nals have begun to foster the notion that "first is best." It has
now become commonplace for authors to contact journal edi­
tors ahead of time to see if their work can be given special
consideration because of its perceived importance or popular
appeal. As a matter ofgeneral policy, the leI does not provide
such advance determinations. This is because a preliminary
judgment based upon a phone call or an abstract is prone to
significant error. Also, the assessment of "importance" and
"interest" usually requires opinions from experts in the particu­
lar field, i.e., peer review. The Journal also does not promise
expedited review of selected manuscripts. Selecti vely accelerat­
ing peer review fora specific manuscript by prearrangement
increases the possibility of inadequate evaluation of the work
and imparts to the reviewers and editors an implicit bias in
favor of acceptance. Also, other authors whose papers were
accepted earlier following conventional review may have their
publication dates unfairly delayed. Furthermore, the authors
seeking a fast track may be motivated by the realization that
other similar work b already under review elsewhere. If they
gained this information by being confidential reviewers of the
other work, The Journal may then be aiding and abetting an
injustice.
The peer review system followed by the JeI attempts to
treat all manuscript submissions in as fair and uniform a fash­
ion as possible. While the editors make every attempt to expe­
dite the overall speed of review (the current average time for
review is 40 days), they must do so without compromising the
quality and fairness of the process. Fast track publishing may
be appropriate for certain types of papers; however, this can be
achieved by using the "Rapid" category, which is available to
all authors who wish to compete on a level playing field, with
defined rules. Finally, it is noteworthy that important and
novel work often experiences a "spontaneous acceleration"
during review. This is because the reviewers are usually excited
about reviewing such work and tend to do so more quickly.
Legal status ofsubmitted manuscripts. Recent attempts by
review have made it necessary to define the legal status of man­
uscripts submitted to The Journal. All such manuscripts are
deemed to be the property of the submitting author(s) until
such time as a decision is made and the copyright is officially
assigned by the authors to the Society. However, by submitting
the manuscript to The Journal, the authors agree to su bject it to
the confidential peer review process outlined in the foregoing
pages.
Scientific integrity. Duplicate publication and outright sci­
entific fraud are rare events that nevertheless have a very seri­
ous impact on the integrity of the scientific community. If the
editorial board uncovers possible evidence for such problems
in submitted manuscripts. it will first confront the correspond­
ing author to complete confidence, to allow an adequate clarifi­
cation ofthe situation. Ifthe results ofsuch interactions are not
satisfactory, the board will contact the appropriate official in
the institution from which the manuscript originated. It wili
then be up to the institution in question to pursue the matter
appropriately. Depending upon the circumstances, The Jour­
nal may also opt to publish errata, corrigenda, or retractiGns,
which will be linked to the original article in the Index
Medicl/s.
A lesser problem arises when a member of the scientific
community disagrees strongly with the methodology and/or
conclusions of an article that has been published in The Jour­
nal, but does not allege actual fraud. The Journal does not have
a "Letters to the Editor" section to publish a communication
regarding this. Therefore, the concerned individual should ei­
ther contact the authors directly to discuss the disagreement. or
allow the natural corrective mechanisms ofscience to settle the
issue with time.
In the final analysis. the peer review process has its inherent
flaws, and in the eyes of the author the outcome of a manu­
script review may not always be equitable. However, in the
absence of a better system, expert refereeing by peers remains a
tried and true method for the scientific community to maintain
its own standards ofexcellence. The editors of The Journal are
com mitted to promoting the quality and fairness ofthis process
in every way possible, as well as enhancing its speed and effi­
ciency. The board remains open to suggestions from the scien­
tific community of ways to improve this process and to sustain
the excellence of The Journal.
Ajit P. Varki
for the Editorial Board
References
I. Varki. A. P. 1992. The times they are a·changin.Changing wilh the times.
J. Clin Invesl. 89:721-722.
EdilOria! vii
 Res Ipsa Loquitur. Positive and Negative Trends Affecting the Jet Editorial

1 2000

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1910 1980 1990

Figure 4. National Institutes of Health research funding trends from

1970 to 1992. Annual NIH budget as a percentage of total federal or
national spending on health care.
1!1113 lfit '985 ,m 1987 1988 19119 '990 1991 liKl2 , _

Figure J. JCI manuscript submission and publication rates. Figures e

z
for 1993 are projected.
~
w
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en
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o ministration research '
0
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200 '/I.
~
y (5 1980 to 1992. Annual
20

10
100
Z

t 1970 1980 1990

VA research budget as
a percentage of total VA
spending on medical
care.
0 a
1981 1989 1991 1993
Table I. JCl Manuscript Submissions by COlJrttryo/Origin
Figure 2. Days from submission to first decision (all manuscripts)
and to final publication (accepted manuscripts). Accurate data not Percent of lotal 5ubmissioll$
available before 1987. Figures for 1993 are based on data from man­
uscripts received through October 1993. 1987 1992

Australia 1.6 1.3

Canada 2.9 3.5
II) 80 France 2.5 4.5
...ii:.
r­
Germany 2 3.4
(.)
II)
Israel 1.3 1.1
:::> 60 Italy
z 1.8 2.4
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1:::= us
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Japan
Netherlands
Sweden
SA
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1.5
8.8
2.0
J.7
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:::> Switzerland 2.0 2.0
iii
United Kingdom 2.0 3.4
~ 20
USA 71.2 60.8
If.
Figure 3. leI manuscript
submissions: US 11'5. nOll- All others 5.6 5.1
0 Us. Data not available be­
1915 1985 1995 tween 1983 and 1986. Accurate cJata not available before 1987.

The Journal of Qinical Investigation, Inc. Ajit Varki. Editor .

Volume 93. January 1994. I Michael Held. Managing 'Editor

Res Ips(1 LoqllilUr: P(Jsilil'e (111(:/ Negatil'e Trends Ajfrciing ,he JCI 1
Editorial
Diabetes, Diabetes, and the American Diabetes
Association
Philip E. Cryer
N
ow at the end of my tenure as editor of Diabetes,
I wish to offer some personal thoughts about our
journal, the disease we oppose, and our Associa­
tion. I am pleased, but not satisfied, with our
journal. I am disappointed, but not surprised, that the disease
remains recalcitrant. I am concerned, but optimistic, about
our Association. The challenges are great, but so are the
opportunities.
DIABETES: PAST. PRESENT, AND FUTURE
National Center, including, but not limited to, Susan Lau,
Established in 1952, Diabetes has become a leading, arguably
Peter Banks, Matt Petersen, Stacey Wages, and Jennifer
the leading, diabetes-oriented research journal in the world.
Gross. Finally, I am grateful to Dr. R. Paul Robertson, the
The history of the journal was summarized by my predeces­
previOUS editor, for his advice and support and for· handling
sor (1).
submissions to the journal from the editors and their ass0­
Diabetes will remain at Washington University in S1. Louis
through 1996, its second 5-year tour at this institution.
However, I will step aside as editor at the end of 1995. Dr.
Julio V.Santiago. the hardest working of the hard-working
associate editors, will serve as editor through 1996. The
rationale for this change included the perception of a poten­
tial conflict between my role as editor of Diabetes and my
role as president-elect and then president of the American
Diabetes Association, as well as the increasingly time-con­
suming extra-university demands of the latter. After all, I still
have a rewarding day job that I hope to retain! The Associ­
ation has selected Dr. Gordon C_ Weir as the new editor for
the term starting in 1997. I wish Dr. Weir and his colleagues
well.
I am grateful to many individuals for making my term as
editor both enriching and pleasurable. They include our
authors. The quality of a scientific journal cannot exceed the
quality of the science submitted to it for publication. They
also include our reviewers, including previous and current
members of the editorial board. Those invaluable volunteers
provide critical expert advice to both authors and editors. It
has been a particular pleasure to work with a diverse group
From the Division of Endocrinology, Diabetes and Metabolism and the General
Clinical Re5e'arch ('A!llter and Diabeles Research and Training ~nter, Washington
University &hool of Medicine, St. Louis, Missouri.
.Address correspondence to Dr. Philip E. CJ:yer, Division of Endocrinology,
DIabetes and Metabolism, Washington University School of Medicine (Box 8121),
660 S. Euclid Ave" St. Louis, MO 63110.
Received for publication 16 June 1995 and accepted in revised form 30 June
1995.
IDDM, insulin-dependent diabetes mellitus; NlDDM, non-insulio-<lependent dia­
betes mellitus; SI, Systente International.
of talented and committed associate editors, who, with their
individual areas of scientific expertise, have taught me a
great deal and, with their concern for science and the
journal, have made my job easy. The associate editors are
Drs. David D. Chaplin, Michael L. McDaniel, Mike M. Mueck­
ler, M. Alan Permutt, Julio V. Santiago, and Josepli R.
Williamson in St. Louis and Dr. George S. Eisenbarth in
Denver. Special thanks are due Mary Weis, who as editorial
assistant continues to lead the St Louis editorial office so
capably, Karen Muehlhauser and Lisa Chandler in that office
and the professional publications staff at the Association'~
ciates. . .
It is appropriate to mention some measures. of journal
performance. Perhaps the most informative descriptive sta­
tistic is the time between manuscript receipt and the initial
editorial decision, a combined measure of the performance
of the editors, the reviewers, and the editorial office (as well
as the various telecommunication and mail services). For
regular publication manuscripts, the mean :t SD (range)
receipt to initial decision interval decreased from 56 :t 24
days (1-154 days) in 1992, our first year, to 44 :t'22 days
(1-173 days) in 1993 (P < 0.001). It was unchanged at 44 :t
23 days (1-125 days) in 1994. Although it is too early to
calculate the final 1995 figure, it does not appear to have
changed substantially. These are similar to the 1989-1991
intervals (1). Thus, this measure'seems to have been reduced
to its minimum using the current editorial methods. Perhaps
new methods can reduce it further.
The interval from receipt to initial (often final) decision for
rapid publication manuscripts also decreased from 15 :t 10
days (1-66 days) in 1992 to 12 :t 7 days (1-33 days) in 1993
(p < 0.05), was unchanged at 12 :t 8 days (1-30 days) in
1994, and has not changed substantially in 1995. Thus, these
receive substantially expedited review. The trade-off is that
there is usually only one outside reviewer and written
critiques are not provided routinely.
The acceptance-to-publication interval is one quantifiable
measure of th.e activity of the National Center publications
office. These intervals were 132 :t 33 days (84-270 days) in
1992, 130:t 17 days (95-266 days) in 1993, and 120 ::!:: 17 days
(86-212 days) in 1994 for regular publication ~anuscripts.
Surprisingly, to me at least, diskette submission has not
shOltened this interval substantially. It has, however, re­
 EDITORIAL
duced the cost of publication of the journal considerably.
Parenthetically, Diabetes is income-neutral to the Associa­
tiOR Its costs are covered by revenue (including subscription
fees) not public support income. The intervals for rapid
1 publication manuscripts have been somewhat shorter. Ef­
forts to further shorten the interval for the latter have been
initiated, but I am chagrined to acknowledge a similar
promissOry note concerning the acceptance to publication
interval for both regular and rapid publications 4 years ago
(1).
Aside from understandable disagre.ements about negative
editorial decisions, there has ~~n rather little conflict be­
tween authors and the editors over the past 4 years. We have
stayed the course with respect to Syslkme International (SI)
units in principle, although we have probably missed some
violations in practice. The SI unit table was u{Xlated and
modifie.d to include suggested numbers of significant digits.
Indeed, my irritation with use of excessive significant digits
has been a source of amusement to some of the 'a5Sociate
editors. Perhaps the issue that continues to raise the most
discussion is our use of the figure of 6.0 to convert insulin
concentrations from tLU/ml (mUll) to pmolfl. The difficulty,
of course, is in converting biological activity to molar units.
V0lund et al. (2) found 1.0 unit to correspond to 6.0 nmol
human insulin by quantitative amino acid analysis. This is
very close to that of 5.95 nrnol/U determined by bioassay (3).
The change to the 6.0 conversion figure in the SI unit table in
Diabetes was made in 1989 by the previous editors. We have
continued to use that figure.
Changes in journal practices have included applying the
Association's duality of interest policy to authors as well as
editors, accepting manuscripts on diskette, increasing page
charges (to $50), and refonnatting the journal. The latter
made Diabetes more readable in my opinion. Readers seem
not to have noticed; we received only one (positive) com­
ment from a reader.
Diabetes has strict editorial page limitations, 1,680 pages
per volume (year). The average was 1,686 pages published
per year in 1992-1994. This necessitates rather high rejection
rates: 68-71% for regular publications and 72-88% for rapid
publications in 199'2-1994. Nonetheless, editorial decisions
have been and con,tinue to be baSed on the editors' scientific
judgment. Indeed, page counts have not been made known to
the associate editors, wh.Q With my concurrence have made
the vast majority of the editorial decisions, until after a given
volume is completed.
Particularly in view of limited editorial space, the editors
believe that Diabetes should focus on publication of original
research. Thus, the bulk of the editorial pages have been
committed to regular and rapid publications. There were 203,
218, and 195 regular publications and 15, 14, and 6 rapid
publications in 1992, 1993, and 1994, respectively. One,
usually invited, Perspective in Diabetes has been published
each month. We do not have a regular letter to the editor
section, although some (five in 1992-1994) letters that clarify
articles published in the journal or speak to controversial
issues stimulated by a published paper have been published.
We have published very few editorials.
Clearly, the journal can be improved. Overall, however, I
Jelieve D'iabetes is not broken and does not need to be fixed
in a major way. It will be interesting to learn the views of the
new editors. Over its 44-year history, Diabetes has become a
widely respected and influential subspecialty jOlUTlal. Its
1 1352
Science Citation Index "impact factor" (basically a measure
of the relationship between the number of citations of
articles in a journal and the nunlber of articles publiShed in
that journal) was 5.861 in the most recent year for which data
are available (1992). That was higher than that of any other
diabetes-oriented journal (range 5.261-0,111). Diabetes is a
successful venture of the American Diabetes Association.
DIABETES: PERFECTED INSULIN REPLACEMENT
Were it not for hypoglycemia, diabetes would be easy to
treat. One would simply give enough insulin (or, in those
individuals with enough residual endogenous insulin secre­
tion, sulfonylurea) to lower plasma glucose levels to or
below the nondiabetic range. However, hypoglycemia is a
reality. Glucose is a critical metabolic fuel, particularly for
the brain. With current treatment methods, hyperinsuline­
mia., whether exogenous or endogenous, sufficient to lower
plasma glucose levels carries the risk of lowering them too
far. Hypoglycemia is, indeed, the limiting factor in the
management of diabetes (4). Because of that reality, the
management of diabetes is currently much more complex
than lowering plasma glucose concentrations.
In theory, we could eliminate iatrogenic hypoglycemia if
we were to learn to replace insulin in a truly physiological
fashion, to prevent, correct, or compensate for compromised
defenses against developing hypoglycemia, or both. The
latter notion is based on the premise that it is the integrity of
the glucose counterregulatory systems--in their broadest
sense, including both phYSiological defenses against falling
plasma glucose concentrations (primarily decrements in
insulin and increments in glucagon and epinephrine) and
symptom-initiated behavioral defenses (e.g., food ingestion)
-that determines whether or not relative or absolute ther­
apeutic insulin excess results in an episode of hypoglycemia
(4). This concept likely explains the frequency and sever­
ity of iatrogenic hypoglycemia Those people with the most
compromised glucose counterregulation, e.g., most people
with fully established insulin-dependent diabetes mellitus
(IDDM), suffer iatrogenic hypoglycemia, including severe
hypoglycemia, most frequently. However, it seems unlikely
that this concept explains all iatrogenic hypoglycemia. The
former notion, physiological insulin replacement, is attrac­
tive because of its conceptual simplicity despite its current
impracticality.
Insufficient insulin secretion is the proximate cause of
diabetes. Relative resistance to insulin action is a feature of
the pathophysiology of both non-insulin-dependent diabetes
mellitus (NIDDM) and IDDM. It may well playa role in the
pathogenesis of NIDDM (5-8) and is relevant to the manage­
ment of NIDDM to the extent that measures that reduce
insulin resistance (e.g., caloric restriction and exercise)
result in improved glycemic control. Nonetheless, regardless
of the degree of insulin resistance, diagnosable diabetes does
not develop until insulin secretion declines and becomes
insuJficient to meet the metabolic demand (5-8). Thus,
relative or absolute insulin defiCiency is a prerequisite of
clinical diabetes.
Ideally, we would like to prevent a given disease. If we
cannot prevent it, we would like to cure it If we can neither
prevent nor cure the disease, we would like to manage it
effectively. If the disease is, like diabetes, the. result of
insufficient secretion of a hormone, effective management
DIABETES, VOL 4·1, DECEMBER lDn~
 p.e.CRYER

implies physiological replacement of that hormone. Few disease and the leading cause of blindness in working-age
chronic homlone deficiency diseases can as yet be prevented adults, of nontraumatic lower extremity amputations, and of
'or cured, but several can be managed effectively. For exam­ end-stage renal disease requiring dialysis and transplanta­
ple, in appropriate doses, thyrorine ingestion in hypothyroid­ tion. The cost of all health care for people with diabetes was
ism mimics normal thyroid hormone secretion and produces estimated to be $105 billion, 15% of all health care expendi­
physiological hormone replacement. That is not the case for tures, in the U.S. in 1992 (10). Notably, less than one-half of
insulin replacement in diabetes. All current insulin replace­ one percent of that sum was spent on diabetes research.
ment regimens are imperfect compared with normal insulin Founded in 1940 as a professional society, the American
secretion. Insulin-treated (or sulfonylurea-treated) people Diabetes Association is now a remarkable amalgamation of a
with diabetes have periodic hypoinsuI!nemia with its result­ leading professional society and a leading voluntary health
ant hyperglycemia and, not infrequently, periodic hyperinsu­ organization. Our Association has grown substantially and in
linemia with its risk of hypoglycemia Parenthetically, even if many ways matured over the past few years. Our volunteers
drugs that enhance sensitivity to endogenous insulin (in a have been highly successful in fund raising; our annual
generic sense) are shown to be safe and effective, it is most expenditures, about two-thirds derived from public support
unlikely that they would produce euglycemia that is sus­ and the remainder from revenue, are now about $90 miJlion.
tained over a lifetime of NIDDM, since NIDDM is typically a The mission of the American Diabetes Association is a
progressive disease (9). Insulin replacement would ulti­ noble one: to prevent and cure diabetes and to improve the
mately be necessary in most, if not all, patients who survived lives of all peopJe affected by diabetes. The Association
to that point in the course of their diabetes. provides organizational and fund raising support and an
Perfect insulin replacement would correct all of the met­ array of programs, organized around the themes of research,
abolic abnormalities of diabetes that are known to be information, and advocacy, to the diabetes community.
clinically relevant, perhaps with no risk of hypoglycemia. It Among these programs, only research will prevent and cure
would alleviate all symptoms and prevent acute metabolic diabetes. Research has inlproved the lives of all people
complications, almost assuredly prevent the specific chronic affected by diabetes, and it will continue to do so.
complications (retinopathy, nephropathy, and neuropathy) Although our research awards and grants budget is small
(10), and likely reduce atherosclerotic risk Aside from the relative to federal research expenditures, our Nationwide
need for therapeutic intervention, it would approximate cure Research Program is unique and makes a difference. It
of the disease just as thyrorine replacement does in hypo­ supports the training of the next generation of diabetes
thyroidism. FurthemlOre, a truly safe and effective method of investigators through Career Development Awards, Mentor­
- ..Derfected insulin replacement would undoubtedly be appli­ Based Postdoctoral Fellowships, and Medical Student Fel­
~le to people with NIDDM as well as those with lDDM. lowships. Furthennore, it supports the testing of innovative
At a minimum, perfected insulin replacement would re­ ideas through investigator-initiated Research Awards, Clini­
quire rninute-to-rninute plasma glucose-regulated insulin de­ cal Research Grants, and Uons SightFirst Research Awards.
livery into the circulation. (To the extent that factors in Finally, it supports selected areas of special research inter­
addition to glucose are relevant to physiological regulation est, including the Association's Genetics of Non-Insulin­
of insulin secretion, even that might not provide perfect Dependent Diabetes (GENNID) study, designed to facilitate
insulin replacement.) Several approaches are on the horizon identification of the gene abnormalities responsible for sus­
(some have been there for a rather long time). These include, ceptibility to NlDDM, and the Diabetes Prevention Trial I,

·Ii
but are not necessarily limited to, development of a dosed­ designed to determine if lDDM can be prevented. Thus, to a
loop insulin delivery system (sensor, ~omputer, pump), large extent, the Association nurtures the human and con­
transplantation of normal ll-1Sulin-secretirig tissues (pancre­ ceptual infrastructure of future diabetes research.
as, islets), and implantation of cells converted to the task of The American Diabetes Association's research awards and
glucose-regulated insulin secretion by gene manipulation. grants expenditures were $8.6 million in fiscal year 1995. i

I
Because we do not know how diabetes will be prevented These were dollars actually spent by investigators. Associa­
and cured, we must continue to support a broad range of tion overhead costs are not included in this figure, nor are
fundanlental research potentially relevant to those goals. other expenses conventionally allocated to research by not­
Diabetes will be prevented and cured, but we do not know for-profit charitable organizations. In fiscal year 1995, train­
when. Pending that time, perfected insulin replacement is a ing awards (n 73), investigator-initiated awards and grants
reasonable short-term goal for the diabetes research COITUllU­ (n = 63), and support of our areas of special research
nity. Pending that time, there is also a pressing need to interest constituted 35, 43, and 22%, respectively, of our
continue to communicate the outcomes of research in peer­ research awards and grants expenditures.
reviewed journals such as Diahetes and for even greater Over the past decade, our research awards and grants
efforts by the volunteers and staff of the American Diabetes expenditures have not grown in parallel with the approxi­
Association. mately threefold increase in our public support. Measures to
increa.')e our research expenditures are being pursued ac­
tively. Policies enacted recently will ultimately increase our
THE AMERICAN DIABETES ASSOCIATION research awards and grants expenditures in parallel with our
--"s the readers of Diabetes know all too well, diabetes is a public support. Among other direct inputs, affiliate voluntary
.Dmmon, currently uncurable but treatable, potentially dev­ contributions to research are critically inlportant and are
astating chronic disease that is extraordinarily expensive in being solicited actively. Although it will invite the charge of
both human and dollar costs. An estimated 14 million Amer­ parochialism, I must point out that tlle Missouri Affiliate
I
j
icans, more than 5% of the U.S. population, have diabetes. It continues to lead the way in this category. In fiscal year 1995,
is a m~or cause of premature death from ?-therosclerotic its voluntary contribution to research was $405,000. If the I~
,~
!"
 other 51 affiliates were to average that sum, our research
• awards and grants budget would triple! Finally, the newly
esta,blished American Diabetes Association Research Foun­
dation is expected to boost the awards and grants budget in
the future, hopefully the near future.
1 The American Diabetes Association Strategic Plan for
1995-1998 reflects widespread support for increased support
of research. It envisions a near doubling of our awards and
grants budget over 3 years, increased support of the training
1 component of our research program, and increased Associ­
ation-wide ownership of our Nationwide Research Program.
It seems clear to me thai the{~arch support gene is
expressed, albeit at diverse ~,'in all American Diabetes
Association volunteers and staff and that the rate of its
transcription is increasing. Nonetheless, there is a critical
need for positive transcription factors. The medical and
scientific community can serve as those transcription fac­
tors. .! would hope that many more physicians, other health
care providers, and biomedical scientists would become
actively involved in their American Diabetes Association
chapters and affiliates, as well as the national organization.
While that involvement might be focused, ideally it would
include participation in the full range of .Association pro­
grammatic themes-research, information, and advocacy-and
the critical area of income development. With the many
already engaged and the legion of other committed Associ­
ation volunteers, we can make a difference. We can acceler­
ate the prevention and cure of diabetes and, pending that,
improve the lives of all people alfected by diabetes through
research as well as through our other programs and services.
REFERENCES
1. Robertson RP: HIstory of Diabeles, the journal (1952-11191). DUlbele.~
41:1-5. 1992
2. V_lund A, Br.mge J, ~ K, Jensen I, Markussen J, Rikel U, Sorensen
AR, Schlichtkrull J: In vitro and in vi\'o potency of insulin analogues
designed for cllnical·use. Diabetic Med 8:839-847. 11191
3. Pingel M, Velund A, Seremen E. Serensen AR: Assessment of insulin
potency by chemical and biological methods. In Hornume D''Ugs. Gueri·
guian JL, Bransome ED. Outschoom AS. Eds. Rockville, MD. U.S.
Pharmacopeia! Convention, 1982, p. 200-207
4. CIyer PE: Hypoglycemia: the limiting factor in the management of lDDM.
Diabetes 43:1378-1389,1994
5. TllYlor SI, Acdli D, Imai Y: Insulin resistance or insulin defkiency: which
is the primary cause ot NIDDM? Diabetes 43:735-740. 1994
6.. Bogardus C: The case for insulin resistance as a necessary and suftlcient
cause of !we n diabetes mellitus.. J lAb ain Med 125:556-559, 1995
7. ROOertson RP: Diabetes and insulin resistance: philosophy, science and
the multiplier bypothesis. J Lab ain Med 125:560-565, 19Q5
8. Pimenta W, KoQltkowski M. Mitrakou A, Jenssen T. Yki.,.Jarvinen H,
Evron W, Dalley G, Gerich J: Pancreatic beta-reU dysfunction as the
primary genetic lesion In NIDDM. J Am Med Assoc 273:1855-1861, 1996
9. V.I. Prospective Diabetes Study Group: U.I. Prospective Diabetes Study
16: overview of 6 years' therapy of type n diabetes: a progressive disease.
Diabetes 44:1249-1258, 1995
10. Diabetes Control and Complications Trial Research Group: The relation­
ship of glycemic exposure (HbA 1,,) to the risk of development and
progression or retinopathy In the Diabetes Control and Complications
Trial. Diabetes 44:968-983, 1995
. DIABETES. VOL. 44. DECEMBER 1995
PROFESSIONAL REFERENCES:
YALE UNIVERSITY 1
PROFESSIONAL REFERENCES:
ACADIANA REGION 2
CURRICULUM VITAE
3
LIST OF PUBLICATIONS
4
ORIGINAL PAPERS
5
INFORMATION ABOUT
SELECTED JOURNALS 6
ORIGINAL PAPERS
7
CHAPTERS IN THE BOOKS
8
REVIEWS
9
ABSTRACTS
10
Proc. Natl. Acad. Sci. USA
Vol. 92, pp. 1545-1549, February 1995
Biochemistry
Long-lived testosterone esters in the rat
WALTER BORG*, CEDRIC H. L. SHACKLETONt, SHAM L. PAHUJA*, AND RICHARD B. HOCHBERG*4
*Yale University School of Medicine, Department of Obstetrics and Gynecology, and the Comprehensive Cancer Center, New Haven, CT 06510; and tChildren's
Hospital-Oakland Research Institute, Oakland, CA 94609
Communicated by Seymour Lieberman, St. Luke's-Roosevelt Institute for Health Sciences, New YorkA NY, November 7, 1994
ABSTRACT Over the past decade it has become increas-
ingly clear that steroid hormones are enzymatically esterified
with fatty acids. These steroidal esters are the natural analogs
of synthetic esters that are used therapeutically. One such
family of pharmacological steroids is the synthetic alkyl esters
of testosterone, androgens with great hormonal potency. We
have investigated whether testosterone esters exist naturally
by using the rat as a model. Most tissues of male rats, includ-
ing blood, have very little if any ester (quantified by immu-
noassay as a nonpolar saponifiable metabolite), but fat and
testes have sizable quantities, -3 ng of testosterone equiva-
lents per g of tissue. Testosterone in fat averages 9 ng/g. The
fat from female rats and long-term (>2 weeks) castrated
males has no detectable testosterone ester. The presence of
testosterone esters was confirmed by GC/MS, which clearly
showed the presence of testosterone in the hydrolyzed ester
fraction of fat from intact males but not long-term castrates.
Upon castration, testosterone levels in the fat completely
disappear within 6 hr. To the contrary, it is not until 48 hr
after castration that a measurable fall in the testosterone ester
fraction was observed; even after 10 days a small amount of
ester is still present in the fat. These experiments demonstrate
the existence of a previously unknown androgen with a po-
tentially important physiological impact; testosterone esters,
natural analogs of potent therapeutic agents, occur in the fat
where they can serve as a reservoir of preformed androgen to
stimulate neighboring target tissues.
Although fatty acid esters of sterols, such as cholesterol, have
been known for decades, the existence of naturally occurring
fatty acid esters of steroids is a much more recent discovery.
In 1979, putative steroidal esters of the A5-3(3-hydroxysteroids,
pregnenolone (1), dehydroisoandrosterone, and 17a-hy-
droxypregnenolone (2), were discovered in the adrenal gland.
They were named lipoidal derivatives to convey their nonpolar
nature and their ability to be converted back to the parent steroid
as a result of mild hydrolytic procedures. They were subsequently
identified as fatty acid esters (3). These findings raised the pos-
sibility of the existence of similar esters of biologicaLly active
steroids. Such compounds would be the natural analogs of syn-
thetic steroidal esters that have been used pharmacologically as
extremely potent and long-lived hormones. The well known ther-
apeutic use of one such family of pharmacological steroid hor-
mone esters, the estrogens (4), led to experiments which showed
that estradiol (E2) is biosynthetically converted into a lipoidal
derivative, LE2 (5), a nonpolar metabolite, which was identified
as a family of C-17 fatty acid esters of E2 (6). Although LE2 is not
estrogenic when esterified (7)-i.e., it does not bind to the es-
trogen receptor directly (8)-it is converted to E2 by esterase
action. The fatty acid esters comprising LE2 are extremely long-
lived (9) and, thus, act as a reservoir of E2. They represent the
most potent of the naturally occurring steroidal estrogens (10,
11).
The publication costs of this article were defrayed in part by page charge
payment. This article must therefore be hereby marked "advertisement" in
accordance with 18 U.S.C. §1734 solely to indicate this fact.
1545
There are now numerous studies showing that fatty acid
esters of almost all of the families of steroid hormones are
synthesized in vitro (12, 13). However, there are only a few
which demonstrate that steroid esters exist endogenously.
After the esters of the A5-33-hydroxysteroids were discovered
in the adrenal gland (1, 2), esters of dehydroisoandrosterone
and pregnenolone were found in blood (14) and pregnenolone
esters were found in human ovarian follicular fluid (15). Fatty
acid esters of reduced metabolites of progesterone and tes-
tosterone have been isolated and characterized by MS, reveal-
ing androsterone esters in human breast cyst fluid (16) and
allopregnanolone (as well as pregnenolone) in bovine corpora
luteum (17). There are very few studies of endogenous esters
of biologically active steroids. Esters of E2 are present in
limited concentration in blood (17), with much greater
amounts in fat (18). Relatively large amounts of E2 fatty acid
esters have been found in human ovarian follicular fluid,
enabling their complete characterization (18). Other reports of
esters of active steroids are more tenuous. Esters of testoster-
one (19,20) and the corticoids, cortisol and corticosterone (21,
22), have been reported to circulate in sizable amounts in
human blood. Although the report of corticoid esters in blood
was first published in 1960, there has been no independent
confirmation. The evidence for testosterone esters in blood is
uncertain since neither long-term inhibition of steroidogenesis
nor castration reduced the concentration of the putative com-
pound (20).
The existence of natural esters of androgens is of impor-
tance because, like estrogen esters, synthetic alkyl esters of
androgens have been used therapeutically for decades due to
their high potency and prolonged action (23). Thus, biological
esterification of androgens, such as testosterone, would be
expected to have a dramatic effect on both the potency and the
life of the male hormone. This paper reports a study in which
the existence of fatty acid esters of testosterone (TL) in tissues
of the male rat was examined and the hypothesis was tested that
TL is long-lived when compared to testosterone.
MATERIALS AND METHODS
[1,2,6,7,16,17-3H]Testosterone (100 Ci/mmol; 1 Ci = 37 GBq)
purchased from New England Nuclear was refluxed with alkali
to remove labile 3H (24) and then purified by HPLC (25); final
specific activity was 92 Ci/mmol. Testosterone stearate and
[3H]testosterone stearate were synthesized by esterification
with stearyl chloride and purified exactly as described (25).
Sprague-Dawley rats (Charles River Breeding Laboratories)
between 3 and 5 months old were castrated under methoxyflu-
rane (Metofane; Pitman-Moore, Washington Crossing, NJ) an-
esthesia (day 0). At the stated times, animals were decapitated
while under Metofane anesthesia and the tissues were removed
and immediately frozen. Blood was obtained by cardiac puncture,
placed on ice, and centrifuged at 4°C, and the serum was re-
moved. Fat from various areas was combinded and mixed. Ap-
Abbreviations: TL, testosterone ester; E2, estradiol; LE2, E2 lipoidal
derivative; THF, tetrahydrofuran.
VTo whom reprint requests should be addressed.
1546 Biochemistry: Borg et al.
proximately 250 mg of each tissue was weighed, transferred to a
test tube (16 x 125 mm) containing 2 ml of methanol and
homogenized with two 10-sec bursts of a Polytron homogenizer
(Brinkmann). To correct for experimental losses, a representative
fatty acid ester, 5000 cpm of [3H]testosterone stearate (13 pg;
testosterone molar equivalent), was added as an internal standard
in 50 ,ul of ethanol. When testosterone was measured, an internal
standard of [3H]testosterone, 5000 cpm, was also added. The
suspension was mixed, 4 ml of chloroform was added, and it was
Vortex mixed again. Two milliliters of water was added and, after
thorough mixing, the suspension was clarified by centrifugation at
1600 x g and the bottom organic layer was removed with a
Pasteur pipette. The aqueous layer with the tissue residue was
extracted again with 4 ml of the organic layer obtained by par-
titioning chloroform/methanol/water in the ratio 2:1:1. The or-
ganic extracts were combined, evaporated under N2, and then put
under vacuum at 50°C for 10 min to remove all traces of alcohol.
With serum, a slightly different extraction procedure was
used to increase the extraction yield. Four milliliters of freshly
distilled tetrahydrofuran (THF) was added to 1 ml of serum,
followed by the 3H internal standards and then 1 ml of brine.
The solution was vigorously mixed and then centrifuged. The
THF was removed and the aqueous residue was extracted
again with an additional 2 ml of THF. The THF layers were
combined and evaporated under N2. The residues from the
extracts of the various tissues and serum were dissolved in 1 ml
of benzene/hexane (3:1) and transferred to a column (6 x 0.5
cm) of alumina (3% H20) equilibrated in the same solvent.
The column was washed with 10 ml of benzene and the TL
fraction (which contains the 3H internal standard) was eluted
with 10 ml of ethyl acetate/benzene (1:20). The column was
washed with an additional 10 ml of ethyl acetate/benzene
(1:20) and the testosterone fraction was obtained with 10 ml
of ethyl acetate/benzene (2:3). The TL fraction was trans-
ferred to a screw cap test tube (16 x 100 mm) equipped with
a Teflon liner and evaporated under N2, and the residue was
dissolved in 100 ,ul of benzene, 900 ,lI of methanol, 100 ,lI of
10% aqueous potassium carbonate, and heated overnight at
50°C. Samples undergoing mock saponification were treated in
the same manner but the potassium carbonate was omitted.
Afterward, 100 ,ul of 9% aqueous acetic acid was added and
any residual ester was removed by extraction with 2 ml of
isooctane. Testosterone esters partition in the isooctane, and
testosterone partitions in the aqueous methanol. The hydro-
carbon layer was discarded and 900 ,ul of water was added to
the aqueous methanol layer. The alcohol was removed under
N2 and the aqueous residue was extracted twice with 5 ml of
ethyl ether. The ether extracts were combined and evaporated
under N2, and the residue was transferred to a test tube (12 x
75 mm) with several washings (total < 0.5 ml) of acetonitrile.
After the organic solvent was evaporated, the residue was
dissolved with vigorous Vortex mixing in 150 p,l of human
serum that had been stripped of endogenous steroid with
dextran-coated charcoal (26). We have found that dissolving
the residue in steroid-free serum and then analyzing for the
steroid by using a nonextraction RIA decreases the blank.
However, this step is not absolutely necessary. An aliquot of 30
Al of serum was assayed to determine the recovery of the 3H
internal standard, usually '40%. Samples in which the recov-
ery was <25% were not used. The unesterified testosterone
fraction, obtained from the alumina column with ethyl ace-
tate/benzene (2:3), was evaporated under N2 and then dis-
solved in steroid-free serum (recovery 70%). Both the TL
(hydrolyzed) and testosterone fractions were analyzed by RIA:
two aliquots of the serum (50 ,u each) were analyzed directly
by using a nonextraction 1251 RIA for testosterone CAC-TKTT
(Diagnostics Products, Los Angeles). The commercial RIA is
described by the manufacturer as specific for testosterone-
that 5a-dihydrotestosterone cross-reacts only negligibly
(which we confirmed). In the assay, 10 pg of testosterone
Proc. Natl. Acad. Sci USA 92 (1995)
displaces '20% of the bound tracer. The blank (no tissue)
carried through the entire procedure was generally 7-10 pg.
The results of the RIA were corrected for the blank and for
recovery of the internal standard and normalized for the size
of the aliquot and the weight of the tissue. They are reported
as pg, molar equivalents, of testosterone (pg T equiv) per g of
tissue.
To verify that the alumina chromatography eliminates tes-
tosterone from the nonpolar TL fraction, two experiments
were performed. In one, 100,000 cpm of [3H]testosterone was
added to 250 mg of fat and the amount of radioactivity con-
taminating the TL fraction was measured: it was - 100 cpm, or
0.1%. In another experiment, 10 ng of testosterone was added
to 250 mg of female fat and the TL was analyzed. There was
no measurable testosterone in the TL fraction (see Table 1).
When the fat samples from female rats or long-term castrated
males (>2 weeks) were analyzed by this protocol, the amount
of TL measured was not significantly different than the blank
(see Fig. 2) and in most experiments it was the same as the
blank. When TL in fat samples from male rats was analyzed,
significant amounts were found (see Table 1 and Fig. 2). If the
TL fraction was not saponified (mock procedure) no testos-
terone was found (see Table 1). We assayed 10 ng of testos-
terone stearate directly by the RIA, and none was detected
(data not shown). The testosterone ester does not cross-react
in the assay unless it is hydrolyzed. The accuracy with which
this assay measures TL was determined by adding various
amounts (100-1500 pg T equiv) of exogenous testosterone
stearate to -250 mg of female rat fat. The TL was measured
as described and the results including the 95% confidence
limits are shown in Fig. 1.
To confirm the RIA identification of testosterone in the TL
fraction, fat samples from male and long-term (>2 weeks)
castrated male rats were analyzed by GC/MS. One gram of
each (divided into four separate 250-mg samples) was ex-
tracted and saponified as described above. After the addition
of acetic acid and extraction with isooctane, the methanolic
solutions were applied to C18 SPICE columns (Analtech). The
columns were washed with 5 ml of methanol/water (1:1), after
which the testosterone was eluted with 5 ml of methanol/water
(7:3). The four samples were combined, the methanol was
removed under N2, and the aqueous residue was extracted
twice with 2 vol of ether. The ether layers were evaporated
under N2 and the residues were dissolved in benzene.
The testosterone fractions were derivatized before analysis
by conversion of the C-3 carbonyl group to a methyloxime and
the 1713-hydroxyl group to a trimethylsilyl ether (27) as follows.
The samples were dried under N2, dissolved in 50 IlI of a 2%
solution of methoxyamine hydrochloride in pyridine (Pierce),
and heated for 1 hr at 60°C. After removal of pyridine under
N2, 50 ,ul of trimethylsilylimidazole (Pierce) was added and
derivatization was allowed to proceed for 1 hr at 100°C. Excess
reagent was removed by diluting the sample with 1 ml of
cyclohexane and passing it through a short column (in a
Pasteur pipette) of Lipidex 5000 (Packard) equilibrated with
cyclohexane. The testosterone derivative was eluted with 2.5
ml of cyclohexane. The solvent was evaporated under N2, the
resulting residue was dissolved in 20 Al of cyclohexane, and 2
,ul was injected into the GC/MS.
The GC/MS analysis was carried out with a DB 1 column (15
m) (J & W Scientific, Rancho Cordova, CA) housed in a
Hewlett-Packard 5790 gas chromatograph attached to a 5970
mass spectrometer (Hewlett-Packard). The sample was in-
jected by splitless injection with the oven temperature remain-
ing cool (50°C). After 3 min, the oven temperature was in-
creased to 230°C at the rate of 27°C/min. The oven temper-
ature was then raised by 2°C/min to a final temperature of
300°C. The eluent was analyzed by selected ion-monitoring
using the parent ion (M+) of testosterone methyloxine tri-
 Biochemistry: Borg et aL Proc. NatL Acad Sci USA 92 (1995) 1547
methylsilyl ether (m/z 389) and fragments m/z 358 (M-OCH3) 2000
and m/z 125 (A-ring fragmentation).

RESULTS
The procedure designed to measure TL in various tissues
quantifies the testosterone released by saponification from the
nonpolar, TL, fraction. An internal standard of [3H]testoster-
one stearate is added as a representative ester of TL to correct
for procedural losses. The tissue is extracted and the extract is
chromatographed on a column of alumina in order to obtain
the nonpolar TL fraction free of testosterone (see above). The
TL fraction is then saponified with potassium carbonate, par-
titioned between aqueous methanol and hexane to remove
unhydrolyzed steroid, and analyzed with a RIA for testoster-
one. The results are corrected for the recovery of the 3H
internal standard. The validity of the procedure was tested in
several ways. We showed that this procedure eliminates tes-
tosterone from the TL fraction. When [3H]testosterone was
added to fat, negligible radioactivity was found in the TL
fraction. Furthermore, when 10 ng of testosterone was added
to female fat (equivalent to 40 ng/g, an amount far in excess
of endogenous testosterone) none of the added testosterone
was measured in the TL fraction (Table 1). When fat from
male rats was analyzed by this procedure, with the exception
that a mock saponification was carried out in which potassium
carbonate was omitted from the incubation, no assayable tes-
tosterone was found in the TL fraction (Table 1). This was
expected since testosterone esters are not measured in the
RIA unless first hydrolyzed to testosterone. When various
amounts of testosterone stearate were added to fat and then
carried through the entire procedure, including saponification,
the exogenous ester was accurately detected (Fig. 1). A variety
of tissues from male rats was analyzed for TL by this assay. As
shown in Table 1, most tissues contain only negligible amounts
of saponifiable testosterone in the Th fraction. This includes
serum in which a larger sample volume, 1 ml, was analyzed in
order to increase sensitivity. However, male fat contains signif-
icant amounts of TL: the TL in fat was assayed in intact males, in
males that had been castrated for periods of >2 weeks, and in
females. The results of this experiment are presented in Fig. 2.
The amount of TL measured in these experiments (in T equiv per
g of tissue ± SEM) is as follows: males, 2400 + 174; females, 54
+ 14; long-term castrated males, 106 ± 45. In the experiments
shown in Fig. 4 (the normal male is at time 0), the TL in male fat
averaged 2700 ± 199. In all experiments on intact male rats, the
TL in fat ranged from 1100 to 4100 pg T equiv per g. Thus, there
is a relatively large amount of TL in the fat of the intact male but
Table 1. TL in tissues of rat
.-
I
0 200 400 600 800 1000 1200 1400 1600 1800 2000
T-St added (pg T equiv.)
FIG. 1. Quantification of testosterone esters in fat. Various con-
centrations of testosterone 17-stearate (T-St) were added to 250-mg
portions of female rat fat. The fat was extracted and the TL fraction
was isolated and saponified; testosterone was measured by RIA as
described in the text. Individual samples are shown. Dotted lines
represent 95% confidence limits.
not in the fat of the female or the long-term castrate. While there
may be some Th in both of the latter groups, the amount is below
the sensitivity of the assay (see Materials and Methods). For
comparison, in the experiments shown in Fig. 4, testosterone in
male fat was also measured, averaging 9700 ± 1100 pg/g.
TL was also detected in the testes (Table 1), where it is 4000
pg T equiv/g. Since the testes have very high levels of testoster-
one, we again showed in this tissue that the TL was not caused by
contamination with the endogenous testosterone. The TL frac-
tion was put through a mock hydrolysis (without potassium
carbonate) and then analyzed. There was no testosterone in the
nonhydrolyzed TL fraction from testes (Table 1).
The hydrolyzed TL fraction isolated from male rat fat was
also analyzed by GC/MS in order to confirm that the immu-
3000 -
male
2500 - 1 female
1-1
T L > 2 week castrate male
._

TL, pg T 0 2000 -
Tissue equiv/g 0

Male fat* 2400 ± 174 0

Male fat (nonsaponified)t ND St0 1500 -
Female fat ND 0.)
Female fat + testosterone (40 ng/g)t ND
Testes§ 4025 ± 537 0O 1000 -

Testes (nonsaponified)t ND IJ
I50
Male serum, female serum, male brain,
male liver, male muscle, male spleen ND 500 -
ND, nondetectable values ranging from 0 to 150 pg/g. Each tissue
was analyzed in at least three different assays. Data for TL are means
± SEM expressed as pg T equiv per g of tissue. 0 -
F-TI. X
*From data in Fig. 2.
tThe TL fraction was isolated as usual and then subjected to a mock FIG. 2. TL in adipose tissue of rat. Samples of fat (-250 mg) were
saponification from which potassium carbonate was omitted. analyzed for TL by RIA of the saponified TL fraction. Results are
ITestosterone, 10 ng per sample, was added to -250 mg of fat. means from -10 separate experiments. Total number of fat samples
§Mean of four experiments on a total of eight different samples: range, analyzed are as follows: male, n = 29; female, n = 22; castrate, n =
1626-5728. 16. Error bars are SEM.
1548 Biochemistry: Borg et aL Proc. Natl. Acad. Sci USA 92 (1995)

2800A 2500B
2600 male 2000 castrate male
2400
1500
2200
1000
2000
1800 500
16.7 mm 17.2 16.7 mi 17.2 16.7 17.2
mm 7.
FIG. 3. GC/MS of saponified TL fraction from rat fat. Partial chromatograms of the [M]+ (m/z 389) of testosterone methoxime trimethylsilyl
ether. Samples of fat (1 g) from intact (A) and long-term castrated (B) male rats were extracted, saponified, and converted to the methyloxime
trimethylsilyl ether as described in the text. The chromatogram (C) is testosterone run simultaneously as a reference. Analysis was performed on
samples in A and B with aliquots that were representative of identical portions of tissue (as determined by recovery of the 3H internal standard).
In each panel the ordinate is the selected ion, m/z 389. The two incompletely resolved peaks at 16.9 and 17.0 min represent the syn and anti forms
of the methyloxime derivative.
noassayable material is testosterone. The TL fraction from a at those times (Fig. 4A) and even after an entire day (Fig. 4B),
normal male and a long-term male castrate was converted to TL levels did not decline appreciably. Only after 48 hr of cas-
testosterone by saponification, purified by chromatography on tration is a decrease in the concentration of TL noticeable. The
a C18 column, derivatized to form the methyloxime trimeth- TL levels in fat declined slowly thereafter, until 10 days when
ylsilyl ether derivative, and then analyzed by single ion mon- only very low levels were found.
itoring GC/MS: at m/z 389 parent [M]+, at m/z 358 [M-
OCH3]+, and at m/z 125 (A-ring fragmentation). The saponified
TL fraction from the intact male rat gave a response for all three DISCUSSION
ions at the correct retention time for the methoxylamine tri-
methylsilyl ether derivative of testosterone. The partial ion chro- These experiments show that TL exists in the fat and testes of
matogram (m/z 389) of a standard of testosterone derivatized in the male rat. Although the structure of TL is not definitively
the same manner and the two fat extracts are shown in Fig. 3. The proven, it is highly likely that TL is a heterogeneous family of
two unresolved peaks at 16.9 and 17.0 min, observed with au- fatty acid esters of testosterone: its physicochemical charac-
thentic testosterone and the male fat extract, represent the syn teristics are the same as the fatty acid esters, and similar
and anti forms of the methyloxime derivative (27). These peaks lipoidal derivatives of other steroids have been shown to be
are not present in the saponified TL fraction of fat from the fatty acid esters (3, 6, 15-17, 28). The evidence that testoster-
long-term castrated male rat. one is released by hydrolysis of the nonpolar TL fraction from
Since steroidal esters are long-lived, presumably because male rat fat rests on strong evidence, both immunological and
they are protected from metabolism (9), we performed an spectral. The immunological (RIA) data show little if any TL
experiment to compare the kinetics of the disappearance of TL in the long-term castrated male or in the female rat (Fig. 2).
and testosterone from fat after castration of male rats. As This is consistent with a metabolite of testosterone. Most
shown in Fig. 4A, almost all of the testosterone in the fat compelling is the GC/MS analysis, which shows testosterone
disappeared by 3 hr after castration and by 6 hr there was no in the hydrolyzed TL fraction of male fat but not the long-term
longer any measurable testosterone in the fat. To the contrary, castrated male rat.
10000 - 5000
A
9000 - 4500
8000 - 4000

0 7000 - ) 3500
co --TL
- 6000 - ., 3000
1-

QL 5000 - ' 2500

.5
v
0
4000 - $ 2000
-j
: 3000 - I~ ~ ~~~~--4
F 1500
2000 - 1000
1000 - 500
0 -
0
0 1 2 3 4 5 6 0 48 98 144 192 240
hours after castration hours after castation
FIG. 4. Effect of duration of castration on concentration of testosterone (T) and TL in male rat fat. Each point is the mean of at least three
separate determinations. Total number of different fat samples analyzed for each point is .5. Error bars are SEM.
 Biochemistry: Borg et aL
There is no TL in the other tissues tested (Table 1), including
muscle and blood. There is also no TL in the brain. This is of
interest because the first demonstration of the fatty acid es-
terification of a steroid hormone was the esterification of
testosterone by a brain preparation (29). In this study, while we
did not find TL, we did find relatively large amounts of
testosterone in the brain (5900 ± 1000 pg/g; mean ± SEM).
Thus, although both the substrate and the enzymatic capacity
to esterify testosterone is in the brain, there is no TL. Although
this might appear to be contradictory, there are several reasons
why this might occur, including rapid hydrolysis of TL; the
acyltransferase enzyme found in the in vitro experiments with
brain has a high Km (low affinity) for testosterone, insufficient
for the in vivo concentration; or the enzyme and substrate are
present in different regions of the brain. Regardless of the
reason, the synthesis or accumulation of TL is obviously more
complex than might be otherwise apparent. The tissue distri-
bution of TL is consistent with our studies of the E2 esters in
humans in which we found that there is very little in muscle or
blood and that most was present in fat (18). It does not agree
with the findings of a substance with the properties of TL in
the blood of men (19, 20). The finding of high levels of a
compound with the properties of testosterone esters in blood
is unusual since the hydrophobic esters of steroids do not
appear to be secreted into blood (18, 30). Although fairly high
concentrations of some steroid esters circulate in blood, they
are the esters of the A5-3f-hydroxysteroids pregnenolone and
dehydroisoandrosterone (14). They are formed in blood by
lecithin:cholesterol acyltransferase (LCAT) for which they are
good substrates (14, 31). E2 esters are in also blood, but E2 is
a poor substrate for the enzyme, and this is probably the major
reason why only very low levels are present. However, testos-
terone is not esterified at all by LCAT (14). As pointed out
above, the compound measured in human male blood (19, 20)
did not disappear after long-term castration (surgical or phar-
macological) or even complete inhibition of steroidogenesis
with aminoglutethimide, and its level in blood was inversely
proportional to that of testosterone (20). There are obvious
differences between those studies and this one, especially the
species used and many of the techniques, and so it is not
possible to conclude that TL is not in human blood. Obviously,
the confirmation of the presence of TL in human blood re-
quires direct experimentation. However, whatever that sub-
stance is, its biological properties are very different than those
that we found for TL in rat fat (see Fig. 4).
These studies demonstrate the presence of a nonpolar me-
tabolite of testosterone, TL, in the fat and testes of the male
rat. This metabolite is extremely long-lived when compared to
the parent steroid, testosterone (Fig. 4). Prolonged biological
half-life (ti12) is linked to increased androgenic potency, as
evidenced by the synthetic androgenic esters that are used
therapeutically (23). This relationship of biological tlq2 and
potency has been confirmed with the naturally occurring E2
17-fatty acid esters, LE2, which because they are protected
from metabolism have a considerably extended biological life
(9) and are therefore remarkably potent estrogens (10, 11).
Likewise, it would be expected that because the endogenous
testosterone esters, TL, are long-lived, they are highly potent
androgens. It is very interesting that in the relatively long
period after castration, when the levels of testosterone are
undetectable, sizable quantities of TL are still present in the fat
(Fig. 4). At these times, although testosterone is not being
synthesized by de novo steroidogenesis, the androgen can still
be produced, not by the steroidogenic enzyme that synthesizes
C19 steroids, the 17-hydroxylase, but by enzymatic hydrolysis of
TL. While the amount of testosterone that is produced may be
small if diluted into the entire body pool, locally sizable
amounts may be secreted. We hypothesize that stimulation of
specific androgen target tissues can occur by a paracrine
mechanism through which TL in neighboring fat supplies testos-
Proc. NatL Acad Sci USA 92 (1995) 1549
terone through the action of esterase(s). Hormonal communi-
cation from the target tissue to the fat could signal adipose cells
to synthesize or activate the esterase, leading to the release of
androgen at times when testicular production or blood levels of
testosterone are low. Since, in this view, the androgenic stimu-
lation would be only through local fat and not the circulation,
specificity of the target tissues is possible. Regardless of how TL
may act, the existence of this highly unusual, long-lived metabolite
of testosterone undoubtedly has important ramifications for our
understanding of the physiology of the sex steroids.
We gratefully acknowledge Donna Raucci and Esther Roitman for
their skillful technical assistance. This work was supported by the
National Institutes of Health (Grants DK-34400 to C.H.L.S. and
CA-25951 to R.B.H.).
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Local Ventromedial Hypothalamus Glucose Perfusion Blocks Counterregulation
during Systemic Hypoglycemia in Awake Rats
Monica A. Borg,* Robert S. Sherwin,* Walter P. Borg,* William V. Tamborlane,‡ and Gerald I. Shulman*
Yale University School of Medicine, *Department of Internal Medicine and ‡Department of Pediatrics, New Haven, Connecticut 06520
Abstract
The ventromedial hypothalamic nucleus (VMH) is neces-
sary for the integrated hormonal response to hypoglycemia.
To determine the role of the VMH as a glucose sensor, we
performed experiments designed to specifically prevent glu-
copenia in the VMH, while producing hypoglycemia else-
where. We used awake chronically catheterized rats, in
which local VMH glucose perfusion (100 mM or 15 mM of
D-glucose) was combined with a sequential euglycemic–
hypoglycemic clamp. In two control groups the VMH was
perfused either with (a) an iso-osmotic solution lacking glu-
cose, or with (b) nonmetabolizable L-glucose (100 mM).
During systemic hypoglycemia glucagon and catecholamine
concentrations promptly increased in the control animals
perfused with either 100 mM L-glucose or the iso-osmotic
solution lacking glucose. In contrast, glucagon, epinephrine
and norepinephrine release was inhibited in the animals in
which the VMH was perfused with D-glucose; hormonal se-
cretion was partially suppressed by the VMH perfusion with
15 mM D-glucose and suppressed by z 85% when the VMH
was perfused with 100 mM D-glucose, as compared with the
control groups. We conclude that the VMH must sense hy-
poglycemia for full activation of catecholamine and gluca-
gon secretion and that it is a key glucose sensor for hypogly-
cemic counterregulation. (J. Clin. Invest. 1997. 99:361–365.)
Key words: VMH • microdialysis • hypoglycemia • glucagon •
epinephrine
Introduction
The central nervous system (CNS)1 plays an important role in
sensing glucopenia and triggering counterregulatory hormone
release during hypoglycemia. (1–3). Although a region within
or in close proximity to the liver may activate the sympatho-
adrenal system (4), the CNS appears to be the dominant center
responsible for the sensing and integration of hypoglycemic
Address correspondence to Gerald I. Shulman, M.D., Ph.D., Yale
University School of Medicine, Department of Internal Medicine/En-
docrinology, Box 208020, FMP 104, New Haven, CT 06520-8020.
Phone: 203-785-5447; FAX: 203-785-6015; E-mail: gerald_shulman@
qm.yale.edu
Received for publication 19 July 1996 and accepted in revised form
5 November 1996.
1. Abbreviations used in this paper: CNS, central nervous system;
ECF, extracellular fluid; VMH, ventromedial hypothalamic nucleus.
J. Clin. Invest.
© The American Society for Clinical Investigation, Inc.
0021-9738/97/01/361/05 $2.00
Volume 99, Number 2, January 1997, 361–365
signals. This view is best supported by data showing that pre-
vention of intercerebral glucopenia by infusion of glucose into
both the carotid and vertebral arteries nearly abolishes coun-
terregulatory hormone responses to systemic hypoglycemia (2,
5). Recent studies suggest that the ventromedial hypothalamus
(VMH) may be the specific region in the CNS that is responsi-
ble for activation of counterregulatory mechanisms, since focal
lesioning in this area abolishes the hormonal response to sys-
temic hypoglycemia (6). Moreover, production of local neuro-
glycopenia by perfusion of 2-deoxy-glucose into the VMH is
able to trigger the release of counterregulatory hormones, de-
spite systemic normoglycemia (7).
The present study was undertaken to examine whether the
converse is also true; namely, can hormonal responses to sys-
temic hypoglycemia be blocked by preventing neuroglycope-
nia in the VMH, alone? For this purpose, the hypoglycemic in-
sulin clamp technique was combined with bilateral VMH
microdialysis in Sprague-Dawley rats; the microdialysis perfu-
sate contained extracellular fluid (ECF) with added glucose.
This approach allowed us to selectively prevent hypoglycemia
within the chosen brain region, and to test its effect under stan-
dardized hypoglycemic conditions.
Methods
Animals. Male Sprague-Dawley rats were purchased from Charles
River Laboratories (Raleigh, NC). Animals were housed in an envi-
ronmentally controlled room with a 12-h light/dark cycle, and were
maintained on standard ad libitum rat diet (AGWAY Prolab 3000,
Waverly, NY) comprising of 22% protein, 5% fat, and 51% carbohy-
drate (the remaining 22% consists of ash, crude fiber, and moisture).
VMH microdialysis canulas placement. Rats (mean body weight
of z 28065 g, range 250–315 g) were anesthetized by intraperitoneal
injection (1 ml/kg) of a mixture of Xylazine (AnaSed 20 mg/ml; Lloyd
Laboratories, Shenadonoah, IA) and Ketamine (Ketaset 100 mg/ml;
Aveco Co., Fort Dodge, IA) in a ratio of 1:2 (vol/vol) and placed on a
stereotaxic frame. Thereafter, the skull was exposed, and holes were
drilled bilaterally in chosen coordinates, through which the guide can-
ulas were lowered slowly into the brain. The stereotaxic coordinates
were determined from the atlas of Paxinos and Watson (8). Specifi-
cally, VMH canulas were placed by using the coordinates 2.6 mm pos-
terior and 3.8 mm lateral in relation to bregma, and the angle of 208 in
relation to horizontal plane passing through bregma and lambda. The
canulas were then secured to the skull with stainless steel screws and
dental acrylic. Animals were then allowed to recover from the stereo-
taxic procedure for 12–16 d before study. One day before each exper-
iment, microdialysis probes of side-by-side design (9) were inserted
into the guide canulas. The length of the probes was 10.5 mm, as mea-
sured from the bregma-lambda plane. The exposed microdialysis
membrane was 1.0–1.5 mm (approximately the size of the VMH), so
that we could selectively perfuse this brain region. On the morning of
the experiment, the perfusion medium was loaded into 1-ml syringes
and delivered at a flow rate of 2.5 ml/min using a Harvard perfusion
pump (model 22; Harvard Bioscience). Four groups of rats (two ex-
perimental and two controls) were studied. In each the VMH was
perfused with a sterile, ascorbate-free, artificial, extracellular fluid so-
Ventromedial Hypothalamic Nucleus as a Glucose Sensor 361
lution (ECF: 135 mmol/liter NaCl, 3 mmol/l KCl, 1 mmol/liter MgCl2,
1.2 mmol/CaCl2, and 2 mmol/liter sodium phosphate buffer to pH
7.4). The VMH probe was perfused in the first group with 100 mM
D-glucose (metabolically active isomer) and in the second group with
15 mM D-glucose. The third and the fourth groups of animals served
as controls: The third group had no D-glucose added to the perfusate
(i.e., ECF only was perfused into the VMH) and the fourth group of
rats had 100 mM of the non-metabolizable, L-glucose isomer added
to the perfusate. The last group of animals served as a control for the
high osmolarity of the perfusate used in groups perfused with D-glu-
cose. High concentrations of glucose were used in the perfusate to en-
sure that hypoglycemia was prevented throughout the VMH, because
the efficiency of glucose delivery through the VMH dialysis system is
very low, (, 5%). To estimate the efficiency of glucose delivery, we
performed three in vitro experiments, using the same microdialysis
system, where only ECF (without glucose added) was perfused in a
100 mM glucose solution via the VMH microdialysis probe. Under
these conditions the effluent from the probe contained only z 4.2
mM glucose (or z 4% of glucose) in the solution. Calculations were
made, by extrapolating these data to our animal experiments, consid-
ering that in vivo (using identical microdialysis probes, solutions, and
flow rates), the efficiency of the microdialysis system would be much
lower, and the delivery of glucose to be closer to 1–2% of the infused
glucose, or values that approximate brain ECF glucose levels during
euglycemia in the rat which are about 1.5–2.0 mM (10). Given these
considerations we estimate that the doses of glucose delivered to the
VMH did not produce hyperglycemia in brain ECF.
At the end of each experiment, the accuracy of probe placement
was confirmed histologically by cresyl violet staining. Only those ani-
mals that showed bilateral probe placement into the desired brain re-
gion were included (z 25% of rats failed the histological criteria).
Fig. 1 presents a photograph of rat brain with microdialysis guide can-
ulas tracks placed bilaterally in the VMH.
The ability of the microdialysis system to deliver glucose selec-
tively to the VMH, has been validated previously in our laboratory,
using radiolabeled 2-deoxy-glucose (7). Based on these data, we as-
sume that the VMH was specifically affected by dialysis, and that no
other adjacent area could be significantly influenced by this manipu-
lation.
Surgical procedures. At 6–8 d before study (i.e., z 7 d after ste-
reotaxic surgery), animals underwent an additional aseptic surgical
procedure for placement of internal jugular vein and carotid artery
catheters under intraperitoneal pentobarbital anesthesia (Nembutal,
362 Borg et al.
35 mg/kg body wt; Abbott Laboratories, North Chicago, IL). The
polyethylene carotid artery catheter was extended to the level of the
aortic arch, and the silicone internal jugular vein catheter was ad-
vanced to the level of the right atrium. At the end of the procedure,
both catheters were flushed and filled with heparin (42 U/ml) and
polyvinylpyrrolidone (1.7 g/ml) solution, plugged, tunneled subcuta-
neously around the side of the neck, and externalized behind the
head through a skin incision. Catheters remained sealed until the day
of the study. Only those animals that had completely recovered were
used in the studies.
Specifically, the recovery of the animals after both stereotaxic
and catheter surgery was assessed according to a standard protocol
approved by the Yale Animal Care and Use Committee. Briefly, for a
period of one week after each surgery, animals, housed in the Yale
Animal Facility, were monitored for body temperature, feeding activ-
ity and body weight on a daily basis. We defined recovery as: (1)
maintaining normal rat body temperature (z 37.58C); (2) attitude —
acting normally; and (3) weight gain z 7 g/day. Any sign of infection
(focal, localized to the surgerized areas, or generalized) was noted,
and sick animals were excluded from participating in the experiments
(z 10%).
Euglycemic/hypoglycemic clamp. The hyperinsulinemic clamp tech-
nique, as adapted for the rat (11), was used to provide a standardized
hypoglycemic stimulus. Each of the animals was fasted for z 24 h be-
fore the study and then received a sequential euglycemic–hypoglyce-
mic clamp study. On the morning of the experiment, the catheters
were flushed and maintained patent by a slow infusion of saline (20
ml/min) that contained a small amount of heparin (1–2 U/ml). Ani-
mals were fully awake and freely moving about in their cages, unteth-
ered. After a 60-min rest period, blood samples were withdrawn for
measurement of baseline concentrations of glucose, insulin, glucagon,
epinephrine, and norepinephrine. Thereafter, a primed (2,160 pmol
over 1.5 min) continuous infusion (120 pmol/kg21 ? min21) of porcine
insulin (Eli Lilly & Co., Indianapolis, IN) was initiated and main-
tained for 150 min. A variable infusion of exogenous glucose was ad-
justed based on plasma glucose measurements obtained at 5-min in-
tervals to achieve the desired glucose level. During the first 60 min,
the rats were maintained at euglycemia (mean plasma glucose 6.4
mM). Thereafter, plasma glucose was allowed to fall over z 40 min to
hypoglycemic levels (z 2.5 mM) and then clamped at this level for
z 4565 min using a variable infusion of exogenous glucose. Experi-
ments were terminated if the plasma glucose (a) fell below 4.5 mM
during the last 45 min of the euglycemic phase and (b) rose above 3.9
Figure 1. Photograph of the rat
brain with the microdialysis
guide cannulas tracks placed
bilaterally in the VMH. The
exposed dialysis membrane
was approximately the size of
the VMH, that is 1.0–1.5 mm.
Three different concentrations
of D-glucose (0, 15, and 100
mM) and 100 mM L-glucose
were used in the experiment.
mM (secondary to glucose infusion), or inadvertently fell below 2.0
mM during the hypoglycemic phase. Only the studies during which
the mean blood glucose level achieved during hypoglycemia was in
the range of 2.3–2.7 mM were prospectively analyzed. In the first ex-
perimental group of rats, where the VMH was perfused with 100 mM
D-glucose, 14% of animals with proper canula placement (as verified
histologically) did not meet these criteria. In the second group (per-
fused with 15 mM D-glucose) 12% of animals were excluded. Two
control groups (where ECF only or L-glucose perfusion were intro-
duced) had 25% and 20% animals excluded, respectively. Histologi-
cal results and the accuracy of the clamps were the only criteria for
excluding or including the clamp studies for the data analysis.
Blood samples for measurement of plasma insulin, glucagon and
catecholamines were taken during the euglycemic (30- and 60-min)
and hypoglycemic (120-, 135-, and 150-min) phases of the experi-
ments. During blood sampling, dilution by fluid in the dead space of
the catheter was avoided by withdrawal of 0.5 ml of blood before
sample collection. This volume exceeded the dead space volume by
about five fold. A new syringe was then used for the sample collec-
tion. Subsequently, the initial syringe was reattached, and the con-
tents reinfused. Blood recently obtained from littermates was trans-
fused during the clamp to quantitatively replace the blood withdrawn
during the experiment. The protocol was reviewed and approved by
the Yale Animal Care and Use Committee.
Analytical methods and calculations. Plasma glucose was mea-
sured in duplicate using a Beckman Glucose Analyzer II (Beckman,
Fullerton, CA). Plasma insulin (Binax, South Portland, MA), and
glucagon (ICN Biomedicals, Inc., Carson, CA) were determined by a
double antibody radioimmunoassay. Insulin measurements during
the basal and insulin infusion periods were made using rat and por-
Figure 2. Plasma glucose concentrations during euglycemic-hypoglycemic clamps plus VMH microdialysis perfusions.
cine standards, respectively. Plasma catecholamines were measured
with a radioenzymatic method (Amersham Corp., Arlington Heights,
IL), as previously described (6, 7).
Data are expressed as mean6SE. Comparison between the ex-
perimental groups was made by ANOVA with a repeated measure
design, followed by the Student’s t test to localize effects. Glucose in-
fusion rates during the hypoglycemic steps represent average values
for the designated time interval. Values for percent suppression of
hormonal responses reflect changes from the mean of the peak coun-
terregulatory response (i.e., the mean of the 135 and 150 min data
points) results in the control studies.
Results
At the outset of the study, neither the basal concentrations of
glucoregulatory hormones nor the weight of the animals (Ta-
ble I), were significantly different in the four experimental
groups. During the insulin infusion, plasma insulin rose to
nearly identical levels, and plasma glucose was comparable
during each phase of the study in all groups (Table II and Fig.
2). In the hypoglycemic phase of the study, the desired level of
glycemia (i.e., z 2.5 mM) was achieved after z 45 min.
During euglycemia the concentrations of epinephrine, nor-
epinephrine, and glucagon were not significantly different
among the four groups of animals. The effects of the different
VMH microdialysis perfusions on counterregulatory hor-
mones are summarized in Fig. 3. In both experimental groups
(VMH perfused either with 100 mM or 15 mM D-glucose) hor-
Ventromedial Hypothalamic Nucleus as a Glucose Sensor 363
Table I. Basal Hormonal and Weight Data of the
Animals Studied
VMH perfusions with

100 mM 15 mM 0 mM 100 mM
D-glucose D-glucose D-glucose L-glucose

(n 5 6) (n 5 7) (n 5 9) (n 5 8)

Insulin (nM) 0.1160.04 0.1260.03 0.1360.02 0.1260.02

Glucagon (ng/liter) 146613 152617 180615 212643
Epinephrine (nM) 0.760.1 0.660.1 1.260.4 1.160.3
Norepinephrine (nM) 1.760.3 1.660.2 2.260.5 2.160.5
Weight (g) 295620 270620 280630 285625

monal responses were diminished, despite a similar degree of

systemic hypoglycemia. Specifically, 100 mM D-glucose perfu-
sion into the VMH suppressed the release of epinephrine and
norepinephrine by 90% and glucagon by 75% (P , 0.05 as
compared with both control groups). The VMH perfusion with
15 mM D-glucose had a less pronounced effect, but also sup-
pressed epinephrine and norepinephrine by z 75% (P , 0.05
vs. both control groups) and glucagon by z 45% (P , 0.05
only as compared with the VMH perfusion with ECF). In con-
trast, there was a sharp increase in the concentrations of
plasma catecholamines and glucagon in the two control groups,
when hypoglycemia was induced.
The diminished counterregulatory hormone responses in
Figure 3. Effect of D-glucose VMH perfusion on the hypoglycemia-
the animals receiving VMH D-glucose perfusion was associ-
induced increment in plasma counterregulatory hormones.
ated with a 3–4-fold higher rate of exogenous glucose infusion
than was required in the control studies to maintain the plasma
glucose plateau at 2.5 mM (Table II).
the glucagon response, is reduced in the face of systemic hy-
Discussion poglycemia. No inhibition of counterregulatory hormone re-
lease occurred when the VMH was perfused with ECF only
This study demonstrates that when hypoglycemia is selectively (no D-glucose added) or with 100 mM L-glucose or when re-
prevented in the VMH, but not in the remainder of the CNS or sults from those studies are compared with those of naive rats
elsewhere, the catecholamine response, and to a lesser degree previously reported (6). In keeping with these findings, the two
experimental groups receiving the VMH D-glucose perfusion
Table II. Mean Plasma Glucose and Insulin Concentrations required more exogenous glucose to maintain the hypoglyce-
during Euglycemia and Hypoglycemia mic plateau than did control animals which had intact counter-
regulatory responses.
VMH perfusions with
While the characteristics of counterregulatory responses
100 mM 15 mM 0 mM 100 mM during hypoglycemia are well established (6, 7), the physio-
D-glucose D-glucose D-glucose L-glucose logic events that occur to link glucopenia with counterregula-
tory hormone secretion remain obscure. Although the bulk of
(n 5 6) (n 5 7) (n 5 9) (n 5 8)
data suggest that the brain plays a critical role in this process,
Euglycemia (T 5 0–60 min) the specific anatomical location of the center for sensing and
Glucose (mM) 6.460.1 6.460.2 6.560.1 6.460.1 integration of hypoglycemic signals is uncertain (5, 12). In pre-
Insulin (nM) 4.960.5 4.760.4 4.960.5 5.060.6 vious studies we performed hypoglycemic clamp studies in bi-
Hypoglycemia (T 5 105–150 min) laterally VMH lesioned rats as well as in rats with lesions in
Glucose (mM) 2.560.2 2.560.1 2.460.1 2.460.1 different brain areas (6). A marked inhibition of both the glu-
Insulin (nM) 5.060.6 4.960.4 5.060.4 5.260.7 cagon and catecholamine response to hypoglycemia was evi-
Exogenous glucose dent only in the VMH-lesioned animals, consistent with earlier
infusion rate studies implicating the hypothalamus in the activation of hy-
(mg·Kg21·min21) 5.261.2* 4.461.1* 1.560.5 1.360.4 poglycemic counterregulation (13–15).
In this study we establish in a more specific and physiologi-
* P , 0.05. Glucose values were obtained by averaging measurements cal way the critical role that the VMH plays in the counterreg-
during the 0–60 and 105–150 min of the study. Insulin data for the eugly- ulatory response to hypoglycemia. Specifically, these data
cemic phase represent the average insulin level of the sample obtained demonstrate that the catecholamine response to systemic hy-
at the end of this phase. Insulin values during hypoglycemia represent poglycemia is blocked, and the glucagon response is attenu-
the average of measurements obtained at 120 and 150 min. ated by direct glucose delivery to the VMH. By using the se-

364 Borg et al.

quential euglycemic-hypoglycemic clamp technique, we avoided
the confounding effects of variable glycemic levels among the
study groups. Additionally, the bilateral intracranial microdial-
ysis technique allowed us to minimize or to abolish cellular
glucopenia in an area of brain restricted to the VMH. Probe
placement, while obviously invasive, did not appear to signifi-
cantly alter the hormonal response to hypoglycemia, since the
magnitude of the hormonal response in the control rats re-
ported here was very similar to that reported by our group in
naive animals during comparable hypoglycemic clamp studies
(6). It is noteworthy that VMH perfusion with 100 mM D-glu-
cose was sufficient to block the sympatho-adrenal and to atten-
uate pancreatic a-cell response to systemic hypoglycemia,
whereas only partial inhibition of both glucagon and cate-
cholamine response was seen, when 15 mM glucose was per-
fused through the probes. While the reason for this discrep-
ancy is uncertain, it is likely that the low efficiency of glucose
delivery via the probe may have prevented complete abolition
of hypoglycemia throughout all neurons in the VMH during
the 15 mM but not the 100 mM glucose perfusion, especially
VMH neurons located at greater distances from the probe. It is
unlikely that the inhibition of counterregulatory release in-
duced by perfusion of the VMH with 100 mM D-glucose can
be attributed to direct osmotic effects, since perfusion of the
VMH with 100 mM L-glucose had no effect on the counterreg-
ulatory response. Moreover, in previous experiments, perfusion
of 100 mM D-glucose into the VMH had no effect on counter-
regulatory hormone levels under euglycemic conditions (7).
It should be noted, however, that some data do not support
the concept that the dominant glucose sensing neurons are lo-
cated in the VMH. Studies by Donovan et al. have suggested
that peripheral glucosensors may play a role in the activation
of hypoglycemia-induced sympatho-adrenal responses (4). Re-
cent studies performed by these investigators have shown that
portal euglycemia reduces counterregulatory responses to hy-
poglycemia, implying that the VMH may not be the only area
detecting hypoglycemia (16, 17). However, in order to create
conditions of euglycemia in the liver, glucose was infused into
the portal vein which caused a negative arterial-portal glucose
gradient. Since this negative gradient has been shown to be an
important feeding signal (18), it is possible that this might have
affected these results. On the other hand, the current data sug-
gest that if peripheral signaling is involved, it can be overrid-
den if the hypoglycemic stimulus is eliminated at the level of
the VMH. In agreement with this Davis et al. have shown that
localized hepatic hypoglycemia is unable to evoke counterreg-
ulatory hormone release (19). In addition, Jackson et al. (20)
have recently reported that blocking transmission of the vagus
nerves innervating the liver had no impact on the counterregu-
latory response to hypoglycemia. In contrast, when localized glu-
copenia was induced in the VMH by infusion (via microdialysis)
of 2-deoxy-glucose, there was a prompt hormone response even
in the face of normoglycemia (7). Taken together, these observa-
tions suggest that the VMH is a key glucose sensor for triggering
counterregulation. The cellular mechanisms used by the VMH to
sense and transduce the glucose signal remain to be determined.
Acknowledgments
We are indebted to Dr. David Maggs for his comments and sugges-
tions. We appreciate the assistance of Aida Groszmann and Andrea
Belous for their help in the measurements of plasma hormones. We
also are grateful to Jenny Sherwin and Kimberly Tishler for their ex-
pert technical assistance.
This research was supported by Public Health Service grants R01-
DK 20495, R01-DK 40936, and P01-DK 45735. Drs. M.A. Borg and
W.P. Borg are the recipients of fellowship grants from The Juvenile
Diabetes Foundation International.
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Ventromedial Hypothalamic Nucleus as a Glucose Sensor 365
Chronic Hypoglycemia and Diabetes Impair
Counterregulation Induced by Localized
2-Deoxy-Glucose Perfusion of the Ventromedial
Hypothalamus in Rats
Monica A. Borg, Walter P. Borg, William V. Tamborlane, Michael L. Brines, Gerald I. Shulman,
and Robert S. Sherwin
Previous studies have demonstrated that the ventro-
medial hypothalamus (VMH) plays a critical role in
sensing and responding to systemic hypoglycemia. To
evaluate the mechanisms of defective counterregulation
caused by iatrogenic hypoglycemia and diabetes per se,
we delivered 2-deoxy-glucose (2-DG) via microdialysis
into the VMH to produce localized cellular glucopenia
in the absence of systemic hypoglycemia. Three groups
of awake chronically catheterized rats were studied:
1) nondiabetic (with a mean daily glucose [MDG] of 6.9
mmol/l) BB control rats (n = 5); 2) chronically hypo-
glycemic nondiabetic (3–4 weeks, with an MDG of 2.7
mmol/l) BB rats (n = 5); and 3) moderately hypergly-
cemic insulin-treated diabetic (with an MDG of 12.4
mmol/l) BB rats (n = 8). In hypoglycemic rats, both
glucagon and catecholamine responses to VMH glu-
copenia were markedly (77–93%) suppressed. In dia-
betic rats, VMH 2-DG perfusion was totally ineffective
in stimulating glucagon release. The epinephrine
response, but not the norepinephrine response, was
also diminished by 38% in the diabetic group. We con-
clude that impaired counterregulation after chronic
hypoglycemia may result from alterations of the VMH or
its efferent pathways. In diabetes, the capacity of VMH
glucopenia to activate the sympathoadrenal system is
only modestly diminished; however, the communication
between the VMH and the a-cell is totally interrupted.
Diabetes 48:584–587, 1999
S evere hypoglycemia is a major risk of insulin ther-
apy, especially in patients with type 1 diabetes who
are aggressively attempting to achieve near-nor-
moglycemia (1). Patients with diabetes are more
vulnerable to low blood glucose levels, not only because they
are unable to synchronize insulin delivery with meal ingestion
and activity but also because the counterregulatory responses
From the Departments of Internal Medicine (M.A.B., W.P.B., M.L.B., R.S.S.)
and Pediatrics (W.V.T.) and the Howard Hughes Medical Institute (G.I.S.),
Yale University School of Medicine, New Haven, Connecticut.
Address correspondence and reprint requests to Robert S. Sherwin,
MD, Yale University School of Medicine, Department of Internal Medi-
cine/Endocrinology, Box 208020, FMP 1, New Haven, CT 06520-8020. E-mail:
robert.sherwin@yale.edu.
Received for publication 27 July 1998 and accepted in revised form 5
November 1998.
CNS, central nervous system; 2-DG, 2-deoxy-glucose; MDG, mean daily
glucose; PZI, protamine zinc insulin; VMH, ventromedial hypothalamus.
584
that normally protect against hypoglycemia are defective. In
the early stages of type 1 diabetes, the capacity to release
glucagon during hypoglycemia is lost in the early stages of the
disease (2) and subsequently because epinephrine responses
may also diminish (3). In addition, intensive insulin therapy for
diabetes causes reversible suppression in sympathoadrenal
responses to hypoglycemia (4,5). This phenomenon is
thought to be a consequence of iatrogenic hypoglycemia,
because even brief periods of mild hypoglycemia in nondia-
betic and diabetic subjects have been shown to reduce coun-
terregulatory hormone responses to subsequent hypogly-
cemic challenges (6,7). It has been hypothesized that such
defects might be related to adaptive changes in glucose trans-
port or glucose metabolism that serve to make the central ner-
vous system (CNS) less vulnerable to neuroglycopenia (8–12).
Paradoxically, if the CNS glucose sensors also become resis-
tant to neuroglycopenia, this adaptation might delay and
impair activation of protective counterregulatory responses to
falling plasma glucose levels.
Recent studies from our laboratory indicate that the ven-
tromedial hypothalamus (VMH) is a dominant center within
the CNS for sensing of glucopenia (13–15). In rats, focal
lesioning of the VMH abolishes hormonal response to sys-
temic hypoglycemia (13), as does selective prevention of glu-
copenia in the VMH by glucose perfusion via stereotaxically
placed microdialysis probes (14). Conversely, production of
local neuroglycopenia by perfusion of 2-deoxy-glucose (2-DG)
directly into the VMH of awake rats triggers the release of
counterregulatory hormones in the absence of systemic
hypoglycemia (15).
In the present study, we used the microdialysis technique
to perfuse the VMH with 2-DG in awake, unrestrained, and
chronically hypoglycemic nondiabetic rats and spon-
taneously diabetic BB rats. These animal models were cho-
sen because they express similar defects in counterregulatory
hormone secretion (16), as is seen in patients with insulino-
mas (17) and type 1 diabetes (3) during hypoglycemia. The
aim was to directly examine whether chronic hypoglycemia
or diabetes alters the capacity of glucose sensors in the VMH
to recognize and respond to local neuroglycopenia.
RESEARCH DESIGN AND METHODS
Animals. Male nondiabetic and spontaneously diabetic BB rats were purchased
from BB/Wor Laboratories (University of Massachusetts, Worcester, MA). Non-
diabetic BB rats were members of the diabetes- resistant strain of BB rats, of which
<1% develop diabetes. Animals were housed in an environmentally controlled room
DIABETES, VOL. 48, MARCH 1999
 M.A. BORG AND ASSOCIATES

with a 12-h light/dark cycle, and they were maintained on a standard ad libitum RESULTS
rat diet (Agway Prolab 3000, Waverly, NY) comprised of 22% protein, 5% fat, and Effect of chronic hypoglycemia. At the onset of the study,
51% carbohydrate (the remaining 22% consists of ash, crude fiber, and moisture).
Three groups of rats (4–6 months old, weighing 330–370 g) were studied. For each as well as during the baseline period of 5 mmol/l VMH glucose
group, the mean plasma glucose was determined in the fed state by measuring perfusion, mean plasma glucose levels for the chronically
plasma glucose from the tail vein at least three times between 0900 and 2400, and hypoglycemic nondiabetic BB rats and their untreated control
often more frequently, every 2–3 days to adequately determine the overall
glycemic response to each insulin treatment, including the times of the greatest
rats were not significantly different (6.9 ± 0.4 and 7.0 ± 0.5
probability of hypoglycemia, normoglycemia, or hyperglycemia. mmol/l, respectively). However, during perfusion of 2-DG into
Group 1 consisted of untreated nondiabetic rats, aged 4–5 months, with a mean the VMH, the rise in plasma glucose concentration in the
plasma glucose level of 6.9 ± 0.5 mmol/l (mean ± SE), that served as the control chronically hypoglycemic rats was markedly suppressed com-
group (n = 5).
Group 2 consisted of nondiabetic rats that at 3–4 months of age were made
pared with the normal control group (P < 0.05, Fig. 1). Similarly,
chronically hypoglycemic using gradually increased doses of protamine zinc the concentrations of catecholamines and glucagon were sta-
insulin (PZI) (Lilly, Indianapolis, IN) over 1 week, followed by 3–4 weeks of treat- ble and not significantly different in the chronically hypogly-
ment with twice-daily injections of 9–10 U/kg PZI insulin, resulting in mean cemic rats and the control rats during the basal and 5 mmol/l
plasma glucose values of 2.7 ± 0.6 mmol/l (n = 5). glucose VMH perfusion periods. In the 2-DG phase of the VMH
Group 3 consisted of diabetic rats, aged 5–6 months, that were in moderate
glycemic control (mean plasma glucose of 12.4 ± 1.0 mmol/l) achieved by daily perfusion, the rise in plasma counterregulatory hormones in the
injections of PZI insulin in doses of ~11–12 U/kg. The doses of insulin were chronically hypoglycemic rats were markedly suppressed. The
adjusted during treatment to avoid hypoglycemia by frequent monitoring magnitude of the suppression of epinephrine and norepi-
throughout the 24-h diurnal cycle (n = 8). nephrine release was 91 and 93%, respectively. Glucagon
Surgical procedures. Rats were anesthetized as previously described (14) and
placed on a stereotaxic frame. The skull was exposed, and holes were drilled bilat-
responses were also reduced by 77% (P < 0.05), particularly the
erally in chosen coordinates (14,15) through which the guide cannulas were low- peak increment at 60 min, which was diminished by 94%.
ered slowly into the brain and then secured with stainless steel screws and den- Effect of diabetes. Plasma glucose levels in the insulin-
tal acrylic. Immediately after stereotaxic surgery, animals underwent an additional treated diabetic animals in the basal state and during 5
aseptic surgical procedure for placement of internal jugular vein and carotid mmol/l glucose perfusion of the VMH were similar to those
artery catheters. At the end of the procedure, both catheters were filled with
heparin (42 U/ml) and polyvinylpyrrolidone (1.7 g/ml) solution, plugged, tun- seen in control animals (6.9 ± 0.3 mmol/l). As shown in Fig.
neled subcutaneously around the side of the neck, and externalized behind the 1, the rise in the peripheral plasma glucose levels in response
head through a skin incision. Animals were then allowed to recover for 5–7 days. to VMH glucopenia was slightly, but not significantly, reduced
Only those animals that appeared healthy and were able to maintain their weight compared with that in control rats. Figure 2 presents the
were used. The evening before the experiment, animals received their last dose
of PZI insulin, and the microdialysis probes (10.5 mm in length) of side-by-side
hormonal changes during the 100 mmol/l 2-DG VMH perfu-
design were inserted into the guide cannulas, as previously described (18). The sion. There was a 38% reduction (P < 0.05) in the overall
exposed microdialysis membrane was 1.0–1.5 mm (approximately the size of the plasma epinephrine response in the diabetic rats that was
VMH), so that we could selectively perfuse this brain region. At 1 h before the significant at the 60-min time point. However, the reduction
experiment, the VMH perfusion medium was loaded into 1-ml syringes and deliv- in the norepinephrine response in the diabetic group was
ered at a flow rate of 2.5 µl/min using a Harvard perfusion pump (model 22; Har-
vard Apparatus, Holliston, MA). not significantly different from that in the control group. In
At the end of each experiment, the accuracy of probe placement was confirmed contrast, the increase in plasma glucagon that normally fol-
histologically by cresyl violet staining. Only those animals that showed bilateral lowed VMH glucopenia in the nondiabetic animals was
probe placement into the desired brain region were included. totally abolished in the type 1 diabetic rats.
Experimental protocol. Each animal was food deprived for ~4 h before the
study. On the morning of the experiment, the vascular catheters were flushed and
maintained patent by a slow infusion of saline (20 µl/min) that contained a small
amount of heparin (1–2 U/ml), and the VMH microdialysis perfusion was initiated.
Rats were conscious and allowed to roam freely in their cages during the experi-
ment. To achieve comparable plasma glucose levels in each group before study, for
~2 h before the experiment, the chronically hypoglycemic animals (group 2) as well
as the diabetic animals (group 3) were brought to normoglycemic levels (see
RESULTS) by intravenous variable infusion of exogenous 20% glucose or a solution
of insulin (20 mU · kg–1 · min–1), respectively. These infusions were discontinued
20–30 min before initiating the experiment. Thereafter, blood samples were with-
drawn for measurement of baseline plasma concentrations of glucose, glucagon,
epinephrine, and norepinephrine. Subsequently, for the first 30 min of the experi-
ment, the VMH probes were perfused with a solution that contained 5 mmol/l glu-
cose; this was designated as the control phase. Thereafter, 100 mmol/l 2-DG perfusion
was introduced and maintained for 60 min. Arterial blood samples for measurement
of plasma glucagon and catecholamines were taken at 15-min intervals during the
control phase (15 and 30 min) as well as during VMH glucopenia (45, 60, 75, and 90
min). To avoid dilution by fluid in the dead space of the catheter during blood sam-
pling, 0.5 ml of blood was withdrawn before sample collection. Subsequently, the
contents of the initial syringe were reinfused to minimize blood losses. Blood
recently obtained from littermates was also transfused during the study to quanti-
tatively replace the blood withdrawn during the experiment. The protocol was
reviewed and approved by the Yale Animal Care and Use Committee.
Analytical methods and calculations. Plasma glucose was measured in dupli-
cate using a Beckman Glucose Analyzer II (Fullerton, CA). Plasma catecholamines
were measured with a radioenzymatic method (Amersham, Arlington Heights, IL),
and plasma glucagon was measured using a double antibody radioimmunoassay FIG. 1. Effect of chronic hypoglycemia and type 1 diabetes on periph-
procedure (Linco Research, St. Charles, MO) as previously described (14). eral plasma glucose levels during VMH glucopenia. Experimental
Data are expressed as means ± SE. Comparison between the experimental groups included nondiabetic BB control rats (n = 5) ( s), chronically
groups over time was made by analysis of variance with a repeated measure hypoglycemic nondiabetic rats (n = 5) (m), and moderately hypergly-
design, followed by the Student’s t test to localize effects. cemic insulin-treated diabetic BB rats (n = 8) (d). *P < 0.05 vs. normal.

DIABETES, VOL. 48, MARCH 1999 585

 HYPOGLYCEMIAAND DIABETES SUPPRESS COUNTERREGULATION
FIG. 2. Effect of chronic hypoglycemia and type 1 diabetes on plasma
counterregulatory hormones during VMH glucopenia. Experimental
groups included nondiabetic BB control rats (n = 5) ( s), chronically
hypoglycemic nondiabetic rats (n = 5) (m), and moderately hypergly-
cemic insulin-treated diabetic BB rats (n = 8) (d). *P < 0.05 vs. normal.
DISCUSSION
The results of the Diabetes Control and Complications Trial
demonstrated the long-term benefits of intensive insulin ther-
apy aimed at near normalization of glucose levels in patients
with type 1 diabetes (1). However, severe and frequent hypo-
glycemia emerged as a serious complication that has limited
the application of such regimens (1). Defective counterregu-
latory responses associated with type 1 diabetes (2,3) as well
as suppressed hormonal defense mechanisms induced by
iatrogenic hypoglycemia per se (4) contribute to the observed
increased risk of severe hypoglycemia. A better understand-
ing of the mechanisms used to sense glucopenia and how
they are altered by diabetes and iatrogenic hypoglycemia
could therefore offer new therapies aimed at reversing these
counterregulatory defects.
In the current study, we examined how chronic hypogly-
cemia in nondiabetic rats as well as spontaneous insulin-
deficient diabetes in the rat affects the capacity of the VMH
to act as a glucose sensor. For this purpose, we measured the
586
hormonal responses to severe local VMH glucopenia pro-
duced by 2-DG delivered to the VMH via microdialysis. In pre-
vious studies, we also demonstrated that microdialysis probe
placement, although invasive, did not interrupt the ability of
the VMH to stimulate sympathetic and pancreatic a-cell path-
ways in experiments in which systemic hypoglycemia was
produced (14). The microdialysis probes were perfused with
a high concentration (100 mmol/l) of 2-DG, a nonmetaboliz-
able form of glucose, because only a small fraction (~4%) is
actually delivered across the dialysis membrane to the extra-
cellular fluid space of the VMH (14). In earlier studies in nor-
mal Sprague-Dawley rats, we demonstrated that sufficient 2-
DG is delivered by the microdialysis system to produce local
neuroglycopenia, and that this, in turn, provokes brisk coun-
terregulatory hormone responses and systemic hypergly-
cemia (15). Nearly identical changes were observed in the
nondiabetic diabetes-resistant strain of BB rats (group 1)
used in the current study.
As in humans, we have previously reported that nondiabetic
rats made repetitively hypoglycemic with exogenous insulin
show delayed and impaired release of catecholamines and
glucagon during hypoglycemia, and that these changes are
reversible over time (16). We reasoned that if such alterations
were mediated by an impairment of VMH glucose-sensing
neurons to detect neuroglycopenia, there would be a gener-
alized suppression of the hormonal response to VMH 2-DG per-
fusion, as was observed in the current study. To the extent that
our data can be applied to the clinical situation, it is possible
that the suppression of counterregulatory hormone responses
induced by iatrogenic hypoglycemia in normal subjects (6) or
in intensively treated type 1 diabetic patients (19) may also
involve dysfunction of the VMH or any of its efferent pathways.
This defect appears to be glucose specific. In our previous stud-
ies we showed that glucagon and adrenomedullary responses
in chronically hypoglycemic nondiabetic BB rats are pre-
served to nonspecific stimuli (16). Based on the profound
degree of the suppressive effect, one might speculate that it
could involve a variety of mechanisms, such as an impair-
ment in VMH signaling pathways or neurotransmitter release
and/or action as well as an alteration of glucose transport in
this brain area. The exact nature of this defect cannot be
directly established from the current experiments.
The spontaneous diabetic BB rat used in this study, an
established animal model of type 1 diabetes (20), displays
counterregulatory defects remarkably similar to that present
in humans with the disease (21,16). In diabetic BB rats,
glucagon release during systemic hypoglycemia is totally lost
within a week after disease onset, whereas the epinephrine
response is initially preserved but tends to diminish over the
next 6–8 weeks (22). This pattern is similar to that observed
in human type 1 diabetes; however, the time sequence of the
changes is much more rapid in the rat model system (3). The
discrepancy between the appearance of the glucagon and
epinephrine counterregulatory defects in type 1 diabetes may
imply that different pathophysiological mechanisms may
underlie each of these defects. In the diabetic rats, VMH 2-DG
perfusion totally failed to provoke glucagon release. Whereas
this effect was complete, catecholamine release was only
modestly diminished. Although undetected hypoglycemia
induced during insulin treatment of the diabetic rats might
have contributed to the mild epinephrine secretory defect, con-
siderable care was undertaken to avoid hypoglycemia for sev-
DIABETES, VOL. 48, MARCH 1999

eral weeks before study, and in no case was hypoglycemia doc-
umented by glucose monitoring. Thus, it seems likely that in
the diabetic rats, the signal from the VMH was operative, but
mildly impaired, at some level in the path between the VMH
and the adrenal medulla. In contrast, this VMH signal was
totally ineffective in activating the a-cells. Whereas the exact
nature of this a-cell defect is uncertain, it is intriguing to spec-
ulate that it may be due to changes in neural innervation of the
islet, the absence of a b-cell signal, or an intrinsic defect in the
a-cell itself. Extrapolation of these observations in the BB rat
to the clinical setting should, however, be made with caution.
For example, in the clinical setting, type 1 diabetic patients
rarely experience persistent hypo- or hyperglycemia.
In summary, our studies demonstrate that chronic hypo-
glycemia in nondiabetic rats suppresses the ability of the
VMH to recognize glucopenia or activate hormonal counter-
regulation. In diabetic BB rats, the response to VMH glu-
copenia is only slightly diminished for catecholamines but
absent for glucagon. These findings support the hypothesis
that the impaired counterregulation after chronic hypogly-
cemia may result from alterations of the function of the VMH
or its efferent pathways, and that in diabetes, there is a dis-
tinct independent defect in which the communication
between the VMH and the a-cell is interrupted.
ACKNOWLEDGMENTS
This research was supported by grants R01-DK-20495, R01-
DK- 40936, and P30-DK-45735 from the Public Health Service.
M.A.B. is the recipient of a fellowship grant from the Juvenile
Diabetes Foundation International. G.I.S. is an investigator of
the Howard Hughes Medical Institute.
We appreciate the assistance of Aida Groszmann and
Andrea Belous in performing the hormone assays. We also are
grateful to Melissa Huang for expert technical assistance.
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0021-972X/97/$03.00/0
Journal of Clinical Endocrinology and Metabolism
Copyright © 1997 by The Endocrine Society
Resistance to Neuroglycopenia: An Adaptative Response
during Intensive Insulin Treatment of Diabetes*
TIMOTHY W. JONES, WALTER P. BORG, MONICA A. BORG,
SUSAN D. BOULWARE, GREGORY MCCARTHY, DAVID SILVER,
WILLIAM V. TAMBORLANE, AND ROBERT S. SHERWIN
Departments of Internal Medicine, Pediatrics, and Neurosurgery and the General Clinical Research
Center, Yale University School of Medicine, New Haven, Connecticut 06520
ABSTRACT
Counterregulation and awareness of hypoglycemia begins at lower
plasma glucose levels in insulin-dependent diabetes mellitus (IDDM)
subjects given intensive insulin treatment. To determine whether
these changes are associated with an alteration in the susceptibility
of the brain to mild hypoglycemia, we compared central nervous
system responses to hypoglycemia in 8 intensively treated (hemoglo-
bin A1, 8.3 6 0.2%; normal, ,8%) and 11 conventionally treated IDDM
patients (hemoglobin A1, 14.6 6 1.3%) with those in 10 healthy sub-
jects. Plasma glucose was lowered from ;4.6 mmol/L in 0.5– 0.6 steps
using the clamp technique. Glucose levels triggering hormonal re-
sponses and perception of hypoglycemic symptoms were significantly
lower in intensively treated patients compared to their poorly con-
T HE REPORT of the Diabetes Control and Complication
Trial Research Group (1) has established the long term
benefits of intensive insulin therapy aimed at near normal-
ization of glucose levels in insulin-dependent diabetes mel-
litus (IDDM). As a result, this therapeutic approach has been
recommended for (2) and is being offered to an increasing
number of IDDM patients in an effort to prevent or delay
microvascular and neuropathic complications. Unfortu-
nately, the frequency and severity of hypoglycemia are
markedly increased by such regimens despite close medical
supervision (1, 3).
The mechanisms contributing to the greater risk of severe
hypoglycemia during intensive insulin therapy in IDDM
patients have recently been clarified. Although lowering of
target glycemic goals in the face of persisting conventional
risk factors would be expected to promote iatrogenic hypo-
glycemia, impaired counterregulatory defenses against hy-
poglycemia play an important role as well (4 – 6). In the early
stages of IDDM, the capacity to release glucagon during
hypoglycemia is lost (4, 5), and as the duration of the disease
increases, epinephrine responses are also diminished in
some patients (6). In addition, intensified insulin treatment
aimed at restoring glycemia as close to normal as possible
leads to a further deterioration of hypoglycemic counter-
Received June 10, 1996. Revision received August 22, 1996. Accepted
February 28, 1997.
Address all correspondence and requests for reprints to: Dr. Robert
S. Sherwin, Department of Internal Medicine, Yale University School of
Medicine, 333 Cedar Street, New Haven, Connecticut 06520-8020.
* This work was supported by grants from the USPHS (RR-06022,
RR-00125, DK-20495, and DK-45735) and fellowship grants from the
Juvenile Diabetes Foundation International (to W.P.B. and M.A.B.).
1713
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Vol. 82, No. 6
Printed in U.S.A.
trolled counterparts (P , 0.05), and hormonal responses were sup-
pressed compared to those in healthy controls. Similarly directed
changes occurred in the level of circulating glucose required to alter
cortical evoked potentials during hypoglycemia. A greater reduction
in plasma glucose was required to alter P300 event-related potentials
in the intensively treated patients (2.2 mmol/L) compared to those in
the conventionally treated and nondiabetic groups (;3.5 and ;3.0
mmol/L, respectively). We conclude that intensively treated IDDM
patients are resistant to changes in cortical evoked potentials induced
by mild hypoglycemia. This may explain why intensively treated
IDDM counterregulate and experience hypoglycemic symptoms at a
lower glucose level than conventionally treated patients. (J Clin En-
docrinol Metab 82: 1713–1718, 1997)
regulation and symptomatic unawareness of hypoglycemia
(7–10). Recent studies suggest that this phenomenon is
caused by iatrogenic hypoglycemia per se. In both healthy
subjects and IDDM patients a brief period of moderate hy-
poglycemia reduces hormonal responses and symptoms
during experimentally induced hypoglycemia the following
day (11, 12). Conversely, it has been reported that in young,
poorly controlled IDDM patients, hypoglycemic symptoms
and epinephrine responses can be elicited when glucose is
lowered into the normal range (13).
A key issue is whether the divergent changes in glycemic
thresholds for counterregulatory responses in well con-
trolled, intensively treated and in poorly controlled, conven-
tionally treated IDDM patients are mirrored by similarly
directed changes in brain function as the availability of glu-
cose via the circulation is reduced. This possibility is sup-
ported by studies in rats demonstrating that chronic hypo-
glycemia and hyperglycemia, respectively, increase and
decrease the efficiency of glucose extraction by the brain
(14 –16). Furthermore, in normal human subjects rendered
mildly hypoglycemic for several days and IDDM patients
who have been well controlled, brain glucose uptake is more
effectively preserved during hypoglycemia (17, 18). It is un-
certain, however, whether these adaptations in brain glucose
uptake during hypoglycemia are accompanied by corre-
sponding alterations in brain function. Studies using tests of
neuropsychological performance to evaluate the effect of
diabetes treatment on the central nervous system (CNS) re-
sponse to hypoglycemia have generated contradictory re-
sults (19 –22). Studies were, therefore, undertaken to assess
this question by combining the hypoglycemic clamp with
1714 JONES ET AL.
measurements of cortical evoked potentials, an end point
shown to be sensitive to even modest decrements in plasma
glucose (23).
Subjects and Methods
Subjects
A total of 29 subjects were studied, including 19 IDDM patients and
10 nondiabetic controls. Eight of the patients with IDDM were receiving
intensive insulin therapy (multiple daily injections or continuous sub-
cutaneous insulin infusion) for at least 6 months, and 11 were being
treated with conventional insulin regimens (twice daily injections of
regular and intermediate acting insulin). They were eligible for study if
their disease duration was more than 1 yr, they had no symptoms or
physical signs of autonomic neuropathy, and they were receiving no
medications other than insulin and had no acute illness. The clinical
characteristics of all subjects are shown in Table 1. Each gave written
informed consent to participate in the study protocol, which was ap-
proved by the Yale human investigation committee.
Hypoglycemic clamp procedures
Studies were performed after a 10- to 12-h overnight fast. Subjects
with diabetes were admitted to the Yale General Clinical Research Cen-
ter on the evening before the study. An iv catheter was inserted, and
basal insulin was administered as a continuous iv infusion that was
adjusted during the night based on plasma glucose measurements ob-
tained every 30 – 60 min. The plasma glucose concentration did not fall
below 4.0 mmol/L in any of the patients during the overnight period.
The next morning, a modification of the glucose clamp technique was
used to produce a gradual and standardized reduction in plasma glu-
cose. The methods used for this procedure (hypoglycemic clamp) have
been previously described (10). Briefly, two venous catheters were em-
ployed, one in an antecubital vein for administration of glucose and
insulin, and the other in a dorsal hand vein for blood sampling. The hand
was placed in a heated (;65 C) box to “arterialize” venous blood (24).
After a 60-min basal period during which baseline measurements were
obtained, a primed continuous infusion of regular human insulin was
given (Novo Nordisk, Princeton, NJ) in a dose of 80 mU/m2zmin. Plasma
glucose was measured at the bedside in duplicate at 5-min intervals
using a Beckman glucose analyzer (Beckman, Fullerton, CA), and target
glucose levels were achieved by varying the rate of an infusion of 20%
glucose. In all three groups, plasma glucose was maintained at eugly-
cemic levels (;4.6 mmol/L) for the initial 60 min of the study and then
was reduced in 0.5– 0.6 mmol/L steps each hour for 240 min. In inten-
sively treated patients, the study was extended for an additional 60-min
period to allow for an additional hypoglycemic plateau of 2.2 mmol/L.
All subjects were masked to the plasma glucose levels during the study.
Measurements
Blood samples were taken at 10- to 20-min intervals for measurement
of insulin and counterregulatory hormones. In the final 20 min of each
hypoglycemic plateau (beginning at 4.0 mmol/L), symptoms and elec-
trophysiological data were recorded. Symptoms were assessed using a
questionnaire presented on a laptop computer that also recorded subject
responses. Subjects rated the following symptoms on a scale of 1 (not at
all) to 7 (extreme): headache, difficulty with concentration, weakness,
TABLE 1. Clinical characteristic of the study groups and plasma counterregulatory hormones concentration during baseline
Conventionally treated
IDDM (n 5 11)
Age (yr) 23 6 2 (15–32)
Sex (m/f) 6/5
Duration of IDDM (yr) 11 6 1 (5–16)
HBA1 (%) 14.6 6 1.3 (9.9 –22.0)
Epinephrine (pmol/L) 350 6 65
Cortisol (nmol/L) 342 6 60
GH (mg/L) 6.1 6 1.3
Values are expressed as the mean 6 SEM, with the range in parentheses. HBA1 values in nondiabetic subjects range from 4 – 8%.
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JCE & M • 1997
Vol 82 • No 6
difficulty thinking, sweating, slowed thinking, pounding heart, and
shakiness. The sum of these eight items in each subject constituted the
total symptom score at the observation point. In addition, four “filler”
items (i.e. pain in joints, earache, watery eyes, and ringing in ears) were
included to control for nonspecific symptoms not referable to hypogly-
cemia. To obtain cortical evoked potentials, scalp electrodes were placed
at Cz and Pz positions, with a reference electrode placed in the opposite
ear. A bipolar pair of electrodes was placed above the right eye to
monitor for ocular artifacts. P300-evoked potentials were obtained with
an auditory categorization (“oddball”) task, in which subjects were
required to silently count the number of soft clicks. The loud clicks were
presented to the ear ipsilateral to the reference electrode, and the soft
clicks were delivered to the ear contralateral to the reference electrode.
The proportion of soft clicks varied between 10 –20% of a total of 200
clicks. Two replications were obtained at each plasma glucose plateau.
Determinations and analysis
Catecholamines were measured by radioenzymatic assay (Upjohn,
Kalamazoo, MI), and free insulin, GH, cortisol, and glucagon were
determined using double antibody RIAs, as described previously (10).
Averaged evoked potential waveforms for P300 were calculated on-line
and then analyzed off-line by two investigators who were blinded to the
subjects experimental group and to the glycemic levels at which the
evoked potentials were obtained. Peaks and latencies of the P300 po-
tential were measured with a waveform cursor. P300 evoked potentials
were calculated as the difference between potentials evoked by soft
clicks and those elicited by loud clicks; this procedure minimized po-
tentials evoked by clicks per se and isolated those associated with the
counting task.
Demographic data are expressed as the mean 6 sd, and all other data
are expressed as the mean 6 se. Comparisons of glucose levels, hormone
responses, symptoms scores, and P300 latency and amplitude measures
between the study groups were made using ANOVA with repeated
measures design, followed by Student’s t test to localize the effects. P ,
0.05 was considered statistically significant. Hormonal data are pre-
sented as the average of measurements obtained during the last 40 min
of each glycemic step of the clamp studies.
Results
Glucose and insulin levels
As shown in Fig. 1, the hypoglycemic clamp procedure
caused plasma glucose levels to decline in a nearly identical
fashion in each of the three groups during the first 240 min
of the study, i.e. ;0.5 mmol/L each hour to a nadir of ;3
mmol/L. In the intensively treated IDDM subjects, plasma
glucose was further reduced to 2.2 mmol/L for an additional
60-min period. Steady state plasma free insulin levels during
the clamp studies were not significantly different between
the groups (nondiabetic, 847 6 36 pmol/L; conventionally
treated IDDM, 744 6 60 pmol/L; intensively treated IDDM,
828 6 72 pmol/L; P 5 NS).
Intensively treated Nondiabetic
IDDM (n 5 8) adults (n 5 10)
30 6 3 (20 – 41) 24 6 1 (20 –28)
4/4 5/5
15 6 2 (4 –27)
8.3 6 0.2 (7.6 – 8.9)
308 6 51 231 6 35
329 6 73 295 6 28
6.3 6 2.4 1.9 6 0.3
 INTENSIVE INSULIN THERAPY AND NEUROGLYCOPENIA
FIG. 1. Plasma glucose levels (mean 6
SEM) during the stepped hypoglycemic
clamp procedure in intensively treated
IDDM (8), conventionally treated
IDDM (11), and control (10) subjects.
Counterregulatory hormones and symptoms
The plasma counterregulatory hormone responses of each
group during the hypoglycemic clamp study are summa-
rized in Fig. 2. During the hypoglycemic phase of the study
a significant rise in plasma epinephrine above basal values
occurred at the 4.0 mmol/L step in the conventionally treated
IDDM patients, whereas there was a small, but also signif-
icant, increase at the 3.5 mmol/L step in the nondiabetic
subjects (P , 0.05 for both groups). In the intensively treated
patients, a significant rise in plasma epinephrine did not
occur until plasma glucose was lowered below 3.0 mmol/L,
and plasma epinephrine levels were substantially lower than
those in the other groups (P , 0.05). Plasma cortisol rose
significantly at 3.0 mmol/L glucose in both conventionally
treated IDDM and nondiabetic subjects (P , 0.05), whereas
a glucose level of even 2.2 mmol/L was not sufficient to elicit
a significant response in the intensively treated patients.
Moreover, significant increments in GH first occurred at a
higher glucose level in conventionally treated IDDM and
nondiabetic subjects (3.5 mmol/L) compared to the level in
the intensively treated patients (3.0 mmol/L; P , 0.05).
As shown in Fig. 3, symptomatic awareness of hypogly-
cemia followed a similar pattern. Hypoglycemic symptom
scores increased significantly (P , 0.05) above baseline at 4.0
mmol/L in conventionally treated patients, and at 3.0
mmol/L in nondiabetic subjects and the intensively treated
group. There were no changes in control symptoms in any of
the groups throughout the study (data not shown).
Electrophysiological measures
Figure 4 depicts P300 amplitude in the three groups. At
baseline, P300 amplitude was not significantly different
among the groups. During the hypoglycemic phase, the con-
ventionally treated IDDM patients showed a significant (P ,
0.05) reduction in P300 amplitude at the 3.5 mmol/L glucose
plateau, a higher glucose level than that producing a signif-
icant P300 change in nondiabetic control subjects (3.0 mmol/
L). In contrast, the well controlled IDDM patients failed to
show a significant change in P300 amplitude until plasma
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1715
glucose had been reduced to 2.2 mmol/L. Moreover, P300
latency significantly increased by ;9% in the conventionally
treated IDDM and in the nondiabetic controls at the 3.0
mmol/L step (P , 0.05), whereas a small, but insignificant,
increase (;5%) occurred at the 2.2 mmol/L step in the well
controlled IDDM patients.
Discussion
In keeping with the earlier reports (7, 8, 10), our intensively
treated IDDM patients required a greater hypoglycemic
stimulus to trigger counterregulatory hormone responses
and symptoms than did poorly controlled, conventionally
treated patients with IDDM. A key unresolved issue is
whether these changes associated with IDDM therapy are
accompanied by a similar shift in the glucose level at which
brain function becomes impaired. This is of importance clin-
ically because the consequences of hypoglycemia depend at
least in part on the therapeutic window between counter-
regulatory responses and/or symptoms and onset of CNS
dysfunction. The results of the current study suggest that the
shift in counterregulatory responses to hypoglycemia in
IDDM is, in fact, mirrored by similarly directed changes in
neuroglycopenia onset, as assessed by P300 measurements.
Thus, intensive therapy may have led to an adaptation in
brain glucose metabolism that resulted in greater preserva-
tion of cortical evoked potentials in the face of subnormal
glucose levels, levels that caused subtle neuroglycopenia in
conventionally treated IDDM patients. This conclusion is
supported by the experimental data in nondiabetic and di-
abetic rats (14 –16, 25, 26) and in human subjects (17, 18). In
rats, chronic hypoglycemia increases and chronic hypergly-
cemia decreases the efficiency of brain glucose extraction and
metabolism (14 –16). Furthermore, chronically hyperglyce-
mic BB rats are more susceptible (25) and recurrently hypo-
glycemic diabetic BB rats are resistant to the adverse effects
of hypoglycemia on brain stem function (26). Recent studies
suggest that these changes may be due to changes in blood-
brain barrier glucose transport (27). In humans, several days
of sustained mild hypoglycemia or intensive insulin treat-
1716 JONES ET AL.
FIG. 2. Plasma counterregulatory hormones responses of each sub-
ject group to stepped reduction in plasma glucose concentrations
during hypoglycemic clamp studies.
ment leading to near-normal glycated hemoglobin levels in
IDDM patients has been reported to prevent the decline in
whole brain glucose uptake (measured by internal jugular
venous sampling) produced by experimental hypoglycemia
(;3.0 mmol/L) using the stepped hypoglycemic clamp tech-
nique (17, 18).
Previous studies examining the effect of glycemic control
of IDDM on CNS function during hypoglycemia, however,
Downloaded from jcem.endojournals.org on April 7, 2006
JCE & M • 1997
Vol 82 • No 6
FIG. 3. Total hypoglycemic symptoms score (mean 6 SEM) of each
subject group during hypoglycemic clamp studies. The total symptom
score represents the sum of eight hypoglycemic symptoms. Asterisks
represents significant difference vs. baseline (P , 0.05).
FIG. 4. P300 amplitude during each hypoglycemic plateau in nondi-
abetic, conventionally treated IDDM, and intensively treated IDDm
subjects. Asterisks indicate significant amplitude reduction compared
to baseline (P , 0.05).
have yielded conflicting results (19 –22, 28, 29). It has been
suggested that intensively treated IDDM patients may be
more, rather than less, vulnerable to neuroglycopenia than
poorly controlled counterparts when conventional electro-
encephalogram recordings are used as an end point (22). In
contrast, studies using neuropsychological tests to assess
cognitive performance during hypoglycemia in IDDM pa-
tients have found either no change (19, 21) or a lowering of
the plasma glucose level required to provoke cognitive dys-
function in patients treated intensively (20, 28, 29). It should
be emphasized that these discrepancies may be more appar-
ent than real because the various tests of cognitive function
are likely to involve specific brain regions that may have
different glucose requirements.
In the current study, brain function was assessed using
P300, an event-related potential elicited during discrimina-
tion of signals with a low subjective probability. The P300
waveform, unlike the electroencephalogram, which mea-
sures the spontaneous electrical output of the brain, is gen-
erated by the active cognitive processing of stimulus infor-
 INTENSIVE INSULIN THERAPY AND NEUROGLYCOPENIA
mation and is not affected by the physical characteristics of
the stimulus. It requires the active participation of the subject
and involves higher brain centers, particularly the hip-
pocampus, and the parahippocampal gyrus (30). Although
the P300 may be influenced by such external factors as the
probability of the stimulus and the relevance and difficulty
of the task, and may only be relevant for specific cognitive
functions, it is useful in analyzing effects in which the subject
acts as his/her own control (31). In this context it has been
shown to be sensitive to small decrements in circulating
glucose (23, 32). These changes appear to be produced by
hypoglycemia per se because the infusions of multiple coun-
terregulatory hormones have no effect on P300 under con-
ditions of euglycemia (33).
Our observation that intensively treated IDDM patients
require a greater and poorly controlled, conventionally
treated IDDM patients require a smaller decrement in
glucose concentration to alter P300 event-related poten-
tials is consistent with data cited above suggesting the
development of a CNS adaptation depending on the in-
tensity of insulin treatment (14 –18, 25, 26). Our data are
consistent with those of an earlier report that also used the
P300 to monitor changes in cognitive function during hy-
poglycemia in IDDM patients (34). However, in that study
the assessment of glycemic thresholds for P300 changes
was limited by the fact that hypoglycemic stimulus was
brief, the magnitude of stimulus was not controlled, and
the measurements of P300 were made under rapidly
changing, nonsteady state conditions. Recent studies sug-
gest that there is a delay before changes in plasma glucose
alter measurement of P300 (34).
In summary, both ends of the spectrum of glycemic
control of IDDM influence in a similar way not only the
level of glucose required to trigger counterregulatory re-
sponses, but also the responsiveness of at least some brain
functions to mild hypoglycemia. Although the nature of
this association is uncertain, its existence may be more
than just a coincidence. It is conceivable that the same
molecular mechanisms affected regions of the CNS re-
sponsible for glucose sensing (35, 36) as well as others
involved in cortical event-related potentials (30). It should
also be noted that although P300 was preserved during
mild to moderate experimental hypoglycemia in inten-
sively treated IDDM patients, they are at much higher risk
of severe hypoglycemia in real life than conventionally
treated patients. Therefore, this treatment-induced adap-
tation may have a clinically adverse effect if plasma glu-
cose falls to values well below those that can be compen-
sated for by changes in brain glucose metabolism.
Acknowledgments
We thank Aida Groszmann and Andrea Belous for their help with the
measurements of plasma hormones, and Elizabeth Roessler for her tech-
nical help with the measurement of evoked potentials.
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1986 Chronic hypoglycemia increases brain glucose transport. Am J Physiol
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adapts to iatrogenic hypoglycemia in IDDM [Abstract]. Diabetes. 44(Suppl
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35. Borg WP, During MJ, Sherwin RS, Borg MA, Brines ML, Shulman GI. 1994
Ventromedial hypothalamic lesions in rats suppress counterregulatory re-
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 ORIGINAL
ARTICLES

Enhoncedodrenomedullory response
ond increosedsusceptibility to
neuroglycopenio : Mechonisms
underlyingthe odverseeffects of sugor
i n g e s t i o ni n h e o l t h yc h i l d r e n
TimothyW. Jones,vo, Wolterp. Borg,vo. SusonD. Boulwore.
uo.
GregoryMcCorthy,pno.RobertS.Sherwin,vo, ond
WilliomV. Tomborlone,MD
Fromthe Deportmentsof Pediotrics,
InlernolMedicine,ond Neurosurgery
ond the Generol
centers,yole university
clinicolReseorch schoolof Medicine,New Hoven,connecticut

oblecllve: Eoling simple sugors hos been suggesled os hoving odverse behov-
lorol ond c.ognlllve ellecls in children, buf o physiologic me-chonism hos not
been esloblished. rhis srudy wos performed to oddresJ thls lssue.
Deslgn: Metobollc, hormonol, ond symptomofic responEes lo o slonctqrd orol
glucose lood (1.75 gm/kg; moxlmum, r20 gm) were compqred In 25 heolthy
children ond 23 young odults, ond lhe hypoglycemlc clomp, logether wilh
meosuremenls of p300 oudlfory evoked polenliols, wqs used fo ossesswhether
chlldren ore more vulneroble lhon odulls to neuroglycopenlo.
SettlngzChlldren's Cllnicol ReseorchCenler, Yole UniversltySchool ot Medtcine.
Pesults|Bosellne ond olol glucose-siamuloted plosmo glucose ond insulin lev_
els were simllor in bofh groups, including fhe nodir glucose level 3 to s hours of-
ler orql odmlnlslrollon ol glucose (3.4 -r 0.1 mmol/t (6,1r l.g mg/dl) in children
ond 3.5 r- 0.t mmol/t (63 -* l.E mg/dtt in odulfs). rhe lole glucose decleose
sllmuloted o lise ln plosmo epln6phrlne levets thol wos fwololJ hlgher In chlldren
lhon fn odulls (2260 t 269 vs t03t + 147 pmo'/L l4o7 -r 52 vs tg6 + 26 pg/mll, p
<0.0{) ond o slgniflconl increose in hypoglycemic symplom scores in chlldren
(p <0.0f )' bul nol ln qdulls. During conlrol experimenls, In which stx ot the heolthy
chlldren Ingesfed q sugor-tree drlnk, lhere were no slgnlficont chonges In
ploimo glucose levels, hormone concenlrollon!, or hypoglycemlc sympfom
scores. Durlng lhe hypoglycemic clomp, p300 polenilols dld not chonge In ony
ot eighl odull sublecls unlll lhe plosmo glucose concenlrollon wos lowered to
3.0 mmol/L (54 mg/dl), whereos similor chonges ln p300 polenilqls were ob-
served ln slx of seven chlldren of glucose levels 3.6 lo 4.2 mmol/l (65 fo 75
m9/dl).
concluslon: Enhonced odrenomedullory responses lo modest reducllons in
plosmo glucose concenlrolion ond Increosed suscepilblllty fo neuroglycope-
nlo moy be impoilonl conltlbuting locfors lo qdverse behqvlorol ond Jognlfive
eftecls ofler sugor ingesllon in heolthy children. (J peoren ig95;126:ll1-71

Supportedby grants RR06022, RR00125, DK20495, and Reprint requests:William V. Tamborlane,MD, Departmentof
HD3067l from the NationalInstitutesof Healthand by a grant Pediatrics,Yale University Schoolof Medicine, 333 Cedar St..
fromthe JuvenileDiabetesFoundationInternational. New Haven,CT 06510-8064.
Copyrighto 1995by Mosby-Year Book, Inc.
Submitted
for publicationSept.6, 1994;acceptedOcr,.26,1994. 0022-3476lesl$3.00
t + 0 9/2o/6rs76
I
I
I
I
t7l
172 Joneset al.
The question of whether refined sugar adverselyaffects the
behavior or cognitive functions of healthy children is a con-
tinuing source of controversy. Whereas parents and clini-
cians have frequently reported that even healthy children
are prone to the development of behavioral changes and
cognitive defectsafter eating simple sugars,the outcomesof
research studies have been complex and discrepant.l-aIn
addition, possible physiologic mechanisms for enhanced
sensitivity to dietary sugar during childhood have not been
clear. The presumed negative reactionsto sugar have been
attributed to an early rise or late fall in the plasma glucose
concentration, and to an immunologic responseto sucrose.5
Unfortunately, given the lack of consistentobjectivedata to
substantiatetheseassumptions,all thesehypothesesremain
open to questron.
The results of our previous studies of counterregulatory
respons€sto hypoglycemia in children6'7 prompted us to
propose a new hypothesis to explain the mechanisms
underlying adverseeffectsof sugar ingestionin children. We
hypothesizedthat, although the changesin plasma glucose
levels after sucrose ingestion do not differ between adults
and children, the children would show enhanced adreno-
medullary and symptomatic responsesto these changesin
comparison with those of adults. Several lines of evidence
See related article, p. l7E.
support this hypothesis.Although sugar ingestion does not
normally causeseverereductionsin plasma glucoselevelsin
the late postprandialperiod in children,s'eour previous
study showed that plasma epinephrineresponsesto identi-
cal, modest insulin-induced reductions in plasma glucose
are twofold greater in healthy children than in healthy
adults.6 In addition, the plasma glucoselevel that triggers
epinephrinereleaseand symptoms is substantiallyhigher in
children than in adults,T reaching values (plasma glucose
levels4.4 to 3.4 mmol/L [80 to 6l rng/dl]) that are com-
monly observed 3 to 5 hours after oral glucose ingestion.
To test our hypothesis,we compared the metabolic, hor-
monal, and symptomatic responsesof healthy children and
healthy young adults with a standardized, large glucose
load. In addition, the hypoglycemic clamp technique was
combined with serial measurementsof cortical auditory
evokedpotentials to assesswhether young subjectsare more
susceptibleto the adverseeffectsof reduced glucoseavail-
ability on cognitive function.
METHODS
Subjects. Forty-eight nonobesesubjects(25 children' 23
adults) were studied. To be eligible, the subjectshad to be
The Journal of Pediatrics
Februarv 1995
healthy, taking no medications, and have no history of di-
abetesor carbohydrate intolerance. The children included
eight boys and 17 girls between 8 and 16 years of age; the
adults included 9 men and 14 women between 20 and 30
years of age. Subjects with attentional, behavioral, or psy-
chiatric problems or with a history of unusual sensitivity to
sugar were excluded from the study. All subjectswere con-
suming weight-maintaining diets containing at least 115
gm/mz body surface area of carbohydratesper day before
the study. Ofthe 25 children, eight were prepubertal (Tan-
ner stage I), and the other l7 had Tanner stage II to IV de-
velopment.Bodymassindex(mean + SD)averaged18.2 +
2.2kglm2 in the children and22.6 -r 2.8 in the adults. The
study was approvedby the Yale University School of Med-
icine Human Investigation Committee, and informed writ-
ten consentwas obtained from all subjectsand their parents
(for the children).
Procedures.All subjectswere admitted to the Yale Gen-
eral Clinical ResearchCenter, where a history was obtained
and a physical examination performed. The studies were
started between8 and 8:30 epr, after the subjectshad been
fasting for l0 to 12 hours overnight. With all procedures,
an intravenouscatheter was inserted in a vein of a hand or
distal portion of a forearm for blood sampling, and that
"arterial-
hand was kept in a heated box (60o to 65" C) to
ize" the blood.
Oral glucose loading. All subjects took part in the oral
glucose loading study. They were allowed to rest for at least
30 minutes after insertion of the blood sampling catheter
before baselinemeasurementswere obtained. Glucosewas
ingestedin a dosageof 1.75 gm/kg body weight to a max-
imum of 120 gm (actual amount, I l0 + 5 gm in adults and
86 + 6 gm in children [mean + SD]) with a decaffeinated
cola preparation (General Medical Corp., Richmond, Va.).
Blood sampleswere obtained every l0 minutes from -30 to
300 minutes for measurementof the plasma glucose con-
centration, and every 30 minutes for measurement of
plasma levels of insulin, catecholamines,and other coun-
terregulatory hormones (growth hormone, cortisol, and
glucagon).
Each of the subjectsrated a list of symptoms before and
every 60 minutes after glucose ingestion, as previously de-
scribed. Symptoms (recorded on a lap-top computer) were
rated on a scale of I (not at all) to 7 (extreme). The eight
hypoglycemic symptoms included pounding heart, feeling
shaky, feeling weak, having difficulty concentrating, head-
aches,feeling anxious, slowed thinking, and feeling sweaty.
The sum of these symptoms at each observation point con-
stituted the total hypoglycemic symptom score at that time.
In addition, four filler items (earache, pain in joints, watery
eyes,and ringing in ears) were included to account for non-
The Journal of pediatrics
Volume126,Number 2
specificeffects not referable to glucoseand antiinsulin hor-
mones.
Control experiments were also performed in three boys
and three girls, aged 10 + 3 years (mean r- SD), who had
participated in the oral glucoseloading studies.These con_
trol experiments were performed as describedabove; how_
ever, the oral glucoseload was replacedby an equal volume
of sugar-free decaffeinatedcola drink (Coca-Cola Co., At_
lanta. Ga.).
Hypoglycemic clamping. Eight of the children, aged
ll + 2 years (mean + SD), and eight of the adults,aged
24 -t 2 years, who had taken part in oral glucose loading
experiments participated in the clamp protocol. However,
the cortical evoked potentials of one of children could not
be analyzed becauseof technical problems and was not rn-
cluded in the analysis of electrophysiologicdata.
The methods used for the hypoglycemicclamp have been
describedin detail elsewhere.l0For this procedure,a second
cathcter was inserted in an antecubital vein in the arm op-
posite to the blood-sampling hand for administration of ex-
ogenous glucose and insulin.
After a 30-minute rest period, three blood sampleswere
obtained during a 40-minute interval for measurementof
baselinc glucose and hormone levels.A primed continuous
infusion of rapid-acting human insulin (Novolin; Novo
Nordisk, Princeton, N.J.) was then begun at a continuous
rate of 480 pmol . m-2 . min-I.
After the insulin infusion was begun, the desired plasma
glucose level was achieved by varying the rate of 20Vogltt-
cose infusion on the basis of measurementsof plasma glu-
cose obtained at S-minute intervals. Blood samples for
measurementof insulin and epinephrinewere taken at 20-
minute intervals throughout the study. In all subjects,
plasma glucosewas initially maintained at fasting euglyce-
mic levelsfor 60 minutes and then reducedin hourly -Q.J6
mmol/L (10 mg/dl) steps to a nadir of 3.0 mmol/L (54
mg/dl). The subjectswere masked to plasma glucoselevels
during the study.
Electrophysiologic recordings were obtained during the
last l0 to 15 minutes of each glycemicplateau.Scalp elec-
trodes were placed at the C, and P, positions,with a refer-
ence electrode placed on one ear and the ground electrode
placed on the opposite ear. A bipolar pair of electrodeswas
placed above and below the right eye to monitor for ocular
artifacts. The P300 evokedpotentialswere obtained with an
auditory categorization ("oddball") task in which subjects
were required to count silently the number of soft clicks de-
livered in a train consistingof a random mix of frequent loud
and infrequent soft clicks. The loud clicks were presentedto
the ear ipsilateral to the reference electrode, and the soft
clicks wcre deliveredto the ear contralateral to the reference
Joneset al. 173
electrode.The proportion ofsoft clicks varied between l0Zo
aad 20Vaof 200 clicks, and subjectsreported their count of
soft clicks at the end of each run. Two replicationswere ob-
tained at each baseline(before insulin infusion) and at each
plasma glucose plateau.
f)eterminations.Plasma glucose was measuredin dupli_
cate at the bedsidewith a glucose analyzer (Beckman In_
struments Inc., Fullerton, Calif.). Epinephrine and norepi_
nephrine were measured with a radioenzymatic assay
(Amersham Corp., Arlington Heights, Ill.), glucagon (ICN
Biomedicals,Inc., Costa Mesa, Calif.), cortisol (Diagnostic
Products Corp., Los Angeles, Calif.), and growth hormone
(Kallestad Diagnostic Inc., Chaska, Minn.) were deter_
mined by radioimmunoassay.The intraassaycoefficientsof
variation for these assayswere as follows: for epinephrine,
20.2Voat 175 pmol/L (31.5 pg/ml) and 6.j%oat l168
pmol/L (210 pg/ml); for growth hormone, 6.2Voat 3.5
pg/L (3.5 nglml); for glucagon,9Vaat t22 ng/L (t22 pgl
ml); and for cortisol, l2go.Plasma insulin was measuredby
double-antibody radioimmunoassay (Binax Inc., South
Portland, Maine).
Statistical methods and analyses. Glucose and hormone
responsesto orally administered glucoseand during clamp
studies were compared betweon groups by analysis of var!
ance with repeated measures design. Other comparisons
were made by analysisof variance,unpaired Student , test,
and chi-square analysis where appropriate. The p values
(0.05 are reported as significant.
Group differencesin symptom scores after glucose in-
gestion were examined with time and at the plasma glu-
cosenadir. For the latter comparison,the symptom assess-
ment that occurred at or immediately after the nadir
plasma glucoselevel in each subject was used. During the
hypoglycemicclamp procedure,the plasma glucosethresh-
old for epinephrine releasein each individual subject was
defined as the glucoselevel at which a sustainedelevation
of >410 pmol/L Qa pg/ml\ above basal values was ob-
served, as previously described.TThe glycemic threshold
for changesin P300 potentials in individual subjectsduring
the clamp procedure was defined as the plateau plasma
glucoselevel at which a 30Voor greater reduction in p300
amplitude was observed.Demographic data are presented
as mean + SD, whereas other data are presented as
mean + sEM.
RESULTS
Glucose ingestion. Basal plasma glucose levels and plas-
ma insulin levels (55 + 5 pmol/L [8.8 t 0.8 pUlm|
in children;60 {- 5 pmol/L [9.6 + 0.E pUlm[ in adults)
were similar in both groups, and the glucose and insu-
lin profiles were similar in children and adults after glucose
,,,t,rRU
11 4 Jones et al The Journal of Pediatrics
Februarv 1995

Ioble l. Basal and nadir plasma glucoseand basal and Toble ll. Total hypoglycemic and filler (control)
peak hormone concentrations (mean -r SEM) after symptom scoresat baselineand at the postprandial
glucose load glucose nadir

Chlldren Adults Children Adulfs

P l a s m a / g l u c o s e( m m o l / L ) Glucose Glucose
Basal 4.6 + 0.1 4.8+ 0.1 Boseline nodir Soieline nodll
Peak ?.5 + 0.3 8.1 + 0.4
Nadir 3.4 + 0.1 3.5+ 0.1 Total hypoglycemic scores
P l a s m a e p i n e p h r i n e( p m o l / L ) Mean 12.8 22.O' l0.o l 3.o
Basal 229 + 27 I9l + 27 sE 1.0 3.0 0.5 1.7
Peak 2260 + 289* l03l + 147 Filler (control) scores
Plasma growth hormone (pg/L) Mean 5.0 5.5 5.0 5.2
Basal 1.7+ 0.3 l.l + 0.2 sE 0.5 0.6 0.4 0.5
Peak 1 9 . 5+ 2 . 5 1 8 . 3+ 2 . 8 tp <0.01 versus baseline.

Plasma glucagon (ng/L)

Basal 94+12 1 2 0+ l 8
Peak 2 0 1+ 3 l 180 + 25
To convert to metric units: multiply glucosevalue by 18. epinephrinevalue
by 0.I8. growth hormone value by 1.0, and glucagon value by L0.
tp <0.01 versus adults.
ingestion (data not shown). Peak and nadir plasma glu-
cose levels observed in the postprandial period in individ-
ual subjects determined by frequent sampling (every 10
minutes) were virtually identical in children and adults
(Table I).
Baseline plasma epinephrine levels were similar, and
mean epinephrine concentrationsrose in both groups in re-
sponseto the late postprandial fall in plasma glucose (Ta-
ble I). However, the rise in the plasma concentration of
epinephrinewas significantly greater in the children, reach-
ing peak values that were nearly twofold higher in the chil-
dren than in the adults (p <0.01) (Table I). On the oth-er
hand, peak postprandial plasma growth hormone and glu-
cagon levelsdid not differ betweenthe groups.Basal plasma
concentrationsof cortisol and norepinephrinewere similar
in healthy children and adults, and levelsof thesehormones
did not change significantly in either group after oral glu-
cose (data not shown). Results of subgroup analysesfailed
to demonstrate a significant effect of gender or pubertal
stageon the rise in epinephrinelevelsafter glucoseingestion
by the 25 healthy children.
Total hypoglycemic and filler (control) symptom scores
were similar in both groups at baseline(Table II), and the
symptom scores remained unchanged in the adults after
glucoseingestion. In contrast, total hypoglycemicsymptom
scoresrose sharply in the children in associationwith the
late fall in plasma glucoseconcentration (p <0.01 vs base-
line). As in the adults, filler (control) symptom scoresdid
not changein the children throughout the study. The change
in hypoglycemic symptom scoresin the children was mainly
due to significantly increased reporting of feeling shaky
(from 1.7 + 0.2 to 3.2 + 0.6), sweaty(1.5 + 0.2 to 2.8 +
0.5), or weak (1.9 + 0.3 to 3.8 + 0.5), or having a
pounding heart I ."7+ 0.2 to 2.5 + 0.5) (p (0.05 vs base-
line).
ln contrast to the response to glucose ingestion, no
changesin plasma epinephrine levels were observedafter
the sugar-free cola drink. As a result, plasma epinephrine
levelswere significantly higher after glucoseingestion ver-
suscontrol valuesat 240 minutes and 270 minutes (p <0.05)
in these subjects (Fig. l). Total hypoglycemic symptom
scoresalso did not change from baseline values (ll + 2)
during the control study, in contrast to the increasein hy-
poglycemicsymptomsin thesesubjects( I I -r 2 to 25 + 4)
after glucoseingestion.
Hypoglycemic clamp studies. As shown in Fig. 2, the
plasma glucose concentration was gradually reduced in
nearly identical 0.56 mmol/L (10 mg/dl) stepsfrom 4.8 to
3.0 mmol/L (86 mg/dl to 54 mgldl) in both children and
adults during the 240-minute hypoglycemic clamp proce-
dure. As expected,Tthis controlled reduction in the plasma
glucoseconcentrationstimulated an exaggeratedrise in the
plasma epinephrineconcentration in children, in compari-
son with that in adults (e.9.,4830 -t 334 vs 2365 t 3ll
pmol/L [870 -r 60 vs 426 -r- 56 pg/ml] at 240 minutes; p
<0.011. The plasma glucoselevel that stimulated a rise in
epinephrinewas also significantly higher in children than in
adults (3.6 + 0.1 vs 3.0 -r 0.1 mmol/L [65 + 1.8 vs 54 +
1.8 mg/dll; p <0.01), even though steady-stateplasma in-
sulin levelsachievedduring the insulin infusion were sim-
ilar in both groups (903 + 48 pmol/L [144.5 t 7.6 pU/
mll in childrenvs 857 * 42pmollL [137 + 6.7 pUlml] in
adults).
At baseline(before the start of the insulin infusion) the
P300 amplitude was not significantly greater in the children
than in the adults (l 1.7 t 1.5 vs 9.7 + 1.4, respcctively),
and no change in either group was observed at thc cnd of
the initial euglycemic period (plasma glucose level, 4.E
mmol/L [86 mgi dl]) (Fig. 3). Most important, no change
 The Journal of Pediatrics
volume 126,Number Z Jones et al. I 75

2 10 0

18 0 0

15 0 0
Plasma
12 0 0
Ep r n e p n n n e
(mmo/L) eoo
500

300

0 60 120 180 240 300

TIME (minutes)
Flg' {. Plasma epinephrinelevels(mean + SEM) in six of the healthy children
before and after ingestionof oral glucose
(a) and a sugar-free cola drink (L). Asterisk indicates
significant difference in values between oral glucoseand control
e x p e r i m e n t sI < 0 . 0 5 ) . T o c o n v e r t t o m e t r i c u n i t s , m u l t i p l y e p i n e p h r i n e
value by 0.1g.

Plasma
Glucose
(mmol/L)

Plasma
Epinephrine
(pmol/L)

o 50 240 3oo
,,i? ,-,",,:::
Fig. 2. Plasma glucoseand epinephrinelevels (mean + SEM) during hypoglycemic
clamp studies in children (tr) and
adults (I). Asrerisk indicates significant difference (p <0.01) versuscorrespondingvalue
in adults. To convert to metric
units, multiply glucosevalue by 18, and e p i n e p h r i n ev a l u e b y 0 . 1 8 .

in P300 potentials was observedin any of the adults until glucoseconcentrationwas lowered to 4.2 mmol/L (75 mg/
the plasma glucose concentration was lowered to the last dl) (p <0.05 vs baseline)and the p300 amplitude remained
step (3.0 mmol/L [5a mg/dl]). In contrast,in the children significantly reduced throughout the remainder of the
the P300 amplitude was significantly reduced when the study. All but one of the children had alterations in cortical

.,*--
I 76 Jones et al
- l
-2
A of P3O0
Amplitude -3
@v) -4
-5
-6
-7
8
6A5AL
Fig.3. Deltaof P300amplitudeduringeachglycemicplateauinchildren(O)andadults(I).
icant differences versus euglycemia in the children (rp <0.05). Dagger (l\
cemia in adults (p <0.01).
evoked potentials at glycemic levels greater than 3.0
mmol/L (5a mg/dl) (p <0.002 vs adult values).
DISCUSSION
Our findings indicate that the late postprandialrise in the
plasma epinephrineconcentration was markedly greater in
children than in adults, whereasthe responsesof other an-
tiinsulin, counterregulatory hormones were not different.
Epinephrine r€sponseswere exaggeratedin children, even
though a glucoseload larger than the standard 75 to I 00 gm
was given to adults and, more important, the peak and na-
dir plasma glucose levels were nearly identical in the two
groups.
Enhanced adrenomedullary responsesin the children
were associatedwith an increasein symptoms,such as feel-
ing shaky and sweaty, that are commonly attributed to
stimulation of th€ sympatheticnervoussystem,lI' l2 whereas
the scoreson filler items included to control for nonspecific
fatigue effects did not change. Moreover, adults who had
blunted epinephrine responsesremained free of symptoms
throughout the study, even though the lowest plasma glu-
cose level in the postprandial period, as determined by fre-
quent measurements,was nearly identical in the two groups.
These data suggestthat discrepanciesin symptom aware-
nessof the late fall in the plasma glucoseconcentrationaf-
ter an oral glucoseload are more likely related to differences
in epinephrine responses than to the absolute plasma
glucose level achieved. The plasma glucose concentration
fell to only 3.4 + 0.1 mmol/L (61 + 1.8 mg/dl) in the
children, so "enhanced adrenomedullary responsiveness,"
rather than "reactive hypoglycemia," might be a more ap-
The Journal of Pediatrics
February 1995
4.E 4.2 3.0 3.0
cLyCEutCLEVEL (mmal/L)
Asterisksindicatesignif-
indicates significant difference versus eugly-
propriate term to describethesephenomena.To excludethe
possibility that the findings reported above might have been
caused by nonspecific effects not connected with the oral
glucose load, we performed control experiments with a sug-
ar-free drink on a subgroup of the healthy childrcn wbose
responses to glucose ingestion were typical of the cntire
group of children studied, and no changes in plasma
hormone concentrations or hypoglycemic symptom scores
were noted.
The P300 evoked potential is a neuroelectrophysiologic
measureof cognitive function produced when a subject at-
tends to and discriminates a given stimulus.l3 The cortical
auditory evoked potential has been shown to be adversely
affected by modest reductions in plasma glucose levelsl4 and
may therefore provide a sensitiveindex of neuroglycopenia.
During controlled reductionsin the plasma glucoseconcen-
tration, cortical potentials are normally maintained until a
critical threshold glucosevalue is reduced.r5In this study,
P300 potentials were markedly altered in almost all the
children when the plasma glucose concentration was low-
ered to values that were equal to or higher than the nadir
plasma glucose level seen after glucose ingestion in this
group. On the other hand, in adults P300 potentials were
preserved until the plasma glucose concentration was low-
ered to 3.0 mmol/L (5a mg/dl), values rarely observedin
either group after glucose ingestion. These data suggestthat
healthy children are more vulnerable to the effects of hypo-
glycemia on cognitive function than are adults. Becausere-
lease of epinephrine in responseto a fall in the plasma glu-
cose concentration appears to be mediated through the
central nervous system,l6' l7 increased susceptibility to neu-
ril
 The Journal of Pediatrics
Volume 126, Number 2
roglycopenia may, in turn, account for the higher plasma
glucose level that triggered release of epinephrine in the
children.
The putative adverseeffectsofdietary sugar on behavior
and cognitive function in children have been the subject of
marked controversy.lE-20 Previous studies in this area that
have been focused on children with attention deficit disor-
der have tended to make exaggeratedclaims regarding the
global effectsof sugar and other food additives on their be-
havioral problems. Kinsbourne2l noted that the problems
caused by dietary sugar appear to be much less severeor
prevalent than some studiessuggest.On the other hand, we
have shown in this study that consumption of glucosein an
amount roughly equivalent in carbohydrate content to two
l2-ounce cans of Coca-Cola is followed by a fall in the
plasmaglucoseconcentrationsufficient to induce hormonal,
symptomatic, and neurophysiologic changes in healthy
children. However, the rise in the plasma epinephrinecon-
centration and in associated adrenergic symptoms was
acute and self-limited, and occurred only in the late post-
prandial period. These data do not indicate that dietary
sugar is the cause of hyperactivity problems, but they em-
phasizethat most children could benefit from eating mixed
1 nitive function and later activation of glucose counterregula-
mealsthat include protein, fat, complex carbohydrate,and
fiber to limit postprandial reductions in plasma glucose lev-
cls and increasesin plasma epinephrine levels. [n keeping
I with this conclusion,Wolraich et al.l were unableto dem-
I onstrate any effects on behavior and cognitive function in
I preschooland school-agechildren by adding or subtracting
Ii sucrosefrom a balanced diet.
I vest 1994;93:1677-82.
i 17. Biggers DW, Myers SR, Neal D, et al. Role of brain in coun-
R EF E R E N C E S
L WolraichML, LindgrenSD, StumboPJ,SteginkLD, Appel-
baum MI, Kiritsy MC. Effect of diets high in sucroseor
aspartame
on the behaviorand cognitiveperformanceof chil-
dren.N Engl J Med 1994;330:301-7.
:. Milich R, Wolraich M, Lindgren SD. Sugar and hyperactiv-
rty: a critical review of empirical findings.Clinical Psychology
I effects of sucrose on preschool children. J Abnorm Child psy-
R e v i e w1 9 8 6 ; 6 : 4 9 3 - 531.
t ,$
L Crook WG. Food allergy: the great masquerader.Pediatr Clin
! N o r t h A m 1 9 5 1. 2 2 : 2 2 1 - 3 8 .
I. Rapp DJ. Does diet affect hyperactivity? Journal of Learning
D i s a b i l i t i e s1 9 7 8 ; lI : 3 8 3 - 9 .
i Wcnder E. Review of researchof the relationship of nutritive
swcetenersand b€havior. In: Diet and behavior. Washington,
D . C . :N a t i o n a l C e n t e r f o r N u t r i t i o n a n d D i e t e t i c s .l 9 9 l : 6 5 -
80.
Jones et al. 177
6. Amiel SA, Simonson DC, Sherwin RS, Lauritano AA, Tam-
borlane WV. Exaggerated epinephrine responsesto hypogly-
cemia in normal and insulin dependent diabetic children. J
PEDTATR 1 9 8 7 ; ll 0 : 8 3 2 - 7
7. JonesTW, Boulware SD, Kraemer DT, Caprio S, Sherwin RS,
Tamborlane WV. Independent effects of youth and poor dia_
betes control on responsesto hypoglycemia in children. Diabe-
tes l99l;40:358-63.
8. RosenbloomAL, Wheeler L, Bianchi R, Chin FT, Tiwary CM,
Gorgic A. Age-adjusted analysis of insulin rcsponses during
normal and abnormal glucosetests in normal children and ad-
olescents.Diabetes 1975t24:820-8.
9. Grant DB. Serum-insulin levelsin children during glucosetol-
erance tests. Acta Paediatr Scand 1968;57:297-9.
10. Amiel SA, Simonson DC, Tamborlane WV, DeFronzo RA,
Sherwin RS. Rate of glucose fall does not affect counterreg-
ulatory hormone responsesto hypoglycemia in normal and di-
abetic humans. Diabetes 1987;36:518-22.
I l. Cryer PE, Binder C, Bolli GB, et al. Hypoglycemia in IDDM.
D i a b e t e s1 9 8 9 ; 3 8I: 1 9 3 - 9 .
12. Heller SR, Herbert M, MacDonald IA, Tattersall RB. Influ-
enceof sympathetic nervoussystemon hypoglycemic warntng
s y m p t o m s .L a n c e t I 9 8 7 ; 2 : 3 5 9 - 6 3 .
13. Sutton S, Tueting P, Zubin J, John ER. Information delivery
and the sensingevoked potential. Science 1976;155: 1436-9.
14. DeFeo P, Gallai Y,Mazzotta G, et al. Modest decrementsrn
plasma glucoseconcentrationscauseearly impairment in cog-
tion in the absenceof hypoglycemic symptoms in normal man.
J Clin Invest 1988;82:436-44.
15. JonesTW, McCarthy G, Tamborlane WV, et al. Mild hypo-
glycemia and impairment of brain stem and cortical evoked
potentials in healthy subjects.Diabetes I 990;39:I 550-5.
16. Borg WP, During MJ, Sherwin RS, Borg MA, Brines ML,
Shulman GI. Ventromedial hypothalamic lesionsin rats sup-
press counterregulatory responsesto hypoglycemia. J Clin In-
terregulation of insulin-induced hypoglycemia. Diabetes
I 9 8 9 ; 3 8 : 7I -6 .
18. Rosen LA, Booth SR, Bender ME, McGrath ML, Sorrel S,
Drabman RS. Effects of sugar (sucrose)on children's behav-
i o r . J C o n s u l t C l i n P s y c h o l1 9 8 8 ; 5 7 : 5 8 3 - 9 .
19. Goldman JA, Lerman RH, Contois JM, Udall JN. Behavioral
.S
chol 1986:14:565-77.
20. Wender EH, Solanto MV. Effects of sugar on aggressiveand
inattentive behavior in children with attention deficit disorder $
with hyperactivity and normal children. pediatrics l99l:
88:960-6.
21. Kinsbourne M. Sugar and the hyperactivechild. N Engl J Med
I 994;330:355-6.
 Yolume126 FEBRITARY1995 Number 2

TFIE JOLIRNAL OF
PEDIffiRICS Medlcol progress 261 Sweat chlorides in Mauriac syndrome polack er al.

163 Allergic colitis in inltnts Odze et al.

263 Transformation of neutropenia into leukemia in child treated
with G-CSF Weinblatt et al.
Orlglnot orilctes
l7l Adrenomedullery responseand susceptibility to neuroglvcopenia 266 Keratoderma and photophobia in tyrosinemia type II
efter suglr ingestion Jones et al. Rabinowitz et al.

178 Effects of hyperglycemig on mental efficiency in adolescentswith 269 Loss of antibody to hepatitis B in immunized patients with
diebetes Gschwend et al. hemophilia Maris, Butler, and Cohen

lE5 Subsequentinsect stings in Hymenoptera hypersensitivity-

Felol oncl neonolql medlclne
Hauk et al.

l9l Relotion between infent feeding and infections 212 EfIect of maternal glucocorticoids on intraventricular
Eeaudry, Dufour, and Marcoux hemorrhage in preterr4 infa.nts Garland, Buck, and ltviton

l9E Effect of neonetel immunization with DT toxoids on responsesto 2E0 Reducing blood donor exposures by use of older red blood cells
Haemophilus conjugete vlccines Lieberntan et al. Lee et al.

20,6 Antibody responses after different sequencesof Haemophilus 2E7 Effects of L-carnitine on fat metabolism in premrture neonates
conjugate vaccinesGreenberget al. Bonner et al.

212 Risk fectors and outcomes in patients hospitalizedwith RSV

infection l|/ang et al. 293 Congenital CMV infection causedby nonprimary diseasein
mother with AIDS Sclueb&e el a/.

220 Hmpitelizrtion rNtes for lower respirrtory tract illness in infants

McConnochre, Roghmann, and Liptak Phormqcology ond lheropeullct

230 Binding oI Pseudomonosto respiratory cells in cystic fibrosis

297 Growth and growth holmone axis in children treated for asthma
Zar et al.
Crowley et al.

23.f Spectrum of herpes simplex encephalitisSthlesinger et al.

304 Corticosteroid therapy for ventricular tachycardia in lymphocytic
myocarditis Ino et al.
242 Lipid rbnormelities in Turner syndrome Ross et al.

246 Lysinuric protein intolennce with bone marrow abnormalities 309 Granisetron vs chlorpromazine plus dexametha$ne to prevent
Parenti et al. ifosfamide-inducedemcsis Hiihlen et al.

252 Reduction in bone mess after severe bttns Klein et al. 313 Amoxicillin-clavulanatcduring URI for preventionof otitis media
Heikkinen et al.
Edllor'r column
Currenl lllelqlule ond cllnlcol lrsues
257 Venom immunotherapy Eierman

317 Antenatal corticosteroid therapy to prevent RDS Ryan and Finer

llons

*"5l,gPlls,*k*"o."9M 327 Acknowledgmenl ol reylewe]3

n t sl i s t e do n p a g e s5 A . 6 A , 7 A . 8 A , 9 A , l 0 A , l l A

lvl vrosuy
llt30 WestlineIndustrialDrive ".i'
St. Ianis! Missoui 531.163318 :..rr-.: t,,ti,Jij,.,
rSSN002di&6: .l:r:,
Ventromedial Hypothalamic Lesions in Rats Suppress
Counterregulatory Responses to Hypoglycemia
Walter P. Borg,* Matthew J. During,t Robert S. Sherwin,* Monica A. Borg,* Michael L. Brines,* and Gerald 1. Shulman*
Yale University School ofMedicine, Departments of * Internal Medicine and tSurgery, New Haven, Connecticut 06510
Abstract
The central nervous system has been implicated in the activa-
tion of counterregulatory hormone release during hypoglyce-
mia. However, the precise loci involved are not established. To
determine the role of the ventromedial hypothalamic nuclei
(VMH) in the hormonal response to hypoglycemia, we per-
formed hypoglycemic clamp studies in conscious Sprague-
Dawley rats with bilateral VMH lesions produced by local ibo-
tenic acid injection 2 wk earlier. Rats with lesions in the lateral
hypothalamic area, frontal lobe, sham operated (stereotaxic
needle placement into hypothalamus without injection), and
naive animals served as control groups. The clamp study had
two phases. For the first hour plasma glucose was fixed by a
variable glucose infusion at euglycemia ( 5.9 mM). Thereaf-
ter, for an additional 90 min, glucose was either allowed to fall
to (a) mild hypoglycemia ( 3.0 mM) or (b) more severe hypo-
-
glycemia ( - 2.5 mM). Glucagon and catecholamine responses
of lateral hypothalamic area-, frontal lobe-lesioned, sham
operated, and naive animals were virtually identical at each
hypoglycemic plateau. In contrast, glucagon, epinephrine, and
norepinephrine responses in the VMH-lesioned rats were mark-
edly inhibited; hormones were diminished by 50-60% during
mild and by 75-80% during severe hypoglycemia as compared
with the other groups. We conclude that the VMH plays a
crucial role in triggering the release of glucagon and catechol-
amines during hypoglycemia. (J. Clin. Invest. 1994. 93:1677-
1682.) Key words: ventromedial hypothalamus * hypoglycemia
* glucagon epinephrine * counterregulation
-
Introduction
The role of the central nervous system (CNS) in the regulation
of counterregulatory responses to hypoglycemia remains con-
troversial. Although several lines ofevidence strongly implicate
the CNS in hypoglycemia detection and counterregulation ( 1-
3), the precise brain regions involved are not known. While
various nuclei have been implicated, current data suggest that
counterregulatory responses during hypoglycemia are acti-
vated, at least in part, via the hypothalamus (4-6). It has
been frequently suggested that ventromedial hypothalamus
(VMH),' known as a regulator of food intake ("satiety
Address correspondence to Gerald I. Shulman, M.D., Ph.D., Yale Uni-
versity School of Medicine, Department of Internal Medicine/Endocri-
nology, 333 Cedar Street, FMP 104, New Haven, CT 06510.
Receivedfor publication 5 October 1993 and in revisedform 6 De-
cember 1993.
1. Abbreviations used in this paper: FL, frontal lobe; LHA, lateral hypo-
thalamic area; VMH, ventromedial hypothalamus.
J. Clin. Invest.
© The American Society for Clinical Investigation, Inc.
0021-9738/94/04/1677/06 $2.00
Volume 93, April 1994, 1677-1682
center") (7, 8), may also contain glucosensitive tissues that
could mediate the responses to hypoglycemia (9, 10). This
hypothesis was primarily based on the observations that injec-
tions of 2-deoxy-glucose into the third ventricle causes hyper-
glycemia (8). Initially, the VMH was considered a sympathetic
center, controlling mainly catecholamine secretion in response
to hypoglycemia (4, 11 ); glucagon responses were thought to
be triggered by intraislet rather than CNS mechanisms ( 12,
13). However, Frohman and Bernardis (14) demonstrated
that electric stimulation of the VMH caused an increase in
plasma glucagon. This work has been supported by recent stud-
ies performed by Biggers et al. ( 1 ) and Havel et al. ( 15). While
these studies do not address the role of the VMH during hypo-
glycemia directly, they do suggest that the VMH could poten-
tially serve as a key center for the activation of hypoglycemic
counterregulation. However, since that report, there has been a
paucity of data examining this specific issue. Indeed, the rela-
tive role of the CNS or extracerebral glucose sensors in initiat-
ing counterregulatory responses has remained the subject of
controversy.
To determine the role of the VMH nuclei in the hormonal
response to hypoglycemia, we combined the hypoglycemic in-
sulin clamp technique with bilateral VMH lesions produced by
stereotaxic ibotenic acid injection in Sprague-Dawley rats. Le-
sions in the lateral hypothalamic area, frontal lobe, sham oper-
ated, and nonlesioned (naive) animals served as controls. This
approach allowed us to introduce highly specific lesions within
the chosen brain region and to test their effect under standard-
ized hypoglycemic conditions.
Methods
Animals
Male Sprague-Dawley rats were purchased from Charles River Breed-
ing Laboratories (Wilmington, MA). Animals were housed in an envi-
ronmentally controlled room with a 12-h light/dark cycle and were
maintained on standard ad lib. rat chow (Prolab 3000; AGWAY, Wa-
verley, NY) comprising of 22% protein, 5% fat, and 5 1% carbohydrate
(the remaining 22% consists of ash, crude fiber, and moisture).
Lesions
Rats (mean body wt 290 g, range 270-310 g) were anesthetized by
-
intraperitoneal injection (1 ml/kg) of a mixture of xylazine (20 mg/
ml) (AnaSed; Lloyd Laboratories, Shenandoah, IA) and ketamine
(100 mg/ml) (Ketaset; Aveco Co., Fort Dodge, IA) in a ratio of 1:2
(vol:vol). Thereafter, they received bilateral stereotaxic infusions of
0.12 M ibotenic acid (Research Biochemicals Inc., Natick, MA) dis-
solved in a sterile artificial extracellular fluid solution (NaCl 135 mM,
KCI 3 mM, MgC12 1 mM, CaCl2 1.2 mM, ascorbate 200 ,M, and a
sodium phosphate buffer of 2 mM to pH 7.4) (16). The solution was
infused at a rate of 0.25 1 /min. The needle was placed with the bevel-
ing directed anteriorly, and 0.5 ytL of ibotenic acid was infused, then
beveling of the needle was reversed, and 0.5 Al was infused into poste-
rior directions. The needle was left inside the tissue for a 3-min period,
to allow diffusion and to prevent backflow of ibotenic acid through the
Role of Ventromedial Hypothalamus in Counterregulation 1677
needle track. All stereotaxic coordinates were determined from the
atlas of Paxinos and Watson (17). Five different groups of animals
were prepared as follows.
Group 1. VMH-lesioned rats were injected at points located 2.5 mm
posterior, 0.6 mm lateral in relation to bregma, and 9.6 mm below the
horizontal plane passing through bregma and lambda.
Group 2. Frontal lobe (FL)-lesioned rats were injected using the
coordinates: 2.0 mm anterior, 2.0 mm lateral in relation to bregma,
and 2.0 mm below the horizontal plane passing through bregma and
lambda.
Group 3. Lateral hypothalamic area (LHA)-lesioned rats were in-
jected using the coordinates: 2.0 mm posterior, 2.0 mm lateral in rela-
tion to bregma, and 8.4 mm below the horizontal plane passing
through bregma and lambda.
Group 4. Sham operated animals were prepared by lowering the
injection needle in the proximity of VMH using the coordinates 2.5
mm posterior, 0.6 mm lateral in relation to bregma, and 8.6 mm below
the horizontal plane passing through bregma and lambda, but no toxin
was infused.
Group 5. Control (naive) animals did not receive any surgery. Le-
sioned animals were studied 12-16 d after the stereotaxic procedure. At
the end of the experiments, lesion placement was verified histologically
by cresyl violet staining. Lesions were identified as areas of neuronal
loss. Only the animals that showed bilateral destruction of the desired
brain regions were included. From all animals studied, in the mild
hypoglycemia group 11% of VMH and 29% of LHA did not meet the
histological criteria. In the severe hypoglycemia group 16% of VMH
were excluded. All other animals studied met histological criteria.
Surgical procedures
At 6-10 d before the study and 7-9 d after stereotaxic surgery, animals
underwent an additional aseptic surgical procedure for placement of
internal jugular vein and carotid artery catheters under intraperitoneal
pentobarbital anesthesia (Nembutal 35 mg/kg body wt; Abbott Labo-
ratories, North Chicago, IL). The polyethylene carotid artery catheter
was extended to the level of the aortic arch, and the silicone internal
jugular vein catheter was advanced to the level of the right atrium. At
the end of the procedure both catheters were flushed and filled with
heparin (42 U/ml) and polyvinylpyrrolidone (1.7 g/ml) solution,
plugged, tunneled subcutaneously around the side of the neck, and
externalized behind the head through a skin incision. Catheters re-
mained sealed until the day of the study. Only those animals that had
recovered completely and showed no signs of infection within 36 h
after surgery were used.
Euglycemic/hypoglycemic clamp
The hyperinsulinemic glucose clamp technique, as adapted for the rat
( 18), was used to provide a fixed hypoglycemic stimulus. Two sets of
experiments were performed: In the first, all five groups of animals
were studied, and the plasma glucose concentration was lowered to
3.0 mM. In the second, only VMH-lesioned and naive (control)
animals were studied, and a more severe hypoglycemic stimulus
( 2.5 mM) was produced.
The rats were fasted for 24 h before the study. On the morning of
- plasma insulin rose to nearly identical levels, and plasma glu-
the experiment, the catheters were flushed with saline and maintained
patent by a slow infusion of saline (20 Mll/min) that contained a small
amount of heparin ( 1-2 U/ml). Animals were fully awake and freely
moving about in their cages, untethered. After a 60-min rest period,
blood samples were withdrawn for measurement of baseline glucose,
insulin, glucagon, epinephrine, and norepinephrine concentration.
Thereafter, a primed (2,160 pmol over 1.5 min) continuous infusion
( 120 pmol/kg-'* min' ) ofporcine insulin (Eli Lilly & Co., Indianapo-
lis, IN) was initiated and maintained for 150 min. A variable infusion
of exogenous glucose was adjusted based on plasma glucose measure-
ments obtained at 5-min intervals to achieve the desired glucose level.
During the first 60 min, the rats were maintained at euglycemia (mean
plasma glucose - 5.9 mM). Thereafter, plasma glucose was allowed to
fall to hypoglycemic levels ( - 3.0 mM for the first set or 2.5 mM for
- 1. Despite a comparable hypoglycemic stimulus, epinephrine,
1678 Borg, During, Sherwin, Borg, Brines, and Shulman
the second set of experiments) and maintained there for 90 min. Exper-
iments were terminated if the plasma glucose (a) fell below 4.5 mM
during the last 45 min ofthe euglycemic phase, (b) rose above 3.9 mM
(secondary to glucose infusion), or (c) inadvertently fell below 2.0 mM
during the hypoglycemic phase. Only the studies during which the
mean blood glucose level achieved during hypoglycemia was in the
range of 2.8-3.1 mM (for the first set) or 2.2-2.5 mM (for the second
set) were analyzed. In the mild hypoglycemia group 18% of FL prop-
erly lesioned (as verified histologically) and 40% of naive animals did
not meet these criteria. In the severe hypoglycemia group 16% of con-
trol studies (naive rats) were excluded. Histological results and the
accuracy ofthe clamps were the only criteria for excluding or including
the clamp studies for the data analysis; exclusions were never made
based on the knowledge of the hormonal results.
Blood samples for measurements of glucagon, epinephrine, and
insulin were taken during the euglycemic (30- and 60-min) and hypo-
glycemic (90-, 120-, 135-, and 150-min) phases of the experiments.
During blood sampling, sample dilution by fluid in the dead space of
the catheter was avoided by withdrawal of 0.5 ml of blood before sam-
ple collection. This volume exceeded the dead space volume by about
fivefold. A new syringe was then used for sample collection. Subse-
quently, the initial syringe was reattached, and the contents reinfused.
Blood obtained from littermates at least 30 min before the study was
transfused during the clamp to quantitatively replace blood withdrawn
during the experiment. The protocol was reviewed and approved by the
Yale Animal Care and Use Committee.
Analytical methods and calculations
Plasma glucose was measured in duplicate using a Glucose Analyzer II
(Beckman Instruments Inc., Fullerton, CA). Plasma insulin (Binax,
South Portland, MA), and glucagon (ICN Biomedicals, Inc., Carson,
CA) using porcine standard were determined by a double antibody
radioimmunoassay. Insulin measurements during the basal and insulin
infusion periods were made using rat and porcine standards, respec-
tively. Plasma catecholamines were measured with a radioenzymatic
method (Amersham Corp., Arlington Heights, IL).
Data are expressed as mean±SE. Comparison between the study
groups was made by ANOVA with a repeated measure design, followed
by the Student's t test to localize effects. Glucose infusion rates during
the hypoglycemic steps represent the average values during the desig-
nated time interval.
Results
Set 1: mild hypoglycemia. As summarized in Table I, basal
glucose, insulin, glucagon, epinephrine, and norepinephrine
levels were not significantly different between any of the study
groups. The average weight of the animals on the day of the
study was 290±10 g (VMH), 250±5 g (LHA ), 290±15 g (FL),
290±5 (sham operated), and 290±10 g (naive). The weight of
the LHA-lesioned animals was significantly lower as compared
with other groups (P < 0.05). During the insulin infusion,
cose was indistinguishable during each phase ofthe study in all
groups (Table II). During the hypoglycemic phase ofthe study,
the desired level of glycemia (i.e., 3.0 mM) was achieved in the
first 30 min. When euglycemia (5.9 mM) was maintained, the
concentrations of glucagon and norepinephrine were not dif-
ferent between the studied groups, whereas during the euglyce-
mic phase, plasma epinephrine was significantly decreased in
the VMH-lesioned animals as compared with other groups
(0.3±0.01 nM [VMH] vs 0.9±0.1 [LHA], 0.7±0.1 [FL],
0.9±0.1 [sham operated], 0.8±0.2 nM [naive]; P < 0.05).
The effects of VMH lesions on hormonal counterregulatory
responses to mild hypoglycemia (3.0 mM) are depicted in Fig.
Table I. Basal Characteristics of the Animals Studied
VMH FL Naive LHA Sham operated
(n = 8) (n = 9) (n = 6) (n = 5) (n = 5)
Insulin
(nM) 0.1±0.04 0.1±0.02 0.1±0.02 0.1±0.02 0.1±0.05
Glucagon
(ng/liter) 136±24 122±16 112±10 201±51 191±8
Epinephrine
(nM) 0.6±0.1 0.8±0.2 0.8±0.3 0.4±0.2 0.7±0.2
Norepinephrine
(nM) 0.9±0.2 1.4±0.2 1.3±0.2 1.2±0.2 1.1±0.2

norepinephrine, and glucagon responses in the VMH-lesioned
rats were significantly blunted (by 50-60%) compared with
-
the other groups (P < 0.05). LHA-lesioned, FL-lesioned, sham
operated, and naive animals showed indistinguishable hor-
monal responses to mild hypoglycemia (Fig. 1).
The diminished hormonal response in the VMH-lesioned
rats was associated with a higher glucose infusion rate required
to maintain the 3.1 mM hypoglycemic plateau during the final
30 min of the study (13.8±1.3 mg/kg-'. min-' [VMH] vs
5.2±0.7 [LHA], 6.9±0.7 [FL], 5.8±1.0 [sham-operated],
7.0±1.4 mg/kg'- min-' [naive]; P < 0.05).
Set 2: severe hypoglycemia. To determine ifthe diminished
hormonal responses during hypoglycemia seen in VMH-le-
sioned animals persisted with a stronger hypoglycemic stimu-
lus, plasma glucose was lowered to 2.5 mM. The average weight
of the VMH and naive animals on the day of study was 295±10
and 270±5 g, respectively. As in set 1, during the insulin infu-
sion plasma insulin rose to nearly identical levels, and plasma
glucose was indistinguishable during each phase of the study in
the two groups (Table III). During the hypoglycemic phase of
the study, the desired level of glycemia (i.e., 2.5 mM) was
achieved in the first 30 min. As shown in Fig. 2, VMH lesions
caused a marked reduction in peak elevations of circulating
glucagon (241±45 ng/liter [VMH] vs 796±112 ng/liter in
naive animals, P < 0.01), epinephrine ( 12.8±0.9 nM [VMH]
vs 69.3±4.1 nM in naive animals, P < 0.01 ), and norepineph-
rine (3.3±0.4 nM [ VMH ] vs 45.1±4.5 nM in naive animals, P
< 0.01) in response to the 2.5 mM hypoglycemic plateau.
In keeping with this finding, the VMH-lesioned animals
required a higher glucose infusion rate to maintain plasma glu-
cose at 2.5 mM during the final 30 min of the hypoglycemic
step (3.0±0.7 mg/kg-1*min-' [VMH] vs 1.1±0.2 mg/
kg- . min-' in naive animals, P < 0.05).
Discussion
The current data demonstrate that bilateral selective lesions of
the VMH produce striking reductions in the magnitude of the
glucagon, epinephrine, and norepinephrine responses to both
mild and moderately severe hypoglycemia. Neither sham sur-
gery nor selective lesions of the LHA or the FL had such an
effect.
Whereas the role of individual counterregulatory hormones
in hypoglycemia correction has been studied extensively ( 19-
22), the mechanisms that link glucopenia with activation of
the counterregulatory system are poorly understood. There is
much controversy concerning the tissues that sense glucopenia
and coordinate the counterregulatory responses. In fact, numer-
ous neural centers have been proposed to control counterregu-
latory hormone release (2, 23). The hypothalamus has long
been considered a potential center for the integration of the
hypoglycemia-induced adrenergic response (4, 24-26). Stud-
ies have implicated the ventromedial portion of this brain re-
gion, in particular. However, the role of the VMH in modulat-
ing counterregulatory hormone release has never been directly
tested under hypoglycemic conditions. Rather, it has been
shown that electrical or mechanical stimulation of the VMH
caused hyperglycemia (25, 27, 28). Moreover, injection of 2-
deoxy-glucose into the third ventricle also resulted in hypergly-
cemia (8, 29). However, this does not localize the locus for the
counterregulatory response to hypoglycemia specifically to the
VMH. Interestingly, in contrast to traditional opinion that

Table II. Mean Plasma Glucose and Insulin Concentrations during Mild Hypoglycemia
VMH FL Naive LHA Sham operated
(n = 8) (n = 9) (n = 6) (n = 5) (n = 5)
Euglycemia
Glucose (mM) 5.8±0.2 5.9±0.1 5.9±0.1 5.9±0.2 5.8±0.2
Insulin (nM) 4.9±0.6 4.7±0.7 4.7±0.5 5.0±0.6 4.8±0.6
Hypoglycemia
Glucose (mM) 2.9±0.1 3.0±0.1 3.0±0.1 2.9±0.2 2.9±0.2
Insulin (nM) 5.0±0.6 4.8±0.4 4.9±0.4 5.0±0.5 4.9±0.4

Glucose values were obtained by averaging all glucose measurements during the euglycemic or hypoglycemic phases of the study. Insulin data for
the euglycemic phase represent the average insulin level of the samples obtained at the end of this phase. Insulin values during hypoglycemia
represent the average of measurements obtained at 90 and 150 min.

Role of Ventromedial Hypothalamus in Counterregulation 1679

 IELIGLYCEMIA
YL [HYPOGLYCEMIA: 3.0 mM EUGLYCEMIA IHNPOGLYCEMA: 2.5 mM|

EPINEPHRINE EPINEPHRINE
(nM) (nM)

NOREPINEPHRINE NOREPINEPHRINE
(nM) (nM)

* *
700-
* *
600
1000-
500
800-
GLUCAGON 400 GLUCAGON *
(ng/L) 600-
300' (ng/L)
400-
2001
A 200
100-
0 30 60 90 120 135 150
0 30 60 90 120 135 150
Time (nOn)
Tom (mim)
Figure 1. Effect of VMH lesioning on counterregulatory hormone re-
sponse to mild (3.0 mM) hypoglycemia. The asterisk denotes signifi- Figure 2. Effect of VMH lesioning on counterregulatory hormone re-
cant statistical difference as compared with all control groups (P sponse to severe (2.5 mM) hypoglycemia. The asterisk denotes sig-
< 0.05). nificant statistical difference as compared with all control groups (P
<0.01).
only catecholamine release is critically dependent upon the
CNS (2), electrical stimulation of the VMH in rats has been region of the hypothalamus impinge on the endocrine pan-
found to cause an increase in plasma glucagon concentration creas (30).
( 14), consistent with evidence that efferents from the ventral It should be noted, however, that some data do not support
the concept that the neurons controlling the response to gluco-
penia reside in the VMH. In fact, it has been suggested that they
Table III. Mean Plasma Glucose and Insulin Concentrations are not located in the forebrain (which comprises cerebral
during Severe Hypoglycemia hemispheres, thalamus, subthalamus, hypothalamus, and
VMH Naive epithalamus). Cantu et al. (31 ) reported finding glucorecep-
(n= 5) (n= 5) tors located within the spinal cord that are capable of augment-
ing catecholamine secretion during hypoglycemia. Goldfien et
Euglycemia al. (32) also concluded that there are similar centers in the
Glucose (mM) 5.7±0.3 5.8±0.2 cervical portion of the spinal cord. In keeping with this conclu-
Insulin (nM) 4.6±0.5 4.7±0.6 sion DiRocco and Grill (33) have demonstrated that the sym-
Hypoglycemia pathetic response to systemic 2-deoxy-D-glucose was not pre-
Glucose (mM) 2.5±0.1 2.6±0.2 vented by complete decerebration of the rat. Ritter et al. (34)
Insulin (nM) 4.7±0.5 4.8±0.8 showed that the obstruction of the cerebral aqueduct (that con-
nects the fourth ventricle located in the hindbrain with third
Glucose and insulin data were obtained as indicated in Table II. and lateral ventricles situated in the forebrain) failed to sup-

1680 Borg, During, Sherwin, Borg, Brines, and Shulman

press the hyperglycemic response to 5-thioglucose injected into
the fourth ventricle. Furthermore, under these conditions the
hyperglycemic response to 5-thioglucose injection into third
ventricle was abolished. From these data authors concluded
that glucoreceptors are located in the hindbrain (which consists
of pons and medulla oblongata) and not in the hypothalamus.
This view is consistent with data generated by Cane et al. (35),
who reported that counterregulatory responses were not inhib-
ited when glucose was infused in the carotid arteries to abolish
forebrain hypoglycemia during systemic hypoglycemia. How-
ever, these results may not exclude an important role for hypo-
thalamic glucoreceptors. Studies performed by Biggers et al.
( 1) and more recently by Frizzell et al. (36) demonstrated that
bilateral infusion of glucose into the carotid as well as vertebral
arteries suppressed counterregulatory hormone responses to pe-
ripheral hypoglycemia. Thus, it is still plausible that the hypo-
thalamus plays a role in hypoglycemia detection or in integra-
tion of information generated from glucoreceptors localized
elsewhere (37-39).
Controversy surrounding the loci responsible for triggering
hypoglycemia-induced counterregulation may at least in part
be methodology related. Firstly, in many studies, nonphysiolo-
gic stimuli were used to generate cellular glucopenia, such as
the use of systemically administered metabolic inhibitors. The
degree of glucopenia with 2-deoxy-D-glucose is difficult to con-
trol and therefore difficult to relate to physiologic hypoglyce-
mia. Secondly, it is very difficult to interpret data generated by
transecting the brain or spinal cord at different levels in experi-
mental animals (31, 40). The operative separation of the hypo-
thalamus from the lower centers causes a marked and persis-
tent increase in the basal secretion rate of epinephrine, and in
turn, hyperglycemia (31, 40). Moreover, epinephrine secretion
is increased further when the blood glucose level declines under
the influence of insulin, even before the normal fasting level of
glucose is restored (31, 40). In contrast in the normal animal,
there is a definite level of blood glucose, well below fasting
glucose concentration, at which epinephrine release abruptly
begins (41 ). Thus, neuroaxis transection itself produces an ab-
normal condition, promoting nonspecific release of epineph-
nne.
In our study, we have attempted to overcome potential limi-
tations ofearlier studies. The sequential euglycemic-hypoglyce-
mic glucose clamp technique was used to control glucose levels,
providing more physiological and reproducible stimuli be-
tween studied groups. Selective chemical lesioning technique
was used to destroy the specific neural regions. Chemical le-
sioning with ibotenic acid, a glutamate analogue, is superior to
classical (electric and mechanical) lesioning procedures since it
destroys selectively neuronal cell bodies without affecting
fibers of passage (42). This method also diminished the con-
founding effect of simple surgical brain stem dissection on cate-
cholamine secretion. In our experiments, no basal hyperglyce-
mia, hyperadrenalemia, or hyperglucagonemia was observed
in the LHA-, FL-lesioned, or sham operated groups as com-
pared with the normal animals. Quite surprisingly, a significant
decrease in the epinephrine level was noted in VMH-lesioned
rats during euglycemic phase of the study. This suggests that a
tonic activity of VMH under euglycemic hyperinsulinemic
condition is necessary to maintain blood epinephrine concen-
tration on the basal level. Potential nonspecific effect of ibo-
tenic acid on counterregulation was excluded since neither
LHA- nor FL-lesioned animals showed any defect in hormonal
counterregulatory responses. It is noteworthy that chemical le-
sions located in hypothalamus (LHA), but outside VMH,
failed to change the counterregulatory response. Finally, sham
operations, which included all manipulation involved in the
chemical lesioning of VMH except ibotenic acid infusions, had
no effect on counterregulatory response.
In summary, the current studies demonstrate a profound
decrease in the magnitude of hormonal counterregulation after
selective lesioning of the VMH. These data suggest that the
neurons located in VMH are essential for the integrated hor-
monal response to glucose deprivation. However, it should be
emphasized that our studies cannot answer the question if glu-
cosensors are located in the neurons of VMH. The specific role
of these neurons in detection of hypoglycemia and/or coordi-
nating counterregulatory response remains to be established.
Acknowledaments
We appreciate the assistance of Aida Groszmann and Andrea Belous
for their help in the measurements of plasma hormones. We also grate-
fully acknowledge Jeffrey Tamborlane and Nicole Hamlet for their
expert technical assistance.
This research was supported by grants from the U.S. Public Health
Service (DK-20495, DK-40936, DK-45735, and NS-28227) and a
fellowship grant from The Juvenile Diabetes Foundations Interna-
tional (W. P. Borg).
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Diabetologia (1997) 40: S 75–S 82
Microdialysis techniques in the study of brain and skeletal muscle
D.G. Maggs, W. P. Borg, R. S. Sherwin
School of Medicine, Yale University, New Haven, USA
Summary Traditionally, plasma measurements have
been used to monitor metabolic events and the ac-
tions of hormones that are actually taking place with-
in tissue beds that are anatomically separated from
the vascular compartment. It is generally assumed
that the extracellular fluid (ECF) within metaboli-
cally active tissues is composed of substrates and hor-
mones in concentrations that closely approximate
those in plasma. Indeed, this view is implicit in non-
steady-state tracer calculations. However, through
the use of microdialysis techniques in the study of tis-
sue metabolism this view is being challenged. Our
data suggest that there may be substantial concentra-
tion gradients for a variety of fuels between plasma
and ECF, i. e. fuels (e. g. glucose) removed from the
circulation being lower and fuels (e. g. glycerol, lac-
tate, some amino acids) produced by tissues being
higher than plasma levels. In short, the metabolic
Microdialysis offers a powerful investigative tool
which enables in vivo sampling of extracellular fluid
(ECF) from body tissues [1, 2]. Alternative methods,
such as positron emission tomography and magnetic
resonance spectroscopy, enable insights into tissue
metabolism, but are indirect and observations are de-
rived. The Fick principle, through measurement of
tissue blood flow and arteriovenous differences, is a
more direct approach, however, it has anatomical
limitations. In humans, this technique has mostly
Corresponding author: Dr. D. G. Maggs, Section of Endocrinol-
ogy, Yale School of Medicine, P. O. Box 20 80 20, New Haven,
CT 06520-8020, USA
Abbreviations: ECF, Extracellular fluid; VMH, ventromedial
hypothalamus; IDDM, insulin-dependent diabetes mellitus; 2-
DG, 2-deoxyglucose; GABA, g-aminobutyric acid.
 Springer-Verlag 1997
milieu seen by individual tissues (and hormone re-
ceptors?) may, at least in some instances, be strikingly
different from that in plasma, and as a result, plasma
measurements by themselves may not appropriately
define the contributions of specific tissues to meta-
bolic events, and overlook the importance of meta-
bolic processes which are largely restricted to individ-
ual tissue beds. Through the use of microdialysis as a
means of directly sampling ECF from metabolically
important body tissues and with the evolution of its
use in animal and human research, this technique
will continue to offer exciting new insights into tissue
metabolism and to investigate fundamental issues
that cannot be addressed by other methods. [Dia-
betologia (1997) 40: S 75–S 82]
Keywords Brain, skeletal muscle, interstitial fluid.
been applied to the study of the limb as a means of
‘isolating’ skeletal muscle, but these studies are con-
founded by the contributions of other tissues to net
metabolic activity [3]. Moreover, arteriovenous dif-
ferences across a tissue bed assess ‘net’ changes but
may underestimate the turnover of a substrate in the
tissue in question. For example, in the limb, high rates
of glycerol uptake and release occur, despite a small
arteriovenous difference [4, 5].
To date, microdialysis has been used mainly in the
study of animal brain, where the focus has been pre-
dominantly in the area of neurotransmission [6–8].
The application of microdialysis in humans has most-
ly been directed at fuel metabolism in adipose tissue
although, more recently, it has also been applied to
the study of skeletal muscle. From a local standpoint,
we have applied microdialysis techniques to the in
S 76
vivo study of both animal and human brain as well as
the investigation of peripheral tissue metabolism in
both skeletal muscle and adipose tissue. In animal
brain, we have directed our attention to the role of
the ventromedial hypothalamus (VMH) in glucose
sensing and the effect of glucose availability on the
release of neurotransmitters. Whereas, in the periph-
ery, we have focused on human skeletal muscle, a tis-
sue that plays a key role in fuel homeostasis. Through
the unique access to specific tissue beds that microdi-
alysis offers, we have applied this method in two main
directions: (i) perturbing the local extracellular envi-
ronment of a specific target tissue by the perfusion
of substrates or pharmacologic agents via the micro-
dialysis catheter, (ii) sampling local tissue ECF from
the microdialysis catheter during systemic metabolic
perturbations.
Methodologic considerations
In view of our application of this technique in brain
and peripheral tissues, it is important to address
some general methodologic issues that concern the
microdialysis process and some further, more spe-
cific, issues that we have encountered. Microdialysis
is based on the principle of diffusion of substances
across a permeable membrane between two compart-
ments. Its typical use in vivo involves the perfusion of
an isotonic artificial ECF solution (perfusate) into a
tissue bed where perfusate equilibrates with the local
tissue ECF across a dialysis membrane; this fluid (di-
alysate) is then collected for measurement of tissue
substrates ex vivo. Although, through the nature of
the microdialysis process, it also feasible to deliver
substrates, pharmacologic agents or even hormones
to the local tissue bed via the microdialysis catheter.
The performance or efficiency of a microdialysis
system is dependent on a number of factors including
the structural design of the microdialysis catheter. A
schematic representation of the microdialysis system
that we have used in peripheral tissues is shown in Fig-
ure 1, however, other similar prototypes exist, some
with structural differences. Efficiency is also depen-
dent on the nature of the dialysis membrane and a
range of cellulose ester, polysulfate and polycarbonate
membranes are in use, each with specific physical char-
acteristics. It is theorized that the nature of the perfu-
sate may also influence the dialysis process and that
to minimize artifact caused by the perfusate itself it is
recommended that catheters should be perfused with
a solution that closely resembles tissue ECF. For this
reason, we use an artificial ECF solution (135 mmol/l
NaCl, 3 mmol/l KCl, 1 mmol/l MgCl2, CaCl2
1.2 mmol/l and sodium phosphate to buffer the perfu-
sate to pH 7.4) which closely approximates tissue ECF.
In vivo, the concentration of substances in
dialysate is invariably a fraction of the actual ECF
D.G. Maggs et al.: Brain and skeletal muscle microdialysis
20 mm
Inlet tube
Outlet tube 250 µm
Membrane
Fig. 1. Schematic representation of the microdialysis probe we
utilize in the study of adipose and skeletal muscle tissues. Fluid
is perfused (perfusate) via the inlet tube into the cylindrical
chamber comprizing the dialysis membrane and subsequently
exits via the outlet tube (dialysate)
concentration and this reflects the ‘recovery’ of the
microdialysis system. Recovery is often expressed as
a percent (i. e. [dialysate]/[ECF] × 100) and is easily
calculated in vitro by placing a microdialysis catheter
in an aqueous solution containing a known amount of
substrate. The catheter is perfused at a constant rate
and substrate concentration is measured in dialysate
enabling the calculation of in vitro recovery (i. e. [di-
alysate]/[solute] × 100). In vivo recovery is generally
less than that seen in vitro, and this is thought to re-
flect the reduced capacity for substrates and other
molecules to diffuse in the ECF space surrounding
the membrane when compared with diffusing capac-
ity in an aqueous solution in vitro. However, it is pos-
sible to calculate absolute ECF concentrations, and
therefore in vivo recovery, by a number of methods,
two of which we have utilized in our studies: the ‘no
net flux’ [1] and ‘zero flow rate’ [9] procedures. Both
of these methods have been validated in the past and
we have utilized both procedures in vitro and in
vivo. The no net flux method is based on the principle
of perfusing a microdialysis system with different
concentrations and, by measuring dialysate concen-
trations of substrate, it is possible to calculate a stea-
dy-state where perfusate concentration equals ECF
concentration, in other words, a steady-state of ‘no
net flux’. This estimate represents absolute ECF con-
centrations of the substrate in question. Figure 2
shows representative examples of ‘no net flux’ cali-
bration procedures carried out in healthy human sub-
jects for the measurement of glucose in the ECF
space of adipose tissue and skeletal muscle.
The ‘zero flow rate’ method is based on the princi-
ple that the relative recovery of substrate across dial-
ysis membrane is inversely related to perfusate flow
through the microdialysis system, and when flow rate
is zero the perfusate and ECF are in a state of com-
plete equilibrium. Therefore, by measuring dialysate
concentrations of substrate at different perfusate
flow rates, it is possible to plot the inverse relation-
ship and to extrapolate to zero flow rate by non-linear
regression, thus estimating absolute concentration of
D.G. Maggs et al.: Brain and skeletal muscle microdialysis
Fig. 2. Data from ‘no net flux’ calibration procedures carried
out in a non-obese human subject. Data indicates glucose con-
centrations (mmol/l) expressed as the difference between di-
alysate and perfusate concentrations on the y-axis, plotted
k U
against perfusate concentration on the x-axis. Data is plotted
from adipose ( ) and skeletal muscle ( ) dialysate at four
different perfusate concentrations of glucose (mmol/l). As in-
dicated, a regression line is extrapolated through the four
data points for each tissue bed and the estimate of absolute
ECF concentration is the point where the line crosses the point
of [dialysate]-[perfusate] = 0 on the y-axis, the point of no net
flux
Fig. 3. Data from a ‘zero flow rate’ calibration procedure car-
k
ried out in a non-obese human subject. Data indicates (a) glu-
U
cose and (b) lactate concentrations (mmol/l) in adipose ( )
and skeletal muscle ( ) dialysate at different dialysis flow
rates (ml/min)
substrate in ECF. Figure 3 shows representative ex-
amples of ‘zero flow rate’ calibration procedures car-
ried out in healthy humans to measure glucose and
lactate concentrations in adipose tissue and skeletal
muscle ECF. In addition, as further validation of
these techniques, we have shown that estimates of pe-
ripheral tissue ECF concentrations of glucose, lactate
and some key amino acids by these two methods are
virtually identical.
A significant drawback with these calibration tech-
niques is that they are inherently time consuming and
the more recent description of an alternate calibra-
tion technique [10, 11] involving isotopic perfusion is
of interest as this method allows an almost ‘immedi-
ate’ estimate of microdialysis recovery. The tech-
nique is based on the principle that through the addi-
tion of substrate in isotope form to the perfusate, the
S 77
relative delivery of isotopic substrate from perfusate
into local tissue ECF equals the relative recovery of
cold substrate from tissue ECF into dialysate. This
method seems to compare favourably with the no
net flux calibration procedure; however, data pro-
duced by this technique raise some methodologic
concerns [11]. Apparent overestimates of ECF glu-
cose levels in rat adipose tissue measured by this
technique can be explained by an accumulation of
isotope in the local tissue surrounding the microdialy-
sis catheter thereby resulting in an underestimate of
the delivery of glucose isotope to the tissue and artifi-
cially overestimating calculations for cold levels of
glucose in ECF. Finally, with the question of measur-
ing absolute ECF levels of susbstrates in mind, Arner
and colleagues are utilizing a microdialysis system
which they propose has an approximate 100 % rela-
tive recovery [12]. In other words, dialysate concen-
trations of substrate are equal to those in ECF. This
high efficiency is allowed because the microdialysis
catheters have a large surface area of dialysis mem-
brane (30 mm length) and are perfused at very low
rates (0.3 ml/min).
A further concern with microdialysis studies con-
ducted over many hours is the ‘stability’ of the micro-
dialysis system. In other words, could changes in sub-
strate concentrations observed during study interven-
tions be a manifestation of an artifact created by the
probe itself resulting in a shifting baseline? This is an
area of some contention as it has been suggested by
some that microdialysis may cause a depletion of sub-
strate from the local tissue bed causing a time-depen-
dent shift in dialysate substrate concentration [1].
However, others contest that this phenomenon is not
a significant concern [13]. Furthermore, this potential
phenomenon has only been described for glucose and
not for other substrates. To attempt to address this is-
sue, we carried out a series of studies in healthy sub-
jects under basal conditions and found no significant
time-dependent change in skeletal muscle and adi-
pose tissue dialysate concentrations of substrates un-
der basal conditions over a 6 h period.
An additional concern with the microdialysis pro-
cess is the possible artifact that locally altered blood
flow may have on the recovery of ECF substrates. A
recent study, involving the coupling of laser Doppler
flowmetry as a measure of local blood flow with mi-
crodialysis, showed that insertion of the microdialysis
catheter into skin caused a short lived hyperaemic re-
sponse which quickly ( < 15 min) resolved [14]. Thus,
in the bounds of the short-term metabolic studies we
and others conduct, the catheter itself does not seem
to significantly alter local blood flow. However, in
the context of metabolic studies involving hyperinsu-
linaemia, especially with concurrent hypoglycaemia,
where one would expect physiologic alterations in
blood flow it is important to consider the potential in-
fluence that blood flow may have on the recovery of
S 78
substrates by microdialysis. This issue was first raised
when ethanol clearance from microdialysis perfusate
was developed and validated [15] as a method of at-
taining a qualitative measure of local tissue blood
flow at the site of microdialysis catheter insertion.
Studies demonstrated that, in animals, gross changes
in tissue blood flow alter the recovery of glucose by
microdialysis [16] (i. e. an increase in local blood
flow increases dialysate recovery of glucose) and sim-
ilar findings have since been reported in human adi-
pose and muscle tissues but with a less predictable ef-
fect of altered blood flow on the recovery of ECF lac-
tate [17].
To address this issue, we studied the potential ef-
fects that insulin-induced hypoglycaemia may have
on the recovery of ECF glucose [18]. We studied heal-
thy subjects during hypoglycaemic clamps (plasma
glucose 2.8 mmol/l) and measured ECF glucose levels
in peripheral tissues by two different methods. On
one occasion, we indirectly estimated tissue ECF glu-
cose during hypoglycaemia by calculating absolute
levels of ECF glucose at baseline and therefore the
in vivo recovery of our microdialysis system. We
then applied the baseline recovery to indirectly calcu-
late ECF glucose during a hypoglycaemic clamp ([hy-
poglycaemia dialysate glucose] × baseline recov-
ery = [hypoglycaemic ECF glucose]). On the second
occasion, we made direct estimations of absolute
ECF glucose concentrations during stable hypogly-
caemia using the no net flux calibration procedure.
If the microdialysis recovery of glucose had been al-
tered by hypoglycaemia itself, then the indirect and
direct estimates of tissue ECF glucose during hypo-
glycaemia would differ. However, we found no differ-
ence between the indirect and direct estimations of
ECF glucose levels under these conditions, therefore
suggesting that the relative recovery of glucose from
the tissue bed by microdialysis was not altered in this
particular model of insulin-induced hypoglycaemia.
In contrast to these findings, the blood flow and ECF
glucose changes that occur during insulin-induced hy-
poglycaemia have been described in some detail in
rat muscle and adipose tissue with evidence that hy-
poglycaemia-induced blood flow changes may affect
microdialysis recovery of glucose [19], however, these
studies were done under non-steady-state conditions.
Brain
Although the vast majority of work in the field of mi-
crodialysis has been in animal brain, little attention
has been directed to the study of brain fuel homeo-
stasis and, more specific to our area of interest, the
role of the brain as a glucose sensor under conditions
of hypoglycaemia. The recent report of the DCCT
Research Group [20] demonstrated the long-term
benefits of intensified treatment in insulin-dependent
D.G. Maggs et al.: Brain and skeletal muscle microdialysis
diabetes mellitus (IDDM) and, as a result, this ther-
apy has been recommended for, and undoubtedly
will be offered to, an increasing number of IDDM pa-
tients in an effort to prevent or delay microvascular
and neuropathic complications. Unfortunately, the
frequency and severity of hypoglycaemia is markedly
increased by such regimens [21]. In light of this, the
neurohormonal response to hypoglycaemia in health
and diabetes has been extensively investigated in re-
cent years, resulting in a better understanding of the
defective counterregulatory mechanisms that exist in
IDDM. However, it is still not clear what mechanisms
are involved in glucose sensing and the initiation of
the neurohormonal response to hypoglycaemia.
A role for both cerebral and extra-cerebral glucose
sensors has been proposed [22, 23]. Although there is
some evidence that the liver may play a role in the ac-
tivation of sympathoadrenal activity [24], most data
point to the central nervous system as the dominant
centre for the sensing and integration of hypoglycae-
mic signals. This view is perhaps best supported by
studies showing that bilateral infusion of glucose
into the carotid and vertebral arteries (maintaining
intracerebral euglycaemia in the face of systemic hy-
poglycaemia) nearly abolishes hormone release dur-
ing hypoglycaemia [22, 25]. These studies, however,
do not define the precise brain regions involved.
While the hypothalamus has long been viewed as the
most likely site [26], others have suggested that the
glucose sensor is located in the hindbrain or spinal
cord [27, 28]. Recent data from our laboratory pro-
vide strong evidence that the VMH is essential for hy-
poglycaemic counterregulation [29]. We observed
that conscious VMH-lesioned rats (bilateral lesions
produced by local ibotenic acid injection 2 weeks ear-
lier) had blunted glucagon, epinephrine and norepi-
nephrine responses to a hypoglycaemic stimulus
(3 mmol/l or 2.5 mmol/l) when compared with re-
sponses noted in controls. We therefore reasoned
that, if glucosensors are in the VMH, glucopenia lim-
ited to this centre should cause counterregulatory re-
sponses despite peripheral normoglycaemia. At this
point, we applied microdialysis techniques to study
the role of the VMH in triggering counterregulatory
responses to hypoglycaemia [30]. In the VMH or
frontal lobes (controls) of awake rats (n = 20), 2-de-
oxyglucose (2-DG) or glucose (to serve as a control)
was perfused via microdialysis catheters to produce
localized cellular glucopenia. Perfusion of 2-DG
(but not glucose) into the VMH caused a striking in-
crease in plasma glucagon (by 200 %), epinephrine
(by 600 %), norepinephrine (by 400 %) in association
with a prompt elevation of circulating blood glucose.
It should also be noted that 2-DG had no effect
when delivered to the frontal lobes. These data there-
fore suggest that the neurons sensing glucopenia are
in the VMH. To follow the findings from this study,
we have used an opposite experimental paradigm
D.G. Maggs et al.: Brain and skeletal muscle microdialysis
again to determine the role of VMH in glucose sens-
ing. Under conditions of systemic hypoglycaemia,
we used microdialysis to perfuse the VMH bilaterally
with glucose preventing VMH hypoglycaemia [31].
Data indicate that hypoglycaemic rats with ‘euglycae-
mic’ VMH have markedly diminished hormonal re-
sponses to systemic hypoglycaemia, again suggesting
that the VMH is the dominant glucose sensor for acti-
vation of the counterregulatory response to hypogly-
caemia.
A concern with these experiments relates to whe-
ther the anatomical positioning of the catheters was
appropriate and whether the local perfusion with 2-
DG confined its effect to the VMH. The hypothala-
mus is a small, albeit highly complex, area of the brain
and, despite positioning the catheters with stereotactic
surgery, one must be careful in attributing these find-
ings to an area as small as the VMH. However, the ap-
propriate anatomical localization of the catheters was
confirmed histologically. In addition, in a small num-
ber of rats (n = 4), further studies were catheters per-
formed where [3H]2-DG was perfused via the cathe-
ters and local radioactivity was measured in VMH
and surrounding structures. This procedure confirmed
that radioactivity was largely restricted to the VMH;
and the radioactivity in the surrounding tissues was
only slightly above background levels. In other words,
the local perfusion of glucose via the microdialysis
catheters was indeed confined to the VMH.
The cellular mechanisms used by the VMH to
sense and transduce the glucose signal are unknown.
It is intriguing to speculate that the VMH glucose
sensor shares common features with the only glucose
sensing cell that has been well characterized, the pan-
creatic beta cell. Recent studies support this view. Jet-
ton et al. [32] have reported that cells within the me-
dial hypothalamus express glucokinase as well as
GLUT2. Furthermore, VMH neurons contain ATP-
sensitive potassium channels, a key signal transduc-
tion protein in beta cells [33]. In keeping with this hy-
pothesis, we have recently reported, again through
the utilization of microdialysis catheters in rat sub-
stantia nigra, a brain region rich in KATP channels as
determined by sulfonylurea binding [33], that this
area responds to changes in local glucose availability
via effects on KATP channels. Perfusing the dialysis
catheter with 10 mmol/l glucose increased g-ami-
nobutyric acid (GABA) release two-fold. Local per-
fusion with the sulfonylurea glipizide had a nearly
identical effect; whereas perfusion with the specific
KATP channel activator, lemakalim, or 2-DG with oli-
gomycin inhibited GABA release by 45–50 %. The
latter effect was blocked by glipizide. When systemic
hypoglycaemia was produced in awake rats, nigral di-
alysate GABA concentrations decreased by approxi-
mately 50 %, as well. These data suggest that glucose
may modulate nigral GABA release via an effect on
KATP channels, a pattern which bears a striking
S 79
similarity to that of pancreatic beta cells. Thus, glu-
cose could act as a signalling molecule for at least
some neurons in the central nervous system. Taken
together, these observations suggest that the VMH
might function much like the beta cell, a scenario
that might account for functional changes in hormone
release seen with chronic hyper- or recurrent hypo-
glycaemia.
It is well established that glucose passes across the
blood brain barrier by carrier mediated transport
(via GLUT 1 transporters) and unsaturable (diffu-
sion) mechanisms [34]. Once in the ECF, the concen-
tration of glucose seen by neurones and glia is, how-
ever, probably much lower than that of plasma. Esti-
mates of brain ECF glucose levels in animals using
microdialysis or microelectrodes range from 0.5–
2.8 mmol/l [35, 36], suggesting that a steep glucose
concentration gradient exists between blood and
brain ECF. We have recently had the unique opportu-
nity to utilize microdialysis to measure glucose levels
in brain ECF of conscious humans undergoing intra-
cerebral depth electrode monitoring for intractable
epilepsy [37]. Preliminary data suggest that ECF glu-
cose levels in human brain are very different from
plasma levels; i. e. approximately 30 % of plasma lev-
els. These findings imply that neurons are bathed in
a metabolic milieu different to that seen in the circu-
lation.
Skeletal muscle
Application of microdialysis techniques to the study
of peripheral tissues has increased in recent years
and this technique is particularly well suited to these
tissues since larger catheters can be used (than those
used in the study of animal brain), substantially in-
creasing the efficiency of the microdialysis process
and therefore the ability to detect metabolic change
in ECF. Most attention has been directed to adipose
tissue, mainly because of easy access, and studies
have reported the measurement of ECF levels of glu-
cose, lactate and glycerol [1, 38–42] and characterized
the opposing effects of insulin and sympathetic stimu-
lation on adipose tissue fat and glucose metabolism
[39, 43–45]. The application of microdialysis to the
study of diabetic or insulin resistant states has been
limited but work in this area includes study of the ef-
fects of insulin withdrawal [45] and hyperglycaemia
[46] on levels of substrates in adipose ECF in
IDDM; and abnormalities of glucose and glycerol
metabolism in adipose tissue have also been reported
in obesity [39, 47], patients with liver cirrhosis [48]
and spinal cord injured patients with mild insulin re-
sistance [49].
Microdialysis has been applied to a lesser extent in
skeletal muscle; a tissue that plays a major role in pro-
tein metabolism and insulin-mediated peripheral
S 80
glucose uptake, and that also serves as the major
source of gluconeogenic precursors under catabolic
conditions. In rats, a number of studies have shown
that microdialysis is applicable to this tissue bed [15,
19, 50] and we have used microdialysis in both skele-
tal muscle and adipose tissue ECF in humans. Our
studies were firstly notable for the concentration gra-
dients that exist for key metabolic substrates between
the ECF compartment of both tissue beds and the cir-
culation. High glycerol levels were noted in skeletal
muscle dialysate, suggesting that there is significant
lipolysis occurring in skeletal muscle and that the im-
portance of the glucose-fatty acid cycle may be under-
estimated in this tissue bed [51]. In addition, we also
demonstrated that ECF levels of lactate were higher
than plasma levels indicating that there is an efflux
of lactate from both tissues under fasting conditions.
Whereas, levels of glucose in muscle and adipose
ECF were approximately 30 % lower than arterial-
ized plasma levels indicating a concentration gradient
in the opposite direction in keeping with glucose up-
take.
Peripheral tissue ECF glycerol levels were higher
than levels reported by others [41, 42] raising the pos-
sibility that the high glycerol levels were, in part, arti-
factual. However, in vitro, we confirmed that the
glycerol content of the cuprophan membrane we
used was seemingly negligible. This fact was further
underlined when we used the same catheters in hu-
man brain and found that glycerol levels were immea-
surably low in brain dialysate, a tissue bed where you
would expect negligible lipolytic activity. In addition,
the question that elevated glycerol levels in dialysate
may be a trauma artifact has been largely refuted by
past work showing that the initial trauma reaction
quickly subsides shortly after catheter implantation
[13] and, thereafter, dialysate sampling reflects a sta-
ble ECF environment for hours. Finally, specific to
skeletal muscle, the disparity between muscle ECF
and plasma glycerol raises the question of whether
the muscle probes were positioned appropriately as
the presence of high ECF glycerol could imply that
the muscle catheter was in subcutaneous fat rather
than muscle itself. However, we studied non-obese
subjects and MRI scans of the sites of catheter inser-
tion confirmed that the muscle catheters were posi-
tioned correctly. Moreover, we demonstrated that
taurine, alanine and glutamine levels were higher in
muscle than in adipose tissue dialysate, supporting
the view that the muscle and adipose catheters were
indeed in two distinct tissues. Contrary to our obser-
vations, Samra et al. [52] stated that skeletal muscle
tissue ECF levels of glycerol must be near to plasma
levels on the basis of observing a net uptake of glyc-
erol across the limb following a square-wave intrave-
nous infusion of glycerol, but without directly mea-
suring ECF levels by microdialysis. On the other
hand, using a microdialysis system with approximate
D.G. Maggs et al.: Brain and skeletal muscle microdialysis
100 % recovery, Enoksson et al. [12] reported that ba-
sal ECF levels of glycerol are indeed higher than plas-
ma in skeletal muscle as well as adipose tissue but ab-
solute levels were not nearly as high as those ob-
served by us. We have since tested our original micro-
dialysis system side by side with a commercially avail-
able system in fasted humans during a continuous in-
fusion of stable isotope of glycerol to attain a steady-
state isotope enrichment of glycerol in both plasma
and adipose tissue ECF. Our preliminary data show
that with both microdialysis systems the isotope en-
richment in the adipose dialysate was approximately
10–20 % of plasma enrichments indicating local glyc-
erol production. However, the relative enrichment
of isotope in dialysate was at least twofold higher
(and therefore nearer to plasma enrichments) in the
commercially available catheter when compared
with our original catheter. Accepting these observa-
tions are confined to adipose tissue and that the com-
mercially available microdialysis catheter generated
data that supports observations made by others, this
would suggest our original microdialysis system may
have overestimated glycerol levels in skeletal muscle
and adipose tissues.
A further interesting development in the use of
microdialysis in the study of peripheral tissues is the
application of stable or radioactive isotopes in the
study of local tissue metabolism. As mentioned ear-
lier, isotopes added to the perfusate have been used
as a measure of microdialysis recovery [10, 11] but a
more recent development has been the addition of
substrate isotope to perfusate and the measurement
of the substrate’s metabolite in its isotope form in di-
alysate. Henry et al. [53] recently reported the perfu-
sion of U-13C glucose via a microdialysis catheter
into human adipose tissue and the measurement of
13
C lactate in tissue dialysate as an indicator of local
anaerobic glycolysis [53]. This particular application
of microdialysis techniques may offer a unique in-
sight into local tissue metabolic processes.
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[Suppl 1]: A12 (Abstract)
 J
Local Ventromedial Hypothalamus Glucopenia Triggers
l Counterregulatory Hormone Release
\Valter P. Borg, Robert S. Shen,in, Matthew J. During, i\Ionica A. Borg, and Gerald 1. Shulman
To test the hj1wthesis that nuclei of the ventromedial
hypothaJamus (\~nI) playa key role in the detection of
(l-Qnnterreg1l1atory responses to h.J.poglycemia. 'we delh'­
ered the gIucopen.ic agent 2-deoxyglucose ,ia bilaterally
placed microdialysis probes into the '-"ill of conscious.
chrollicallv catheterized rats. The goal wa.·,:; to produce
cellular glucopenia localized to the ''3ill. TIle volume of
brain tissue exposed to 2-deox.,rglncose was determ.ined
by adding CHjZ.deoxygLllcose to the dialysttte: its distri­
bution in cerebral tissue witS almost exclusively limit~d
to the \'-"ill. Rats \\;th microdialysis probes placed into
the frontal lobes served as a control group. Locttl perfu­
sion of 2-deoxyglucose (bllt lIOt glucose) into the VlVrn
caused a prompt twofold increa.';e in plasma glucose in
a.-;sociation with a striking elevation of plasma glucagon
(:3.5-fold), epinephrine OO-fold). and norepinephrine
(:3.5-fold). No effect was seen when 2-deo~lg1ucose WitS
delh'ered into the fro mal lobes. We conclude that gluco­
penia locallzed to the \~IH triggers the release of COUll­
tenegulatory hormones that defend against h}pogly­
cem.ia. Thus, the neurons that sense gluc~ may be
situated in the V1\UI. Diabetes 44:180--184e
W
hile the role of the- incli,idual cOllnterregula­
tory llOl1110neS in h)1)oglycemia correction has
been srudit,d extfnsil:ely (I), the mechanisms
that link glucopenia with actil:ation of the
counterregulator:r system nre poorly understoocl. Specifi­
cally. there has been contnwersy conceming the tissues that
sense gLucopenia :md coordinate the counterregulawry re­
1 sponse. Both the cent ral l\l't .....ous system (C:\S) and extra­
cerebral glucose Sfnsors ha,'e been implic:lted in the
acti,'ation of counrerTeglllalOr.'i' hormonE' release dming hy­
poglycemia (2-, Recent studies from our labomtoty. based
f on chemical lesioning of ,'aJiollS brain regions. have sug­
gested that the neurons located in the \'entromedial hypo­
thalamus (Vt'lIH) are essential for the integrated homlOnal
response to glucose deprinltion (8). To further clatify the
role of the v';\IH in hypoglycemia detection and counterregu­
lation. we delivered 2-deoxyglueose. a metabolic inhibitor
commonly used to generate cellular glucopenia. \ia microcli­
alysis probes directly into the V-:'IH of awake rats. [t was
From rhe DepartmenL~ of \nternal Medicine anti ~lIr~.:ry I~U.D.l. Yale rniwcsity
SdlOul of :'ledicine. Ne", H:l'·('n. C'mmc'etit'llt.
",llin'$S corre:;pondenc(' and reprim rettllests to Dr. l~t'ralll l. Shulman. Yale
L"niwrsity School or Mellicine. Departmem ur IlItpmaJ )"'<lieine/Endocrinolol:lY.
:J:3J C,>dar St.. Fitkin I. :-:t'w Hawn. C1' 1~)~:2th'iir2U.
Rect'iwo fOr publication ~S :;"prt'mber Hl!c4 ami alT.'ptetl in ..."ised form ti
1 October 19'.4.
eNS. cent!"'.!l nervous system: "MH. ,'(>lttrom",liaJ hyputhalamus: FL. frontal
lobe; UL-\. latem! h}1Jocl1iuamitc area.
t'eC1s.)ned thm. if glucosensors arC' 10,';\[,,([ in [hi' \-\IH. this
manipulation should calise a counrerregU1alory response
clesptte systemic t1ol111ogIycemia. The micmclialysi::; rech­
nique allowed LIS to clelh-er :2-deoxyglucose dtrectly iuro a
localized brain region of awake, unrestr:.lined aninJi1ls. elim.
inaring such confounding factors as anesrhesia and hypogly­
cerma 1I1 other areas of the body,
RESEARCH DESIG:\ AND :\IETHODS
:'lak· Sprague-Dawley rats WE're purch:1.'"d from Ch:lrlt's Ri\'i'!" Labor".
{ori.e~. :~nitnab \\'ere housed in "Ul el1\iro{;.menraHy cO[lrroHed l"I.HJ!lt \\i[i:
:1 1:::-!. ilght'(\ark cycle. and werE: maim::unt'd ')l\ st;:tlHiard ad lthirurll fm
diet i Pmlab :]0<)0..'\G\\·.-\ Y. \l:a'·erly. :-:~'. l")!llpris"{j ut :'::':"'" pmkin. $'.
fat. awi '" ["'J carbohyrtralt' (the remai:~tn2 :'::':"" cOllsbts of ,,,,,II. cmd"
fii It" " "nd nlOisture). Rats (bod,' \\1: :2~I)-:.l!O :; J Wer,· ane~rhdiZt·Li b':
imrap>'l1wneal injeclion (l tlIlikg) of a miC-;lure of c-;'.Iazin,~ ':':'1 Ill"- mi'
and :':eramlae [ [00 n1&ml) in a ratio o( l:~ l\'oh'ol) 'a:ld placed .'); rh~
stt'reOl;lC-;l(:: fnUllE'. Th<' skull was exposed. and holes wen:> c!tiHc-ri
bilari'l":l!ly in chosten coordinates. through which the guide c-annulos
were lowered slowly into the brain. Al! :>tereow_xic ('o~rdinates Wt:,.p
([t'ter.:liI1ed from the atlas of Pa.xlnos a.ad \l:arsol1 18 ,:Two ~rolJPs ~~.
amn,c"s Wf're prepared as follows. r-or group 1. \,}IH cannulas were
pbct'(! by using the coordinares 2.f\ Illnl postetioi:~lnd :1:5 mmlat"t~ll it:
rela:wlI [0 bregma. and at rile angle 0;' ~lr in relation to the IlOn1.0ma:
plan,.. passing through bregma and 1a.1;;b(\a. Fllt group :'!. froI1wl lobe
I FL, ('annl!I,1.~ were placed by using Ihe connEllat!':; :2.'' ' nun antenur ill\(:
::.0 mal lateral in relation [0 bregma at the all!?[e or ~ilJ' in re!atiOll to th~
\'erric-al bregma-lambda plane, The Ca..·1IllililS Wert' then secured to th~
skull with stainless sleel serews ami di?ntal act.....lic. c\pjmab were the~
alio\\'eel to recoq'l' from the stereota.'C(" ;Jrocedtl~·<, for :~-tS ,),1\'S hefor~
st:I(V One (by before each experime~t. standard tnicrodialYsls probe~
or sldt'-h~:,slde destgn (10) wert' i!l.'c1"t<!'d into gUide cnnnulas. Th"
leng::1s ot the \,}IH probes and FL probes were 105 amI ::!.<) mm,
l'esp·:("tiwly (ilS measured from bregtrta-brnbda plane I. On Ih,' morniag
01' tIo", ec-;perimem. perfusion mecli\UTI was loalled ilwJ l-ml synnges an'~i
delt'.~",rE'd at a flow rate of 2.5 ILL'min b:: using a H~u,:ard Pt'l1'usiotl !JlIfl1P
I mor.:d :!:.;, Har-'arrl Bioscience). llm'e kinds ot" perfusates Were used, :;
nunol1 glllC!)Se. 100 nlmolll glucose. and 100 mmol!l 2-<:leoc-;,·g1ucQse. :\.
sl.:n:<:,. pyrogen-free. arrificial. extracellular. t1nld solmion t·I:].3 mm,)ll
\aC, :3 mmolt1 KCL 1 mmol!1 .\!gO:- 1.2 mmolil (·aCL. :2l)f) mmoi 1
asc(),·oate. and 2 mmolt1 sodium phospnare bulfel'{O pH 7.":n "er:eu as :l
soh·-::nt for these solutions. At the end of each ~xperimt'nt. prob"
placement was verified histologically by <:re:;yl \'i0\e( staining. Onl';
anitnills thar showed bilateral prob<; placement inro rhe dl'sirf.'d brai~,
[<>glons Wf.'re included. Of rats with \'}Ill. 5 of IS (2S·".,) and nune of rhe
rats ·.Ii(h fL probes failed the his(l)10?ical criteria. Ihsrolnt;ical ]'('sl1lt;
were (he only criteria for excluding ')r including the stmiil's f(Jr data
aI1ll.iysis.
At G--10 days before study (i.e .. 6-~ clays after stereotnsit: surger,'j
,mimals underwent an additional aseptic sllrgical procedure for plac".
ment of internal jugular vein nnd c;;t[orid arl('l..... c:uhetE'rs under intra.
peritoneal pentobarbit:a\ anesthesia (:-:embuta!. ':35 mykg b"dy wt). The
polyethylene L-:U'otid arrery carhett'r was extemkd (0 tht' ·It',·d. or th!'
aomc arch. and Ihe silicone imernal Jugular vein catheter \Va,; nUVall<ll~!
to the le"el of the right atrium. At the eud 1)1' the prol'P(/Url'. hoth
c[lrheters were /lushe<t and filled with heparin ,·t! Uillli) alUl pIJIYIl'
nylpYITolidone (1.7 glm!) solution. plugged. tttnneled sl!lwU[anI!O\l~h
around the side uf the neLk, and externalized behind the ht'~ld thr(lI1.•i.
1:1 sl,.in incision. Catheters remained sealed until th.., day Ill' the stUll\'
 I nBLE 1
.

pf'rfomwd. In tlw first group (11

WOP. BORG·AND ASSOCtAlES

,1. \ ".'.fH proiJe:" were pt'rfU'i-t'I!

sequentially with a soluli!)n that conrained :) mmoL 1 g!uco~" [,)[ rite fir;;;
Basal char;JC[etistics of rht" animals
:30 min. followpd hy II)!) mm!)!:1 gillms!' for 6r) mill. ,') m!ll011 ~!H"l):'"
J- Perfusion rhrough

DIH
afpin for :30 min. and filnlly I');) mmoll ::·deoxyg!,lCOS>' [.x rh,.· 1:1.-', ,~;,
min of the srudy. In thl' St'c'ond I',ruup (II 6·i. perfusatc'S wen~ (h'li\"~r.:,<l
in the sanle order a~ in tht~ firSt group. bur rht' FLs wen:, Pt'!1'us~t! in;-:tc';'1':
DIH rL (ren~rsedorder) of the \")IH, In the third :;:;r;up I 1/ .)). l·il} mmoll ::·tlt'11xygluCl)sl' \\;r;:.

introduct'd after tIlt' inin;!1 ;) lHln.)ll giu,·,)se Pt'11·I.tSltJn, .lJlerwl hio.),j

1 6 6

11
Insulin (pmoL1"l :!-!ti :::; 1)0 =
:3;3-1 61) ::6-l = -l~
samples w.:re withdrawn ,ltuing rnt' p'-'l-tusron to nlt'asl:rt' glue,),;" e ....,,[-.
10 min ami gIUCa~0n. c,rtecho!;:rmines. and insulin t'\~t'[-; :3') nun. [)unn~
Glucagon (ng1) 1:311 :::; S I."):."! - II l·tS - 23

Epinephrine (" mHon) 0.'3 = I).:~

:10,:::; 0;;)
O.S 0:'>
L:! [)
0,1 0.2

1.1 _ 0.3

blood wirhdt<m·a!. ;:;ampl" dilwi<,n hy thud in rill' ,1c:J!! space of rf.-:

:\orepillepilril1t' (mllov11
Data are m!?~HlS SE.
Only rhDse :1nim:ll.s thar had cnmp[I'lely rE.'co"t'rt"j and show"dno signs
of infection \\.-irhin :]1;' h aftl)f surgt:'ry \\-ere tts~d.
• The rats WNe food·,Jepri'"f'd fol' -2 h bdore rhe start of each
e:'1klllllenr. The catht'lt'rs wert' Hushed wirh saline and maintained
p;ltenr by a slo'" infusion or' saline (20 p.Lmin) that comain"d a smull
amOlllH of hepaIin (1-:; Ulllll, Animals were fully awake and freely
mo\ ing about in their cagps..-lit"r a 50-min rest period. arterial blood
samples ,,-ere \\irhdrawt\ [rom carotid artt;>ry carheter for assay of
baseline plasma glucose. insulin. glucagon, epin.:;phrint'. and norepi­
nephline concenrrari0ns..-\t the sallle tim". perfusions through tht'
microdialysis probes wert' staned. Three groups of e:---periments were
catheter wa.s aH)icit'd tn' \'\lfhdraW;lf c'f -·0.,' tn! ,'It Illon.l 1.<"'"1'''
eollectioll of "aell blt)"d sample I -0. I mil ,,"Hh a ~t'·,·mld ~'.n:;~,.'
Sllhsetluenrl,-. tilt' l"l>l1rt'nrs or" [ht' mirial syring·: w,-:',' rt'H\f>:~,-.l t,.'
minimi.,' biOI)cI i<)Ss. [n adl!itl<)!l. i)!<l<ld "braini'd irom !fr;",nn;\tt.'~ ,,",L­
transfused dUling till' swdy "ja rht' juguJar ,'ein catileter t,l 'lllalHH:1fl·,,·i',
reptac" blood \\irhdra\\ll during till' \'xperinl€'IlL
The \'olume of br:lin t'xpo~e(l to ::·d"OX\',2Iueo::;t:' C';:L"; ,,$,im'Ht'd h'.
including tlw I 'H}2·r!eoxyglu,·ose in tilt' di,{lrS;lr\! ;UHl mea:'il!r!uiZ ir~
distribution in the cerebral tissue' in fOllr raL~. In tht':><' t"")e[lltl~m,-,
V;\IH prob.:,; ,,"pre pf'r-tnsl'CI wirh a lOr) 11l1110Vl :l-d('ox':;;:luco;e Si)lllti,',r:
containing 0.06 f.lCi. mlll( [:Hl:l-dt't)xyglucose for Ill) ;l~tl, At rtl" t'nc! '"
tbe expelimt?nr. the r:lrs \\'ere ill\t'stherized 'with p.;-nrobariJllal ':\emj),;.
tal. :}:) mg;:kg body W!l and decapi!aretl. and the brains wert' [e-t1\""":
and put inco a rodem br:lin slicer. Frozen I·mm coronal sections or ['ral:'
conrainin~ probes werlO' mad.: :md place([ on an k,,·cl)[d fj:u -,un';We

l00mM lOOmM 100 mM

100mM GlUCose
2~O&Oxy·GtUCos, 2-Deoxy-Giucose
Glucose

10001

I GLUCAGON (ngIL)
::1GLUCOSE (mM) 8oo~
I
600 I
8 _ _ A "­

1 400
-:r­

--­
6 FL
FL

L---r-----r~--~-----.
_VMH
VMH
200
=-------::
: O.
o 30 60 90 120 150 180 0 30 60 90 120 150 180
.~' : TIME (min) TIME (min)

loomM
Gluc.".. looml.! 100m'"
GlueOM 2·0e0xy·Gluco$<l
80 30

60 EPINEPHRINE (nM) NOREPINEPHRINE (nM)

20

-0- FL

-
-0-- FL
10 --+-- VMH

VMH

~
20
­
,
- a--~

0
0
120 150 180 0 30 60 90 120 150 180
0 30 60 90
TIME (min) TIME (min) .
FiG. 1. Plasma glucose Ilnd counterregulatory hormone concentrations durlllg microdialysls perrusion!> of the VMU and FLs. -Significant statistical
'<difference as compared with FL perfusion (I' <: O.OS).
~

..
,

~----------~~~ ~~~~
1 ROLEOFVENTROMEDfALWtPOTHALAMUS IN COUNTERAEGUlAltON .'

,. 12
GLUCOSE' 0 GLUCAGON
(mM) ,/ BOO~ (ngll)
10 •

8:.;-~~
, , . ::/"
I
.wO j

2------~~-···~~··~·····~

o :lO 60 00 :JO 60 00
TIME (min) TIME (min)

:JO
I

I
60; EPINEPHRINE NOREPINEPHRINE
, (nM) (nM)
i
I
HORIZONTAL
.w~ 150
~
* ..
10

DPM
:JO 50 00 o :JO 60 00
TIME (min) TIME (min)
FIG. ~. Effect of \")1H perfusion C"ith :!.deoxyglucose introduced at the
beginning of the study. i.e .. after the initial;) ulInoVl glucose perfusion)
on plasma glucose and counterregulatory hormone concentra.tions.
'Significant statistical difference between samples taken during and
after 2·deoxyglucose perfusion. as compared \\ith the baseline and the
i,litial,) mIDol/l glucose perfusion period.

ThE'rt'after. fissue samplt's were collected using :m IS-gauge biopsy

llC'ecllC' from the \~IH and surrounding c£'rebral tissue. including the
inff'110r part of the arcuate nllclE'us. dorsoI1l£'ciial nucleus. perifomical
nucleus. I\l£'dial amygdaloid l\ucleus. ICHNCtl hYPQ[halamic area (LHA).
m\(l third "ertidE': Tissue samples w!:'n: plact'd in scintillation liquid
(Utima-Gold. Packard). sonicated. and counted in a liquid scimi!lation VERTICAL
coumer {Tri·carb 1900; Packard). TIlE' protocol was re\iewed and : ZSO . ..
appro\'etl cby the Yale Animal Care and Cse Committee.
Plasma glucose was measured in duplicatE' by using a Beckman
glucose analyzer II (Beckman). Plasma glucagon (lC';) and plasma
insulin (Bina;,,) concentrations wer!:' dewmlined by a clouble·antibodr
radioimmunoassay, \"ith a porCine srandard anc! a rat standard. respec·
[j\·ely. Plasma concentrations of epinepluine and norepinephrine were
measmed bv a radioenzymatic method I.\mersham).
Dma are 'expressed as means SE. Comparison between the study
groups was made by analysis of variance with a repeated measure
design. followed by Student's I test to localize efl"('Cts.

RESULTS
As summarized in Table 1, basal plasma glucose. insulin,
glucagon. epinephrine. and norepinephrine concentrations
were not significantly differenr between any of the study
groups. The average weights of the animals on the day of the
stucly were also not significantly different between the
groups (340 :!: 20 g [VM.H perfuSion\. 320 ::':: 30 g [FL
=
perfusion],340 30 g [YMH perfusion \\ith reversed order of
the perfusatesJ).
The effects of YMH and FL perfusions on plasma glucose
and counterregulatory hormone concentrations are depicted
in Fig. L Both VMH and FL perfusions with 5 and 100 mmolJl
RIGHT
FIG. 3. The results of the measurements of distributions of the
radjolabeled 2-~eoxyglucose. perfused through \-;\lH probe in four rats..4.
shows the locanon of the samples: V,l/H; Arr. inferior part of arc-unte
nucleus: D,VD, do,:omedia.l nude us; PeF. perifornical nucleus; LH.
Iate~al hypothalamiC area; JfePD, medial amygdaloid nudei; :IV. third
verticll!_ Band C show the radioacthity (expressed as dpm) uf the
samples from cerebral tissue. 'Signillcam statisti<tal difference betweell
VlIrIH and other samples (P <.: 0.001).

182
(1I.illETES. \"(l!. 14. FEBRt"ARY t:u
J . .

hac! no effect on plasma glucose concen(r:1tion.

. , W.P. BORGANDASSOCIAlES

Among: rhl' S[l1Ictun's lo':att:'d near the brain n'nuiciL"5. tilt'

Huwcn:!r. pt'rfusion of tOO 011110\;1 :?-deoxyglucose into tht> nucleus of \-:'IIH. h.ilown a'i a of food lnrak,· f)t" tIlt'
\·:'fH L'~\H"c'd a signific::1I1t increase in pbsma gluctJst.' concen· cenft'l" (I:::.l-!i. Ita:; bt'l'!1 pr\.'po'Sl?d tn Cont,H!l I!l!.l­
tratii)n as c()lllpared \\ith that dUling 100 nlIlloL 1 gluL'ose per· COSt'llsi,iw Ih'lIrOnS tlut ("ould tnelii:He rite COI.l;:[ern':!~lb.
rusion (p < 0.0·::; \'5. 100 mmol/l glucose perfusion 1. \Iore· tmy reSpt)!lSl'S to h}pD::dycemia 1 [S. I I)). This pn5;:,il111ir\'
on'!". 2·(I.·'oxyglucose had no suchetrect when deli\'erecl rt) mainly de!1\'es from rhe 0bSt'IYation that mpc'hanlcal 0'1'
[he FLs ,-\.:'i presented in Fig. l. 2-deoxyglucost' pt'rfllsion pjcctlical stimulation ot' tl\\" \'}lH pt'oduces hYlWrgl'.cc·mii\ ll\
inw \ -:\IH caused a marked increase in Circulating glucagon. anl'sthetizeci rats [l·U -;-j Huwt>n:r, se\'eral scudi;:s' b'."(> 1\1)[
t'pint:phl111e. and norepinepl:tri.nt' concentrarions as com­ sllpponed this cUllcepr. Di RI)e,:o and Grill i 1Sj rp[.)()[T,-<I thar
\\·"h FL p~'rr"usion (P. 0.0·')). \0 sllch dc\';:nion Wa" the sym~\,l[hetic respOt:5P to sy'ste:l1lc inlusion or :2-, !.,")X\"­
n/l;-;,'r'.tc'd .lUting- rhe em'li~l~ ljhase of r1w study when:) or 101} glUCOSe' \';<1"-; !lot aboli5h",d c!t"l'E'rebCHli);; f)( tt~c'
mmni 1 glllcose~ was delin?red w the \ -:\IH, [n addition. the rat. Cane' ef aL (HI'j nD""r'>t'd th,l, COLlnre!TP!."u!a:()r~,: rr'~
C<ltlt,'t'l1trarions of the L'OltntetTegulator:r hOl11v)l1t';;o during FL spouses \\ere not it1hihit~;cl when \\'as illt'ust'd i;,tl;e
pt~rfLlsion wirh :::-c1eo);::'>'glucose \\'ere \1nually identical [t) cnrorid ::mt>lit's to aboli",h forebrain hypog[~"Ct>mia during
thar obst'n:ed dtHing 100 mllloIJ1 glucose p~'lfusioIl. hyyoglycellli,L Tn additioll, Ritter et aL I :21)) ,'ih,)'\'t"!~!
\\'hel1 :2~dC'oC\:yglllcose \\'as introduced at rhe' heginning ot that obstnll'rion of rhL' eert'bral aqueduct 1 \\'hit:h l'Of1nt'cts
tht' swriy, perfusion ot" 2·deo",""yglu\.'ose through \ -:\IH alsl) the founh \t'lHlicie ltKart'd III the hindbrain \\-j,h rh,· third
had a l1:-verglyct'mic etfeet :21. FUI111t:'nllOre. unde!' and brerru H'ntril'ies siElwterl in the forebrain) stiliun~ssc'd
tht:'sC' conditions. ele\·ation of the countelTcgulmory hoI" the h~1Jt'rglycel1\il' rt'sp,)I1:-;t! to the metabolic i!1hibit~;· ,C)-tili,.!.
mone has also been noted tFig. glucose injected into the lateral \·t'ntricle. wiwreas rht' 11-:.
DUling rhe FL perfusions. plasma insulin concentrations perglycelllic response to 5-rhioglul'ose injectt'd into tt~t­
\q;>I"P not significamiy different during both Jt)O mOlol1 fottrth wnnicle was attenuatecl. but not abolished. TIH>Sc­
:::-dt'oxyglucose and 100 mmol/l glucose perfusion (.30 15!.; claw suggested that gtucoreceprors might he locar<~[ i in thtc
\·s. :27{;= ;)4 pmo!Jl: .\"S). Also, 2·cleo:,."-:;glucose perfusion into hindbrain (which consists of the pons and medulla obi.):,.
\"11H prodllced no significant change in cin:ulating insulin gata) and not in the h~Vt)rhalal1\llS, HOI\'e\·er. this \1t".'; is nix
COtH:cnrration as compared with that seen during the 100 supported by clata of Frizzell et aL (-±). who shn\\'ed (ha,
tllmut'1 glucose perfusion (11-! - 31) \-s. 150 = IS ptnol!l 0:S1. bilateral glUcose infusion into the \'enebral circulm;'Jtl
Figun: :3 sllows the distribution of radiobllPlecl 2-cleoxy­ nor attt'l1Ltate the C'uUIHt'lTegl1laror::: response ro
glucose in rats perfused through the niH probe, The radio· mia Tht'}" did. ho\\·e\'t~r. :olio\\" that the release of COUlHp!·.
acti\1(Y of samples obtained from the \-:\IH \\'<1S markedly regulatory hOI"11lOlleS in response to hypogl;':C"etnw cottld b"
higher than that of the sUlTounding tissues (i.e,. infetior pan inhibited when glucose was infused into thl'- c<1l'o[id and
of arcuate nucleus: clorsomeclial. perifornical. and mediai \'ertebr~u arteries simultaneol\sly. suggesting that the
amygdaloid nuclei: LHA: and third wrticlt': P < 0.001). sensor for hypoglyct'mia was indeed located \\'ithin til,,> C\'".
Funhennore. the radioacthity fOlmd in each ()f the AlthOllgh it has long been recognizeel that efreren~s t"ru(;,
of tissuE' outside of the \"1(H was not significantly different the \"('nrral region of the hypothalamus inminge on t!;..
from the backgrollnd le\'el ([.;'S). enc\OCt1nt' pancrE'<lS the \ -:\IH \\"as initialh' ~ol~~i(!;::red ,L-,
n sympathetic center. ('omrolIing mainly catecholamine fe.
DlscrsslO:\ sptmses (:'::::-2:)). Thus. when ir \\'as 5ho\'\'1\ that ei<?l'trical
This stud\' clemonstl"ntes that localized glucopenia produced stimulation of the \ -:\IH in rats promoted glucagon ::'c'<":rerii)n
by cleli\'~ry of 2-cleoxyglucose directly into the niH (17), this \\'<lS thought to reflect acti\·ation of the autrmonUi~
a\\'ake rats triggers the release of connterregulmory hor· nelYOllS system, a potent stimulator of glncngon r",le:l~"
mones in the absence of systemic hypoglycemia. These (11.:26), Howe\·er. mort' recent smdies lU\\'e thcu
findings prodde strong e\ictence for me existence of h:,Vo, the'\'?'1H may playa role in the detection and l'oC)r(lin~.
thalamic glucoreceptors. tion of the cOllnterregulatory responses ro h:.vog1ycemia, b
The role of the C;\S in the regulation of cOU[l[t'lTegllJaror:: these e"'l)erimems. bilateml \"1IH It'sions were produced ir~
responses to hypoglycemia is controversial. AJrh.ough several Sprague-Dawley rats local ibotenic acid injection i.s J. Ra.~
lines of e\idence strongly implicated the C.'iS in h.ypoglyce­ with lesions in the LH..--\ and FL. sham·operated (srerf.:'Ora.,\I~·
min detection nnd counterregwation (2.4.8,11), the precise needle placement iIltO hypothalamus \\ithour injenion) Hili.
brain regions lln-olved were not esrablished. Preiolts studi!:"s mals, ,md naive animals selTecl as control groups. (~ll\cag'm.
lli1\'e demonstrated thnt injections of 2-deoxygIlIcose into the epinephline, amI norepinephrine responses to il1sulin~jn­
third ventricle of anesthetized animals causes h:;,'perglycemia clucecl hypoglycemia were markedly inhibited ill the nil!·
(12.13), suggesting that glucosensith'e tissue may be situated lesioned rats as compared with the other control groups Fh
in close proximity to the third \·entricle. Howe\'er, the This srudy '"';"as intended to further clarify the contribllti'J[!
specific nuclei in\oln?d are difficult to determine by using of the \ -:\IH to hypoglycemic counten-egulml'ln. We l"€':lsow.t!
this approach because many important nuclei (arcuate. that. if glucosensors are located in the \ -:'IIH. glllcopellJ~
pelivenrricular. perifomical, dorsomedial, VMH nuclei, etc.) limited to this neural center should catlse a cOtll\terreguia­
are situated near th~ third ventricle. Furthermore. the wide­ tDry response despite pelipheral nonnoglycemia. The min!}­
spread circulation of cerebrospinal fluid throughout the dialysis techniqllE' (10) prm·idecl a means of lieliverin:?
cerebral ventricles makes any conclusion regarding the :?-deoll..·yglucose direC'tly into a specifically defined region .;(
location of the potential glucoreceptors even more uncer­ awake. unrestrained animals. Deli\'ery of 2·deoxyglllc"sl'
tain. For these reasons, such experiments do not prm;de into the VMH caused .1 rapid and marked increa..'>e in cire'U'
precise infomlation about the location of the brain glucosen­ Iating counterregulatOlY hormones accompanied by h:'l)t:r·
sors. glycemia. These responses were not caused by a nonspedlic
 ROLE OFVENTROMEDIALHYPOTH.ALAMUSIN COUNTERREGULAnON
hyperosmolar effect of the 100 mmolll 2-deoxyglucose solu­
tion. because the same concenrrmion of gillcose perfused as
a contre! had no slich effecL Potential nonspecific effer:-ts of
the microdialysis technique per se were excluded b.... apply­
ing the identical microciialysis procedure to a localized
\'olume of FLs. Finally. the possibility that these changes
were simply due to a time-dependent phenomenon was
excluded by showing the same elfect when 2-deo:-.:yglucose
was introduced m the begiIUling of rhe study. i.e.. after the
initial '5 nunolll perfu3ion. :\ote that the degree of
glucopenia induced with is usually difficult
to comrol and. therefore. difficult to relate to physiological
h~voglycel1lia . .\'en,>n:heless. urilizmioll of radiolabelecl 2-de·
o~-ygillcose perfused rtmmgh a microdialj/sis probe clearly
showt'd that the local glucopenia produced in our e:-..-peli­
;lems W[L<; limited to the \ "1[H.
[n summary. our s£udies demonstrated thm glucopeni<l
localized to the \"1IH the re!'case of glucagon and
catecholamines, These support the hypothesis that
the \ "1IH contains l1E'urons that sense glucopenia and that
this brain region is important for mediating a counteITegula·
tory response to hypoglycemia.
ACK;\OWLEDG?IlE::\TS
This research \va., supported by L·.S. Public Health Seniee
Grams DK-20-195. DK--W9:313. DK-!'57:35. and NS-:2S:227 and by
a fdlowship grant from the .]lI\'enile Diaheres Foundations
International (W.P,R, :'LA,R).
\v-e are indebted to Drs, \Yilliam Tamborlane <md :'lichael
:'kCaleb for comments ancl suggestions, We appreciate thE'
assistance of Ajda Groszmann and :illdrea Belolls for their
help in measuring plasma honnones. We also gratefully
acknowledge Karen Dmis for e~-pen technical assistance.
REFERE~CES
l. ('1'\,<'1' PE: Gltleo~t' ('tJulIit'ITl'l.(u!a!ion in man. Dj(J/}I'(I'S :)O:~!jI-:;f3..l. W:'I
.} Biggers mI'. ~IYl'IS SR. ",e'll D. :';rinson R. Conp>?r :;lB. .filSP"" .IB.
Williams PE. Chenim;tol1 AD. Frizz",! RT: Rot€' of brain in l'oumeIT€'l:!ll'
Inlion or ii1sulin-indue...d hypn.~lycl?lllia in dogs. DI(lI>I'(I',< :17:7-16. UJS~l
:3. Woods Sf. Punt: D .k \','ur..ll cotHrolui Ih" encloerill,· P'Ulcn-'as. Ph!!si'"
~lllt:;l~lln~t"Crcrt!Jn ir. [he dog rollowin~ :':·~:t.·I)X~·~.;[IJ\~t . ,,,;, .l/.'ton ~.""," £~r'l;
R"f' ';..\:501}-IH!1. W7-t
:':5"l-l";"-1-l·}2. It)~6
-t Frizzell RT. .Jon<'5 E::\L Da\is S:". Biggt'rs DW. 2\(yers SR. ('unnoHy CC
BLoum SR. Edwartis A \'. \·aughan \.) TIle r"I,· ()i !lit' .l;.·',fl'lIlU'·
\»;:\1 DW, .Jaspl\n JB. Owningron .ill: ['lllntE'ITt'gul:ltjol\ durin,! h}1)ogiy­
innt'"n·;t~lun in rhe control or glucagon !t':t'a."if>' d:.Hin~ :1·.1)tI~h.l\.. ,.:..:nia in
\'I"l\\la is ,lirectE'd hy \\ldt>:;pread hrain regions. Dil/opll!s .jt:lt::;:.l--1~61. It~t)
lh~ c~:r .f Pltysin' ~:)j:i) 11-6:2:3. W7.. . . .
......
. . .
.) .\iijima A: Glucose sensi(i\-e- atfen~nt llt'n:e fibt~rs in tht.· tI~, {'-r and
rE"gnlarit)f1 o(bl,)od glucose. Brniu R,"s Buil.') ~5qpp[ ~ ·t':":)-t:-:~~ l~)~n
.) Lauu \\\\': Ht'I);l{le nt.~n. r'::i: a Cf"\leW of rht':r furwri'~n:- tJ.r'.d t'~f';~l'~5 (~"" J
Ph!1sil '/ p!trrnll(j("{,f ·),';:;.!O·}-l~:;. U)Sr)
RtLS~t~k ~l ra!11ciparir~n or ltt:p~rk glucort''''::'~lfOt:-; 1:1 ::1t' \'n;:~:-I1; 'J!' {,)oil
int:tk~ .. \-d'IlP' l~)-;-::-fL)IJ<
U)I;:J
:' g'>rg WP. DUring 2\1.J. >Iu.'rwin RS. B"r~ ~L\. Bn:l<"s ~[L :'ht;i:::;m f.;1
\·t"n[t'on:t.~dial hn)orhabnltc lesions tn raj;:: ~uppre~~ t'l)H:Hf!-:'t':.:qi~H()r-.
rE'5pl)n~l?S to h:'VO,:!!Yft""nlia. .f ("lin {lfP:>\;: :'I:~' l'~:-7~l':6'2 ~~{q" •
~'l. PaxlIlo:, (;. \\-~t!son C: 00:' Rill Bnlin if! S/,····01rl.;-/'· ("'J'd'hrul/.'.;:': :':nd ('d
~t"W Yt)f;':..\cadelllil' Press. IDt1L p. ~r.}2 .
P) Dtuin~ ~[J: III \;\0 r~t:urodll)rllisr)'y of ;;:e COn:5.::dl::::- h:u1\;::: hrain:
!!ltrah!~,~·t\c1tnpal mil.:rodiaiY51s in evtlt~~':-::~-- fa JI~/'!"'!'r::~J"':":: ;" [hi'
.\-rfit-#)";'-"·f~rr....-_ Rnhin:-.)n TE, .JusliCt~ .iB .!~'. Ed5, .4"m"'=">~-i!~Ui; c:;"'\1~!".
1;'~.lL p ~~-H-l~
II KH,'! ,'1. \"'rlh RC. Dunnrn'.( BE T,!h,,!,~:,-- GE: R.. :'.· f.• ,' ,' ..'. -:hH:lk
[wr-.. Ot:5 =-,:'-:Sft"Hl (n intTt.)aSe pancft...>.ui,,' St'lTt"~:P!\ d·,:r:::..:. ::iarkt'~
lnsuiir!. mdtH.'ed h:'l)og!yeelnia in d,)gs.. ~1i ~ 1.<'"-: : l..f: ~" ~
!:.:. Onmm:l r Kimura f.:. I)oyama H. ~la<"o T. [~1 :'1. t,:',UU:;'I,:a \ R" .:t'fI.H:al
aCIi\'lth..~,:, o( n'-"nrroIHt'liial and I~Ht'ral h}V.}d~;")!~HUic ar£<L':' >I( c~tt;,. ,; ,~"tft'"
1·j:j·4';4-lS.-,. l~"i.j
I·; '.[.,IU1.' rEo Ellaye!, f.:. HOU!~Uli H. (Jkamc::.t II:. \'anl:,o:. LB. V;,::.d"''; P.
.-'\humr:ld :\\: Honnon::ll anti mt~rabolit~ t'"tc~~,:~S uf nt··ttr,:..,Ut\·Op,:~~::~:.. B,uitt
R··..'- I)i . t:!~r-LI)S. 19~"J:3 . ,
1-1.. f{t"fllt t1:1;;roH ...\.\\', Ran....;;t)n S\\w: The spt)nt~~::t·t)U:S acn~.~:~. ,u~d ,.,.: auak...
ur rar~ '.\ nh h..\1>Olh,)ia:1tic 1t"5ion:$. A.ft) ..J F';~(j .... ;./I : . ) . ~:~:. :.. '-'~i. ~ .~:;
l . ) Bc.'nzu \. -.-\, ThE" h~l)1)rhal~unus anti hlood ~ll1cn:'>t~ r~'.!'!t,Hz"a .';{'f
:j.~:::<;!I~i_~-5 i .3. 19;;;3 ­
tt; Sz:..tbo I).. Szabo ~.u= ~rlldies on tht-. nittt!!~ and m(ltft..• '!l"f:, , . ',f tht<
insuli!l-::'t'flsitlYe gllleor~Ceptor in {he C"':".::":\1 n,,-'"r..<OH:f ~::::;rc:;~ f::.'Jrwfr.,:,
::~"~~::~-"~:~I;. 197.).
t7 fmh!~l:l:! L\. BemanEs LL: Etrec[ of hy!>.. :~.t!;tnl\c ~lit;n':1f)"(\ '~:. :.iasma
~!ut.·o"'t· . m~ulin. and g~llC'agotllt~q:IS_ .-tm ,," PI1ll,-,",J/ :!~: . :::,:Il:_:' ,,,:,,;, l~I:-!
l~. OtRO"("(1 R.I. (;till HJ; Tilt'" forebrain IS n!); t'.:--:-iF;>oual (,)f ::~.1np~:r:~.}:t' irenai
h..\:p~'r~! .\l·t~mil" re.::,pnr~5t' (0 gtucuplinlrttl;', -;n'/'ur:,> :'::11'; <ll"':-:::~" 1ft';':'.
l~t, i- "~Hh~ P ...\~1al R.. I3~~n!!l,an R:-':: Pu(ari\"t" ity:\-,)rhai~l!niC' i<'~n;"t.'\'t.'l :.;'~ pl~l";
thj t:·:o.::-t·:Hl~\l rol~ in [!',r! reSpf)f't.'5t" (() nH.. l':~>~'~Ht' !; .. l)u".!:-... ..;t.~mia' J' ti)v(r',
:J..)::2t}~-~:-7. [9:3.') . .
2U.. Ritr r;;'t Rl....... Slusser PC. Slone $: GIlH~nr(·l·t:'~")rt)r..., and
blond ~luco$e; locanorr in th~ hindbrain, ,,:;,"'h-/lrt?
~ l. '.riller RE: Pancre~riL neuroenciocrinr)Ic,~';:
nisms i:l rhe regulation oftb~ islets orLan~~;'·hat\5.
1951 .
Hil..n:::WI)rr~ RL H~1>I){h~llamic cOfuroll)t" "h:rt"naiirft-:'~:::ii'~I_':-~rtL)i\ ;::, ::---iPOll:'iV
trbHiinl'lH glucos<,-. .f Ph./jsil/{ ~Of),-t II.....; 17. t' '7r)
[0
~:l .-\nand Sf.:. Chhina (;5. Shanna h:...'\. DU:1 ::.. Sin!!!! B: .','u<ir,· .: .-in~I"
r.t'llron~ in [he h:'VGrnaltliHic ft"t"liing l..'t'!:·t:'l'S: t,"[rt"v: .;;' '2tlll'I1::o-,* .1I11".J
Plu!,i,,; ~07: 11-t,;""1 F~. 191H
I ~~::'t"l ::(1-. [n~lt·s DL Gtyeenlic re:5Vl)n~fS indul.. . c"d :',\' h:.r. aj~\mi(~
cHUl!ubaon, '\'~lil'f)~'fr!f)('n"Ilf)I{)yy ~S:~ t~-:':l,j. 1~17~1
~:; . Frohm,;,ul L..\.. ~agai 't\: Central ner\."i)U5 :;.::...... tf'tll-medt~l::·, t :::.£tltH::.... ~irH\ (d

PROFESSIONAL REFERENCES:
YALE UNIVERSITY 1
PROFESSIONAL REFERENCES:
ACADIANA REGION 2
CURRICULUM VITAE
3
LIST OF PUBLICATIONS
4
EXAMPLES OF CITATIONS:
TEXTBOOKS & PAPERS 5
CHAPTERS IN THE BOOKS
6
ORIGINAL PAPERS
7
CHAPTERS IN THE BOOKS
8
REVIEWS
9
ABSTRACTS
10
J

SECOND EDITION

f
ETES
ELLITUS IN
PRE -NAN Y

E. ALBERT REECE, M.D.

Abraham Roth Professor and Chairman

Department of Obstetrics, Gynecology, and

Reproductive Sciences

Professor

Department of Internal Medicine

Temple University School of Medicine

Director, Division of Maternal-Fetal Medicine

Department of Obstetrics, Gynecology, and

Reproductive Sciences

Temple Universiry Hospital

Philadelphia, Pennsylvania

DONALD R. COUSTAN, M.D.

Professor and Chairman

Department of Obstetrics and Gynecology

Brown University School of Medicine

Obstetrician and Gynecologist-in-Chief

Department of Obstetrics and Gynecology

Women and Infants' Hospital

Providence, Rhode Island

Churchill Livingstone
New York, Edinburgh, London, Melbourne, Tok-yo
Contributors

Roberta A. Bhllard, M.D; Nam H. Cho, Ph.D.

Professor, Department of Pediatrics, University of Associate Professor, Department of Preventive iv!edi­

Pennsylvania School of Medicine; Director, Divisipn cine, Ajou University School of Medicine, Suwon,

of Neonatology, Children's Hospital of Philadelphia Korea

and Hospital of the University of Pennsylvania,

Philadelphia, Pennsylvania C. Andrew Combs, M.D., Ph.D.

Associate Director, Department of Maternal-Fetal

Peter H. Bennett, M.B., F.R.C.P., F.F.C.M. Medicine, Good Samaritan Health System, San Jose,

Chief, Phoenix Epidemiology and Clinical Research

California

Branch, National Insrin.He of Diabetes and Digestive

and Kidney Diseases, Phoeni"<, Arizona

Joshua Copel, M.D.

Professor, Department of Obstetrics and Gynecology,

Walter P. Borg, M.D.

Yale University School of Medicine; Director, Depart­

Postdoctoral Fellow and Research Affiliate,

ment of Obstetrics, Yale-New Haven Hospital, New

Department of Internal Medicine, Yale University

Haven, Connecticut

School of Medicine, New Haven, Connecticut;

Resident, Department of Internal Medicine, John

I.arry Cousins, M.D.

Dempsey Hospital. University of Connecticut Health

Director, .Maternal-Fetal Medicine, DivisT6n of Peri­

Center, Farmington, Connecticut

natology, Mary Birch Hospital for Women at Sharp

Memorial and Sharp PeriI1atal Cemer, San Diego,

Florence M. Brown, M.D.

California

Instructor in Medicine, Harvard Medical School; Assoc­

iate Staff Physician, Joslin Diabetes Center, Boston.

Donald R. Coustan, M.D.

Massachuset:t5

Professor and Chairman, Department of Obstetrics

Thomas A. Buchanan, M.D.

and Gynecology, Brown Universiry School of

Medicine; Obstetrician and Gynecologist-in-Chief,

Associate Professor, Departments of Medicine and

Department of Obstetrics and Gynecology, \Vomen

Obsterrics-Gynecology, University of Southern Cali­

and Infants' Hospital, Providence, Rhode Island

fornia School of Medicine; Attending Physician,

Departments of Medicine and Obstetrics and Gyne­

cology, lAC-USC Medical Center, Los Angeles.

Ulf]. Eriksson, M.D.

California
Associate Professor, Department of Medical Cell Biol­

ogy, University of Uppsala, Uppsala, S""'eden

Marshall W. Carpenter, M.D.

Associate Professor, Department of Obstetrics and

Ann .M. Ferris, Ph.D., R.D.

Gynecology, Brown University School of Medicine;

Professor and Head, Department of Nutritional

Director, Maternal-Fetal Medicine, Women and Infants'

Sciences, Uniyersity of Connecticut College of

Hospital, PrOVidence, Rhode Island

Agriculture and Natural Resources. Storrs, Connecticut

vii
1
4
Carbohydrate, Lipid, and
Amino Acid Metabolism In the
Nonpregnant Patient
ROBERT S. SHERWIN
\VILLIA1vf. V. TA1vf.BORLANE
\VALTER P. BORG
METABOLISM AND DIABETES
MELLITUS pears to be an important factor in determining the
Di:tbetes mellitus may be defined as a syndrome in
which a complex interaction of hereditary and envi­
ronmental factors leads to inadequate action of insulin,
due to decreased insulin secretion or resistance of tar­
get tissues to irs action. Regardless of the pathogenic
(insulin-dependent) diabetes mellitus:;
factors causing the disease, the e\'enrual metabolic con­
sequences of the diabetic syndrome primarily reflect
the degree to which there is this absolute or relative
deficiency of insulin. Insulin's critical role in the patho­
physiology of diabetes derives from its central role in
regulating the stOrage and release of metabolic fuels,
namely. glucose, fat, and amino acids.
Insulin Secretion in Diabetes
The defiCiency in insulin secretory capacity in diabetes
may vary from complete failure to a panial defect that is
apparent only in circumstances of increased demands
such as physical stress, obesity, pregnancy, or aging.
In the typical insulin-dependent (or type 1) diabetiC
patient, insulin secretion is either totally defective or
severely impaired; insulin production varies with the
duration of the disease. For up to 3 to 5 years, these
patientS continue to secrete some insulin, despite their
requirement for exogenous insulin.' The extent to
I
which this residual insulin secretion is maintained ap­
stability of long-term metabolic comroL! Ultimatek,
endogenous insulin secretion becomes undetect:1bie
as residual functioning f3-cells are comoleteh' de­
stroyed. Abundant evidence now exisrs that ·autOi~mu.
nfty plays a critical role in the pathogenesis, of type I
In the patienrs with type II (non-insulin-dependent)
diabetes. the secretory failure is less severe. Basal insu­
lin le\-els are generallv normal or mildl\' increased.
whereas glucose-Stimuiaced insulin secretion is dimin~
ished. The magnitude of the insulin secretory defect
usually correlates with the severity of fasting hyperglr­
cemia in these patientS. In itS mildest forms (plasma
glucose approximatel;: 140 mg/dl), the l3-cell defecr
involves only the initial secretory phase; the more-de­
layed insulin response remains intact. In such individu­
als, the loss of responsiveness to glucose is specific,
(Le., normal responsiveness is maintained to Other se­
cretagogues such as f3-adrenergic stimulation or amino
acids).4 Consequendy, insulin defiCiency is much less
pronounced during ingestion of mixed·meals as com­
pared with glucose. s In patientS with more severe fast­
ing hyperglycemia (>200 mg/dt), the capaciry to reo
spond to increases in circulating glucose is \-irtually
lost. These observations suggest that a specific abnor­
mality in recognition of glucose by the l3·cell occurs
35
"
 36 DL\BETES ~IEU.ITUS IN PREGNA:.-';CY
in the earliest stages of I:)pe II diabetes and that this
I defeCt advances as the disease progresses.
The initial reportS by Yalow and Berson6 regarding
plasma insulin levels in [)pe II diabetes emphasized
the presence of h~perinsulinemia, This seeming para­
I dox was subsequently shown to be more apparent than
real when tota:lb.odr weight and ambient blood glu­
cose levels ag~considered. Approximately 80 to 85 per­
cent of eypeI! diiibetics are obese. Obesity per se is
generallr accompanied by hiperinsuIinemia and is as­
sociated with resistance on the pan of targ~ tissues
(muscle. liver, adipose tissue) to insulin? \'I;11en com­
parison is made bet:\veen obese [)pe II diabetic pa­
tiems and appropriate weight-matched nondiabetic
control patients, it is apparent that insulin levels in
1 obese diabetic patients are below those observed in
obese subjects with normal glucose tolerance.s An ad­
ditional factor contributing to the seeming hyperinsuli­
J nemia is the presence of hyperglycemia itself. In other
words, when glucose levels are raised in nondiabetic
individuals to stimulate the glucose tolerance curve
t of the diabetiC patient, the deficiencr of the insulin
response in the diabetes becomes more clearly ev­
ident.
Insulin Resistance in Diabetes
The biologic actiqn of insulin is not only related to its
concentration but is also a function of its ability to
activate cellular events. The first step in the cellular
action of insulin is the binding of the hormone to a
specific receptor on the cell surface, This interaction
triggers a cascade of poorly characterized cellular
changes, termedpostreceptor ecenfS, leading to a meta­
I bolic response. The concentr:uions of insulin required
to activate metabolic processes vary both with respect
to the target tissues and the substrates involved. For
I example, a doubling of systemic insulin levels is suffi­
cient to achieve near-maximal suppression of lipolysis
but has a negligible effecc on glucose uptake by periph­
I eral tissues (muscle and f::u).9 The insulin concentra­
tions needed to promote protein anabolism or sup­
press hepatiC glucose production fall beC"Ween these
extrem.es but again are much lower than those that
1 ma;ximaily increase peripheral glucose uptake,lO.n As
might be expected from this siruation, the conse­
quences of incomplete insulin defiCiency differ sub­
1 ..
I
stantially among the various insulin-sensitive fuels ar
target tissues.
In type II diabetic patients, insulin is markedly Ie
effective. 12 The insulin dose-response curve for au
meming glucose uptake in peripheral tissues is shift(
to the right (decreased sensitivi[)') and the maxim
response is commonly reduced, particularly in patier.
with more severe h}perglycemia. 13 Other insulin-stir.
ubted processes, such as inhibition of hepatic gluco:
production, also sho'!;'" reduced sensitivirj' to insuli
However, by contrast, hepatic insensiti\"irj: is relative
mild and m3.Y be readiii' overcome br larger amour.
of insulin. 13 It is generally believed that insulin res!
tance in type II diabetes results from both a reductic
in insulin receptors and postreceptor defect.H Tr
causes of insulin resistance in nonobese type II dt
betic patients do nOt appear to be different from the
obese counterpartS. Howe\·er, the severirj' of the res:
tant state tends to be accenruated by the co-existenc
ofobesity and diabetes. Overall, the available data inc
cate that insulin resistance contributes importantly [
the development of I:)pe II diabetes. It remains unce
tain, however, whether insulin resistance or the de:
cieney in insulin secretion is the primary e\'ent leadi:-.
to diabetes in these patients. Regarr;lless, bam disn.:
bances undoubtedly imeraa, thereb;1"magnif;.ring r.r
severity of the metabolic derangement Interesting;
the ability of insulin to stimulat~ glucose uptake :
peripheral tissues is also impaired in patientS with [)1'
I diabetes 15 and in animals rendered panially insuli:
deficient by subtotal pancreatectomy. This· insul'
resistance is thought to be medi,ned by a poser,
ceptor defect and is responsh'e to intensi\"e insul:
therapy.16 Thus, even in I1pe I diabetes, insulin r,
sistance may contribute to and impair therapeu,
measures directed at improving glucose COntrol. Tr.
defecrs in insulin action in diabetes are summarize
in Table 4-1.
Table 4-1. Defects in Insulin Secretion and Actior.
in Diabetes
Ti-pe I
Diabetes Type II Dl:lbetes
Insulin secretion
insulin aaion
Absent
Impaired
Impaired (pa:;;icularl:; to glueQ:;·
Severely imp:lired (receptor :1...:.
postreceptor defec-..s)
 CARBOHYDRATE, UPID, AND A..\UNO ACID METABOLISM
Table 4-2. Metabolic Actions of Insulin
[Jver
~ciGl(lbolic effeCtS Decre:lSed
Glycogenolysis
Gluconeogenesis
Ketogenesis
."~'1;lbolic effeCtS Inere:lSed
GI;:cogen synthesis
Fat synthesis
--------~--~~----~==~~----
Metabolic Effects of Insulin
Insulin is the primary hormonal factor that controls
the storage and metabolism of ingested metabolic
fuels. After a meal, augmented secretion of insulin facil­
itates the uptake and storage of glucose, fat, and amino
acids. Conversel~', a deficiency of insulin leads to mobi­
lization and endogenous fuels and reduced use of in­
gested nutrients. The action of insulin involves each
of the three metabolic fuels and is manifested in three
principal tissues: liver. muscle, and adipose tissue,
where insulin exerts both anticatabolic and anabolic
effects, ""hich reinforce each other (Table 4-2).
BODY FUEL METABOLISM IN
NORMAL SUBJECTS
Postabsorptive State
The period after an overnight fast and preceding the
ingestion of the morning meal is referred to as the
postabsorptive state. At this time, the concentrations of
hormones (insulin and glucagon) and substrates (glu­
cose, amino acids, and fat) thar were altered due to
meal ingestion during the preceding day h:l\"e reo
turned to baseline, and the rate of fuel consumption is
closely matched by endogenous fuel production. The
postabsorptive state thus serves as a useful reference
point because it represents the period of transition
1 from the fed to the fasted condition.
After an overnight fast, the decline in circulating in·
sulin leads to a marked reduction of glucose uptake
I by peripheral insulin-sensitive tissues (e.g., muscle and
fat) and a shift toward the mobilization and use of fatty
acids as energy·yielding fuels. Glucose consumption,
nevertheless, continues in the non-insulin-sensitive tiS­
sues (e.g., the brain, renal medulla, formed elements
of blood) and in the splanchnic area, so that total glu­
I
37
Adipose TISSue Muscle
Decfe:lSe:d Decre::l.Sed
Lipolysis Protein bre:t.!.;down
Increased InCTe:lSed
Fat synthesis Glycogen and prOtein synthesis
G~'cerol synthesis Glucose uptake .
cose use continues at a rate of 200 to 250 gld.l7. The
main site of glucose uptake is the brain, >':hich is criti­
cally dependent on an ongoing supply of glucose for
oxidative metabolism. Despite the lack of exogenous
fuel and the ongoing glucose reqUirement, blood glu­
cose remains relath-ely stable as the liver releases glu­
c.ose at rates sufficient to match those of consuming
[tssues.
The hepatic processes involved in the release of glu­
cose into the bloodstream consist of glycogenolysis
and gluconeogenesis. It has been estimated that ap­
proximately 50 to 75 percent of hepatic glucose pro·
duction in the POStabsorptive state is derived from gly·
cogenolysis, with gluconeogenesis contributing the
remalnder. 1 $ The resynthesis of glucose from the gly­
colytiC intermediate, lactate, amounts for"3t least one·
half the gluconeogenic component, and the conver­
sion of glycogenic amino acids comp.t;ises most of the
remainder. Alanine, whose release from muscle and
uptake by liver predominates over that of other amino
acids, is the main amino acid contributing to glucose
S}nthesis. Conversion of fat·derived glycerol and recy­
cled pyruvate contribute less than 2 percent and 1 per­
cem, respectively, to total glucose production. ls Fuel
homeostasis in the postabsorptive state is summarized
in Figure 4-1.
Regarding the hormonal factors regulating glucose
metabolism in postabsorpuve humans, bOth glucagon
and insulin moderate glucose release by the liver. Per­
haps the most compelling evidence that basal glucagon
secretion is important in maintaining glucose produc­
tion in the postabsorptive state derives from sLUdies
in which somatostatin is infused to suppress plasmJ
glucagon and circulating insulin is prevented from fall­
ing by exogenous insulin infusion. In this circum·
stance, a sustained 70 to 75 percent reduction in he­
patic glucose production occurs, indicating the
-.
38 DL-\BETES MEllI1lJS I~ PREG~A;.~CY
r
BLOOD
GLUCOSE
"/­
GLYCOGE~
Liver
GLUCONEOGENESIS
\\
LACTATE
Fig. 4-1. Glucose homeostasis in the pO$[Jbsorpth'e sate in normal human subjects, FFA. free- fatty acid: A-\.
amino acid(s),
importance of basal concentrations of glucagon in op­
posing the inhibitOry actions on this process,19 The
restraining influence of basal concentrations of insulin
on postabsorptive glucose production is also e\'ident
when plasma insulin is suppressed by somarostatinand
circulating glucagon is maimained at the basalb'el by
exogenous glucagon infusion. Under these condi[ions.
hepatic glucose production promptly incre3Ses,~o He­
patic glucose production appears to be regul:ued by a
"push-pull" system, with the opposing actions of insu­
lin and glucagon balancing each mher. In the pOSt­
absorptive state, the hormonal regulation of glucose
homeostasis is primarily directed at endogenous
production of glucose rather than its uptake by tissues,
After overnight fasting. muscle tissue, the main res­
en'oir of body protein, is in negath'e nitrogen babnce
as evidenced by a net release of amino acid5,~t This
net proteolysis in muscle is facilitated by the decline
in circulating insulin to baseline concentrations, Inas­
much as plasma amino acid le\'els remain relatively
constant; amino acid release from muscle must be JC­
companied by amino acid uptake by nonmuscubr tis­
sues (liver and, to a lesser e).,em. kidney and gut). A
net flux of amino acids thus existS bet";een musci::
tissue and norunuscular tissues where nitrogenou:
'waste products (urea and ammonia) are generated,
Ah:hough virrually ali amino adds are rele3Sed b:,
muscle, alanine and glutamine predominate, accour,:
ing for more than 50 percent of the lmal amino ac:.
release. 22 The alanine serves as a substrate for hepa::.
gluconeogenesis, and glutamine as a precursor f.:::
renal ammonia synthesis and as an energy-yielding rue
for the gUt. Because alanine and glutamine account fo
only 10 to 13 percent of the amino acid residues i;­
muscle prmein, their release at higher concentracior::
has been explained on the basis of de nO\'o symhesl'
in muscle_
The carbon skeleton of al:mine is largely derh-e.
from pyru\'are; it is belie\'ed that most of the pyru\'a:~
used in alanine syntheSis in muscle is formed via gl;'
colysis. 23 The branched chJin amino acids (leucino:
isoleUcine, and \~Jline) appear to be the predomina:-:
sources of the nitrogen for alanine formation 2 -l (Fif'
4·2). In contrast to mher amino acids. these amir::
acids are metabolized to a greater extem in muscle
than liver, Furthermore, their oxidation in muscle :!f'
'.

 j
C-\RBOHYDRATE, LIPID. A'.u A.\!INO ACID METABOLISM
I
GLUCOSE
1 amino acid oxidation limit the release of glycogenic
ALANINE «:-(---
1
PYRUVATE
+ night fast allows for the release offree fatty acids (FEAs)
Nilregen Greui'
BCAA
Fig. 4-2. Alanine synthesis in muscle. The Clfbon skeletcn
is m:lin!\' derived from glucose, ""here:lS br:lnched ch:1in
amino a~ids (BC\..l.,.) pby an [mpor..ant role in donating the
nitrogen group.
pears to be sufficient to provide nearly all the nilrogen
required for alanine formation. z5 The apparent cou·
pIing bet,,;een branched chain amino acid cat:lbolism
and alanine s}l1thesis suggests that the [ate of oxidation
of these amino acids may be an imponant factor, mod­
ulating the availability of alanine as a substrJ,te for he­
patiC gluconeogenesis. Leucine oxidation is inversely
correlated with insulin concentration?6 In contrast to
alanine, the carbon skeleton as well as the nitrogen
source for glutamine is most likely derived from in
27
situ muscle catabolism of amino acids.
The partern of amino acid uptake by the splanchnic
area (liver and gut) complements that of muscle re­
lease (I.e., alanine and glutamine predominate).23
However, when hepatic and extrahepatic tissues are
considered indiVidually, mOSt of the alanine is reo
moved bv the . liver, whereas glutamine is taken up
by the g~L29 Nevertheless. glutamine contributes (0
glucose and urea production by the liver, because a
ponion of the glutamine taken up by the gut is con·
vened to alanine, released directly imo the ponal vein,
and ultimately convened to glucose and urea by the
liver (Fig. 4-1). Alanine is thus nOt only a main vehicle
for nitrogen release from muscle but is quantitatively
the most impon:ant protein.derived precursor for he­
patic gluconeogenesis. The rate at which afanine and
other amino acids are convened imo glucose is in large
pan determined by the balance between glucagon
(stimuhtory) and insulin (inhibitory) in the porral vein
as well as the availability of glucose precursors gener­
ated by muscle. The restraining effeCts of insulin on
J
-
39
the dissolution of muscle prOtein and branched chain
amino acids by muscle. therebr complementing its reo
stl.lining effea on hepatiC gluconeogenesis.
Finally. the hll in circulating insulin after an over­
from adipose tissue depots (Fig. 4-3), Insulin is ex·
tremely effective in inhibiting hormone·sensitive li­
pase within the fat cell. which cltaivzes the hvdrolvsis
of stored triglycerides and r...l-te libe;ation of ff_-\5. This
anti[ipolyric action of insulin occurs at concentrations
of insulin well below those neceSSJry to affeCt glu~ose
trJ,nspon.9 The levels of insulin normally present in
the posrabsorptive stJ.te lre suffiCiently low, however.
to permit the flux of Ff.\s from Storlge sites to eX"1race­
rebral tissues, such as muscle. he:lft, renal cortex, and
liver (Fig. 4-3). In these tissues, bay acids are the prin­
cipal energy-yielding fueL The consumption of FFAs
by muscle tissue is an impomm f:lctor in diminishing
muscle glucose upr.a..":e and oxid:uion in the posrab­
sorptive state. FFAs act in this ,;vay by reducing glyco·
lytiC flux as well as emry of glucose·derived pyruvate
imo the Kreb's cycle (through the pyruvate dehydro­
genase step ).30 The r:lte of lipolysis and the magnitude
of the insulin decline in porrJ! blood after an overnight
fase is not, however, of sufficient magn!tude to stimu­
late appreCiably the rate of hepltic convehion of FFAs
to ketones.
Metabolic Adaptation During Short~
Term Starvation
Because liver glycogen is Iimired to about 70 g after
an overnight fasc,3 1 whereas glucose consumption oc·
curs at a rate of approximately 200 to 250 gld, hepatiC
glycogen scores are rapidly dissipated very early in the
course of fasting. Thus, the ini[ial phase ofstarvation is
characterized by an acceleration of hepatiC gluconeo­
genesis to meet ongoing tissue demands for glucose
by the brain. The augmem:l[ion of gluconeogenesis
and the maimenance of glucose homeostasis are me·
diated by both hepatic :Jnd extrahepatic events. The
release of alanine and Ocher glycogenic amino acids
from muscle increases,3 2 and the rate of hepatic con­
version of alanine to glucose accelerares.2 1 The en­
hancement of glucose symhesis from amino acids is
nOt, however, sofely a function of increased a\-ailabilir. .'
of these precursors, since plasm3.levels of alanine and

 40 DIABETES i>IEIlJruS I~ PR.EG~A:'\(CY

INTAKE and PRODUCTION

PROOUCTION
STORAGE RHEASE UTILIZATION

Gl YCEROl

f
\~ FFA~--
\1'"01 lJ~o"
'I TRIGLYCERIDE
CHYlOM1CRON- rG> l'?o~ro'e,,' FFA J
! lIPOPROTEIN- TG lipase \ -;
aGLYCEROl

~I-T! ADIPOSE CELL

[;
{GLYCOG~N fFt-;
\ ; ' /- _ _ GLUCOSE
GLUCOSE

Fig. 4-3. F3.t syntheSiS, storage, and rele3.Se in normJ! humans. Normal fJt homeostasis is dependent on the action
of insulin. \'\'ithin the liver, insulin stimulates the synthesiS of free fatty acids (FFAs) from glucose and their
esterification EO form triglycerides (TG). Both exogenously deri,'ed (dietary) triglycerides (chylomicron.TG) and
endogenous!:' synthesized triglycerides (lipoprotein-TG) are sources of fany acid delivery to adipose tissue. Insulin
acceler::ues the uptake of FFA by adipose tissue by its stimulator:' effect on lipoprotein lipase, Fat storage within
adipose tissue is also enhtlnced by insulin's glycerogenic effects. The amilipolytic actions of insulin (inhibition of
tissue lipase) enhance fat storage as '\vel!, while redUCing the a\-ai/ability of circulating farr:' Jcids. FFAs a;e'released
from adipose tissue when insulin ie':e!s fall and are taken up by muscle, hem, kidney, and liver.

other glycogenic amino acids actually fall despite their
increased release from muscle. These observations
suggest that intrahepatiC gIuconeogenic mechanisms
are stimulated during short-term fasting. An addition::11
factor contributing to glucose homeostasis at this time
is the increased release ofFFAs from adipose tissue.
Oxidation of fam' acids by muscle spares glucose for
use by the brain' whereas their oxidation by the liver
activates key gluconeogenic enzymes and furnishes [he
energy and reducing power necessary for glucose syn­
thesis. 33
These metabolic adaptations (namely, increased glu-
COfleogenesis, amino acid mobilization, andlipolysis)
are facilitated by a decline in insulin secretion below
posrabsorptlve levels as well as a modest increase in
circulating gluclgon !eve!s.34.35 The former appears to
be triggered by a fall in arterial glucose concentration,
which inhibits insulin secretion, whereas the rise in
glucagon is due to diminution in the race of glucagon
metabolism.35 Hypoinsulinemia enhances protein
breakdown and thus the delivery of glycogenic amino
adds from muscle to liver, where increased quantities
of glucose are synthesized under the influence of barh
the elevation of glucagon and the depression of porta!
insulin (Fig. 4-4). Hypoinsulinemia further contributes
to glucose homeostasis by reducing extracerebra! glu­
cose consumption and by increasing the a'v'ailabiliry of
FFAs for oxidative metabolism bv muscle and liver.
The progressive rise in blood ketOnes during Starva·
tion is also regulated by insulin and glucagon36 (Fig. 4­
4). The development of hyperketonemia im'olves three
distincc mecabolic events: (1) delivery of FFA from adi­
pose tissue, (2) hepatic oxidation of FFA5 leading to
ketone formation ("ketogenic capacity"), and (3) a re­
duction in ketone uptake by peripheral tissues. Hypo­
insulinemia activates each of these steps, whereas
hyperglucagonemia contributes by enhancing keto­
geniC capacity.36 Growth hormone may also contribute
by promoting JipolySis.3 7
Exercise
As in starvation, during exercise there is a' need to
generate glucose and FFAs from endogenous sources
to meet tissue demands. Because muscle glycogen

1
 CARBOHYDRATE. LIPID, A"\D A.\II:-iO ACID METABOLIS.\.i 41

t Insulin

I~~i~\ &
t Amino Acid
Mobilization

~
t Gluccneogenic Enzymes
t Ketof;enic Capacity

C It GIUC09~J
--~-~--'--~'---~--l

t Ketosis ---.J
-_._. .

t Glucagon

Fig. 4-4. Incer:J.ction of insulin suppression and giucJ.gon stimulation in promoting gluconeogenesis and ketosis
during stlf'l"ltion. ITA. free fatty acid.

stores are rapidly depleted, energy' for working muscle
must be supplied from blood-borne fuels (Fig. 4-5).
Glucose is supplied by the liver, which ma~: increase
itS production of glucose three- to fivefold. 38 The rate
of hepatic glucose production is precisely regulated to
supply enough glucose to keep blood levels from fall­
ing despite the increased glucose extraction by work­
ing muscle. FFAs are mobilized from adipose tissue at
dramatically increased rates to minimize the need for
glucose from the lh-er's limited glycogen stores. As ex­
ercise continues for prolonged periods, the consump­
tion of FFAS assumes an increasingly important role
in meeting muscle energy requirementS 39 (Fig. 4-5).
This spares the liver from further demands for glucose
production, which, by this time, is occurring co a
greater extent from gluconeogenic precursors. includ­
ing protein-derived amino acids. 39
Current evidence suggestS that the increased con­
sumption of glucose and FFAs by exercising muscle is
mediated largely \-[a local non hormonal mechanisms.
A coordinated hormonal and neural response is, how­
ever, of critical importance for the produaion of ap­
propriate quantities of SUbSlTales. During exerCise,
insulin secretion diminishes in associatiQn with the ac­
tivation of sympathetic nervous system ~cti\'i(y :\1so,
increments in plasma glucagon, epinephrine, gro\'.th
hormone, and cortisol commonly Otcur, particularly
as the intensity of exercise is incre3Sed."o These hor­
monal changes, acting in concert, promote the mobili·
zation of glucose and FFAs from liver and adipose tis·
sue. respectivel~'_
Glucose Ingestion
GLucose ingestion involves a variety of homeostatic
mechanisms that act to minimize the rise in pb5m~
glucose and restore normoglycemia. They include (1)
suppression of endogenous glucose production by the:
liver, (2) stimulation of glucose uptake by spl:mchnk'
tissues, especially the liver, and (3) stimui::ttion of pe·
ripheralglucose uptake, particularly in muscle. These
homeostatic processes are activated by a rise in circl!'
lating insulin or a rise in blood glucose itSelf. SpecifI·
cally. inhibition of hepatic glucose production is exqu:·
sirely sensitive to small elevations of portal insuli"
concentration lOAI but may also occur in response tC;

1
 J
1 42 DLABETES MELLITIJS IN PREGNA;:~CY

100

75 Musde Glycogen FFA Uptake

/ ----­
Fuel

Contribution

50

/ -
to Total
02 Uptake

(%J

25
Exhaustion

o 2 3 4 Hours
'---.--' ,
Glycogen Glucose + FFA Uptake t FFA, .} Glucose Uptake

Fig. 4-5. Time-dependent ch;lOges in the contribution of muscle glycogen and blood-borne fuels (glucose and
free fatty acids [FFA.sj) to [he energy requiremen£s of leg tissues during bicycle exercise.

hyperglycemia per se, provided thar b:15al insulin lev­ ited in muscle tissue. Thus. the muscle and liver bo,'­
els are mainrained.-I2 Glucose upt.:lke by splmchnic tis­ playa crucial role in the homeostatic response to i:J.rg'

sues is stimulated by a rising glucose concentration glucose meals (Fig. 4·6).

and to some extent by hyperinsulinemia.~3 The pres­ A large (75-g) oral glucose load is, however, r.C

ence of basal amoun£s of insulin are required for glu­ representativ·e of either the magnitude of carbohydr:l:'

cose to exert this effecr.-I-l By contrast, peripheral glu­ intake or the amplitude of blood glucose excursio:.

cose uptake is promOted by hyperinsulinemia arid, to observed in healthy individuals ingesting ordinr

a more limited extent, by the mass effect caused br meals. In circumstances of mixed meal intake, hexos

hyperglycemia i£self. 43 Considerably l:1rger amountS of intake is conSiderably less and the blood glucose ge::

insulin are, however, needed to incre:15e peripheral erally varies by no more than 30 mgldl over 24 hou~.

glucose uptake than are required to suppress hepatic This "fine tuning" of blood glucose regulation is dele

glucose production. lO mined to a greater extent by the exquisite sensirjl.:i .

. The elevation in plasma glucose caused by ingestion of the liver to small changes in insulin secretion. \Vhe
of large glucose loads brings into play e:lch of the small amountS of glucose are consumed, peripher.
abm'e metabolic adjustmentS. Hepatic glucose produc· insulin b'els rise modesd)f (less thanrwofold). Ho,
tion is markedly suppressed for several hours until ever, because insulin is released directly into the pore
plasma glucose has returned to baseline. This serves
vein, ponal insulin concentrations rise considera::o
to limit glucose entry into the systemic circulation at
higher. Consequently, hepatic glucose production
a time when the system is overloaded by exogenous
suppressed, whereas peripheral glucose uptake, whi"
glucose. With respect to (he uptake of the exogenous
requires more insulin to be activated 10 is onlv me
glucose load, recent studies indicate that in quantita­
tive terms most of the exogenous glucose load (about estly incre:1Sed. 46 If the quantity of gl~cose co~umc
[v"o-thirdS) is deposited in muscle."; The remainder
is suffiCiently small so that it is compensated for by tr
(abour one-third) is taken up by splanchnic tissues reduction in endogenous glucose production, gluco

(e.g., liver and gut). When one considers that the liver
homeostasis is maintained simply by retaining hep:.;·
also reduces itS endogenous production of glucose by
glycogen stores. Thus, as compared wirh me liver, ITa

more than 50 percent, the net effect is a substantial

a
de and adipose tissue are involved to "more limit

retention of glucose in the splanchnic are!, which ap­ extent in the metabolic adjustment to very small g:

proaches in magnirude,~e amount of glucose depos- cose loads. This phenomenon is a direct consequer:

J
. .:.-.
 J

CARBOHYDRATE, UPID, AND A.\UNO Aero METABOLISM 43

POST ABSORPTIVE GLUCOSE INGESTION

HEPATiC GLUCOSE
PRODUCTION (40g)
HEPATiC GLUCOSE

PRODucn~g) aD GLUCOSE
7Sg

.~
BRAIN B~AIN
(20g) (20g)

PERIPHERAL
TISSUES PERIPHERAL
(lOg) TISSUES
(SOg)

Fig. 4-6. Cumulative rates of hepatic glucose production and glucose disposal by non-insulin-dependent tissues
(brain), the splanchnic bed, and peripheral insulin-sensitive tissues during a 4-hour period either in the pos.absorp·
tive state (fast) or after ingestion of a 75-g glucose load in normal subjects. After glucose ingestion, hepatic glucose
produaion is reduced (by 50 percent) and glucose uptake by splanchnic (Z.5·fold) and peripheral (S·fold) tissues
is increased.

of the disparity of the dose-response CUl>'es of hepatic

and peripheral tissues to insulin. lO
-::: Vaitoe I~1

v--~
::!, 300
Protein Ingestion a
z
f: .-- --1 1
. - 1/
Because muscle is in negative nitrogen balance in the < LeUCH"te ,/
c::
fasting state, repletion of muscle nitrogen depends on
l­
z \ / I holtudne
""uz
_- -----1T
a net upr.a.l::.e of amino acids in response to prOtein 200
a '/ -
feeding. The transfer of amino acids from the gut to u
0 / 1----
/1
-.
muscle after prOtein ingestion is facilitated by the ac­ u V
,,
/
a""
tion of insulin.
= /1 /

In normal healthy subjeCtS, ingestion of a pure pro­ :::;: 100 1 / ,/

tein meal is followed by a large output of amino acids "" / :t
from the splanchnic bed, involving predominantly the
""
:::;:
.I -' OTHER
'"<...J /
/
AM 1110 ACIOS
branched chain amino acids. 47 Valine, isoleucine, and c:. ;;"
.,,/
leucine together account for more than 60 percent of <l
0
the total amino acids entering the systemic circulation.
even though they contribute only 20 percent of the
:. :.. TIME [hr,)
total amino acids in the protein meal (Fig_ 4·7). The
glycogenic amino acids, however, are for the most pan: Fig.4-7. Changes in plasma :UTl:no acids after ingestiOn of a
deposited within the splanchnic area. 47 Simultaneous pure protein meal. IncrementS in the branched chain a!Tlino
with the release of amino acids from the splanchnic acids (leucine, isoleucine. and valine) exceed those of Other
bed, peripheral muscle exchange of most amino acids amino :lCids. (Based on unpublished data.)

44 DL~ETES MEllITUS IN' PREGNA..'{CY
revens from the net outpm observed in the basal state
toa net upt:lk.e. As in the case of sphnchnic exchange,
the net up~1..,",e of amino acids across peripheral muscle
tissue is most marked for the branched chJin amino
acids. The laaer account for more tha..'1 hJlf the total
peripherJI amino acid uptake in the first hour and for
nearly 90 percent at 2 to 3 hours.~7 Leucine, isoleucine,
and valine thus constirute [he mJin substrate for the
immediate repletion of muscle nitrogen after prOtein
intake. Furthermore, because the branched chain
amino acids comprise only 20 percem of the amino
acid residues in muscle prorein,25 it is likely tha( these
amino acids Jre not solely used for protein S}-l1thesis
but are c3tJbolized within muscle. Thus, as in the fast­
ing state mey provide a source of energy for muscle.
Interestingly, the high intracellular le;'els of branched
chain amino acids in muscle induced by protein feed­
ing may have importance beyond delivery of nitrogen.
There is evidence that me branched chain amino acids
have a regulatory role in stimulating protein syn­
thesis. 48
Fat Metabolism
The rise in plasma insulin that normally accompanies
the consumption of mLxed meals accelerates the reo
moval of ingested triglyceride by adipose tissue and
serves to promote triglyceride s;.l1thesis in li\'er and
adipose tissue (Fig. 4·3). In the liver, a significant pro­
portion of the dietary carbohydrate taken up is used
for trigl:'ceride formation. In humans, the liver is quan­
titativel:" a far more important site of conversion of
dieta[\· carbohydrate into fat than is adipose tissue.
Howe~er, bOth' exogenously derived (or dietarr) tri­
glycerides (chylomicron-TG) and endogenously syn­
thesized triglycerides (lipoprotein·TG) provide a
source of FFA for triglyceride synthesis in adipose tis·
sue. Insulin accelerates the uptake of FFA by adipose
tissue by virtue of itS stimulatory effea on lipoprotein
lipase, an enzyme that breaks dO'i.vn Circulating triglyc­
erides.-i9 Triglyceride storage within adipose tissue is
also enh::mced by insulin's glycerogenic effeCtS. A large
proportiOn of insulin-mediated glucose uptake in the
fat cell is used for the formation of a-glycerophos.
phate, which is necessary for the esterification of fatty
acids to form ([iglycerides. The amilipolY1ic actions of
insulin (inhibition of hormone·sensitive lipase) also
enhance fat storage while redUCing FFA concentra­
tions. The net effect of the ancllipolytic, bt symhetic,
an.d glycerogenic aaions of meal-stimubted insulin
elevations is to increase total f:lt stOrage and reduce
circubting FF.-\.5 and ketone
Role of Gender in Glucose
Homeostasis
Assessment of metabolism h15 gene rail;' been per·
formed wimoU[ regard to the sex steroid hormonal
milieu. Recentl:', however, se:era! lines of evidence
indicate me existence of gende;-rel::ued differences in
fuel metabolism. In response to exogenous insulin in­
fusions, the rates of total whole·body gl:Jcose upta.l;:e
or glucose upt:lke per unit of ir.sulin have been shown
to be greater in males than fem:des.so-52 Furthermore
the response to extended fasting is notably iruluenced
by the sex of the individuaL \iihereas the f:lll in circulat·
ing glucose in normal men is gradual and glucose b',
els rarely fall below 50 mgfdl. in nonobese ,,'omen
the process is accelerated and plasma glucose often
decreases to the 40 to 50-mg'dl range after 48 to T2
hours. 53 Although the explanation for these differences
has nOt been established, it h1.5 been suggested that
the smaller muscle mass of women than men leads [Q
the reduction in insulin-stimubted glucose up;:ake, as
well as the changes seen during fasting in females. With
respect LO the latter, it has bee;; demonstrated that the
generation of amino acids f:om muscle is diminished
in fasted fem3les. In keeping with Ll-jis. the fas,ing-in·
duced decline in circularing abnine is more pro·
nounced in women than in mer<.53 The greater decline
in glucose concentrations leads to greater suppression
of insulin secretion and, in ru~n. to a more pronounced
rise in blood ketones in fasted wome:1. Despite the
evidence that women achieve a lower glucose le\'e!
during fasting than men, the literature contains con­
flicting data regarding the e:fect of the gender on
coumerregulatory response [Q hypoglycemi:l. Se\'er:tl
reports have demonstrated that epinephrine, norepi·
nephrine, and grow1h hormone responses to hypogly­
cemia and other stimuli were Significantly higher in
males. 54 .5S By COntrast, Other i:westigators have failed
to demonstrate such differerl':es%
Another situation in which u'1ere is variation in the
sex hormones milieu is the follicular and lute:11 phases
of me menstrual cycle in 'women. Assessment of carbo·
hydrate metabolism under hyperglycemic conditions
 CARBOHYDAATE, LIPID, Ai\'D A.\!I[\;O ACID
1I
,
-~
have demonstrated greater glucose uptake in the pre·
o'fulatorr period. s7 - s9 However, no detectlble differ·
ences in the basal rate of glucose rurnO\'er, insulin·
stimul:ued glucose uptake, or the insulin·induced
suppression of hepatic glucose production has been
obse[\'ed be(ween 1:\....0 phases of the menstrual
cvc!e. 60 - 62 Also, the cOI,mterregulatory hormone reo
SPonses [0 hypoglycemia. are simibr in the follicular
and luteal phase of'the cyde.
63
BODY FUEL METABOLISM IN
even increased basal le\'e[s of insulin ma\' be mlin·
DIABETES
tained but only at the expense of fasting h~perglyce.
Metabolic Dysfunction
The metabolic alterations observed in diabetes primar­
ilv reflect the degree £0 which there is an absolute or
r~lati\'e deficiency of insulin. Viewed in the context of
the role of insulin as the main storage hormone, a
minimal deficiency results in a diminished abilicy to
increase effectively the storage reservoir of body fuels,
because of inadequate disposal of ingested foodstuffs
(e.g., postprandial hyperglycemia, hyperaminoacide·
mia, and ele\'ated trigly'cerides). In its most severe
form (diabetic ketoacidosis), there is overproduction
of glucose and marked acceleration of catabolic pro­
cesses (lipolysis and proteolysis).
Postabsorptive State
After an overnight fast, substrate homeostasis in [he
patient with diabetes resembles that obser....ed during
starvation in nondiabetic individuals, Thus, diabetes
might be thought of as a st:1te of "accelerated starva­
tion," a situ::uion not unlike that seen in normal preg­
lianC\', This should nOt be surprising considering that
the hormonal milieu of diabetes and stan'alion share
mam' common features, namely, insulin deficiency in
asso~iation with relative or absolute glucJgon and
grO\'.'h hormone excess. The principal difference from
the metabolic standpoint is that blood glucose in the
diabetic patient is elevated rather th:ln reduced as it is
in the case during starvation. Such discrepancies may
be due to the persistence of liver glycogen Stores in
the diabetic that aHow glycogenolysis to be maintained
in conjuncrionwith increased rates of gluconeo,
genesis,
In the patient with glucose intolerance, relative insu·
METABOLlS~{ 45
lin deficiency is apparent (br definition) only after
meal ingestion, when augmented glucose uptake by
peripheral insulin-sensitive tissue is required to com­
pensate for increosed glucose emry into the circub·
tion. The postabsorptive glucose level is norm:ll be·
cause basal insulin secretion is adequate to pre....ent
glucose overproduCtion by the li\'er. a process that is
\'ery sensitive to minor incremencs of insulin.
When absolute or re!Jri\'e insulin deficieoC\' OCcurs
in the basal state, an elevmion in fas;ing blood'glucose
ensues, In patients with r;.pe II diJ.betes. norm::ll .or
mia, In such patients, hepatic glucose production (as
determined by radioacc[\'e tracers) ma:: be normal but
is generally increased in propor-ion to the magnitude
of the blood glucose elevation6~ Because only mild
h:perglycemia in normal individuals is sufficien't to in­
hibit hep:ltic glucose production,46 the ~pe II diabetic
patient with fasting h~pergly'cemia is always in a state
of relative or absolute glucose overproduction. In pa·
tients with type 1 diabetes, portal insulin dencienC\' is
invariably present, and thus hep3cic glucose produc.
tion is more consistently elevated. In this situation, the
insulin deficiency leads to hypersecretion of glucagon
and gro\'.'h hormone, which furll~er accentuate glu·
cose overproduction. 6s .66 Because glucose UDG1..l(e (in
contrast to glucose production) in the posrabsorptive
scate largely occurs in non-insulin-sensilive tissues. it
is nOt unexpected that total body glucose uptake tends
to be increased under fasting conditions as a result of
the mass action of hyperglycemi::!. This underscores
the crUCial role that the liver pla\'s in determining the
fasting glucose level in diabetes (Fig, 4~8),
The increased hepatiC glucose production :lccompa·
nying diabetes is characterized by an alteration in the
relative comribution of glycogenolysis and gluconeo·
genesis [0 rotal hepatic glucose production. In type I
diabetes. the presence of glucagon and the absence of
a restraining effect of insulin increase the hepatic up·
take ofglycogenic substrates and facilit::ue theircom'er·
sion ro glucose in the liver. As a result. gluconeogene­
sis accounts for a substantially larger proportion of
hepatiC glucose production in such pJtiems as com·
pared with [hat in normal subjects; the rebti',e contri·
bution of gluconeogenesis is increased [\'.·ofo!d,6- Br
contrast, the magnitude and pattern of amino acid reo
le:lse from muscle in h:perglvcemic r;.pe [ diabetic
46 DLWETES MEllI1US L'-: PREGNA.'-:CY

c
'f. 6
Cl
~
Gl
.s
z
Q
!­ 4
0
:J
0
0
a:
0..
w
(f) 2
0
0
:J
....J
<.:l
0
1= 0
< TYPE It TYPE I DKA
0.. NORMAL
w 0!.~8ETES DIABETES
:c
Fig. 4-8. Influence of diabetes and diabetic ketOacidosis (DKA) on hepatic glucose produaion.

subjeCtS is similar to healthy controls,67 implying thar
changes in intrahepatic process rather in muscle are
primarily responsible for augmented gluconeogenesis
in diabetes. Ke\'ertheless, it is possible that increased
recycling of glycolytic intermediates (e.g., laerate) may
occur as well. Because FFAs are oxidized at an acceler­
ated race in the muscle of diabetic patienES (as a result
of their high cirCulating levels), glucose-derived pyru­
vate cannot readily emer the Kreb's cycle. Similar
changes have also been reported in type II diabetes. 68
The presence of incre35ed gluconeogenesis in type II
diabetes is consistent with the finding that greater
amountS of insulin are necessary to inhibit gluconeo­
genesis as compared with glycogenolysis in Iiver. 69...
In the extreme situation of total insulin lack, an e\'er­
increasing fasting blood glucose level fails to elicit a
secretory response, The absence of insulin together
with the excessive rele35e ofa variety of coumerregula­
to["\' hormones (glucagon, catecholamines, gro"Lh
ho~mone, and cortisol) that ensues causes hepatic glu·
cose production to increase threefold or more above
normal, largely as a consequence of accelerated gluco­
neogenesis. Because of the hypoinsulinemia and
the insulin resistance produced by the elevated levels
of insulin-antagonistic hormones, compensatory in­
creases in glucose disposal (other than renal) are vir·
tually paralyzed. The clinical correlate of this sequence
of eventS is profound hyperglycemia, as is observed
in diabetic keroacidosis or non1::etmic hyperosmolar
Coma,
In the postabsorptive state, patientS wim insulin·de·
pendent diabetes exhibit hyperaminQacidemia. Exami­
nation of individual amino acid levels reveals that the
increment in Circulating amino acids in these patienCE
is due almost entirely to a rise in .the branched char:­
amino acids (leucine, isoleucine, and valine)6:- (Fig. q.
9). By contrast, plasma alanine levels may be reducec
particularly when insulin defiCiency is se\'ere arid he
patic removal of alanine is accelerated 70 The speci~
tissue site accounting for tllis rise in plasma branche,
chain amino acids has nm been fully'clarified. For ex
ample, there is no demonstrable incre35e in the ne
release of branched chain amino acids from eithe
1eg67 or splanchnic tissues in these subjectS 70 Ne'.'e~
theless, recent studies using radioacti,'e tracers der:
onstrate that the delivery of branched chain amin
.acids into the Circulation is augmented in poorly co;
trolled type I diabetic individuals. 71 Considering th
the branched chains are essential amino aCids. the:
studies imply that [mal body protein breakdown is i
creased in such patientS even though they show or;
moderate insulin deficiency. Such changes are nor us
ally discerned in the clinical serung. perhaps becau
compensarory increases in prmein synthesis may mi:
mize the loss of body prmein. This is nm the C:!.S::'
insulin deficiency becomes more se\'ere, as evidenc
 CARBOHYDRO\TE, LIPID, AND A\IINO ACID METABOLISM 47

G PRE-PUMP E::J PUMP DAY 14

C3 PUMP DAY 7 E2Z2J CONTROLS
600 II p<O.025

FASTING

PLASMA

BRANCHED

'CHAIN 400
AMINO ACIDS
-' .
(p.M)

200

250 "*

200
POST­
PRANDIAL
RISE 150
IN PLASMA
BCAA
(p.M) 100

50

Fig. 4-9. Fasting and postprandial incrementS (after mixed me-J! ingestion) of total branched ch:1in ami~o acids
(SCM) in eype I diabetic patientS and healthy controls. The dilbetic patientS were studied before (during poor
contro!) and after 7 and 14 ooys of intensive insulin therapy using a portable pump. (Based on the dara of
Tamborbne et af.1° 2)

by the stunted groMh of young diabetic patienrs in the
preinsulin era and the marked protein wa5cing of the
diabetic individual in ketoacidosis.
The elevated circulating levels of branched chain
amino acids also lead to an acceleration of leucine,
isoleucine, and valine oxidation in the diabetic state.'l
In diabetic animals, oxidation of branched chain amino
acids is increased by 50 percent. 26 The increased in
situ catabolism of these amino acids provides muscle
tissue with the nitrogen groups necessary for alanine
symhesis,24 thereby increasing substrate availabiliry for
gluconeogenesis. 'In' this way, the accelerated break­
down of amino acids in muscle contributes indirectly
to hyperglycemia in diabetes.
The abnormaUties of branched chain amino acid
metabolism described for insulin·dependent patients
may not be evident inpatients with t:-~e II diabetes.
This may be because' the metabolism of branched
chain amino acids is more sensitive to the action of
insulin than is peripheral glucose metaboHsm. l l
In addition to hyperglycemia and hyperaminoacide­
mia, the levels ofFFAs are frequently elevated in post­
absorptive diabetic patientS.72 This phenomenon ap­
pears to be a consequence of accelerated mobilization
of body fat stores and can primarily be attributed to
deficiency of insulin. In type II diabetic subjects. FfA
elevations occur in the presence of normal or in­
creased le,'els of insulin,n suggesting resiStaIlCe to in­

-
"
48 DIABETES MEllITUS I:'>i PREGNA..\;CY

sulin's inhibitory effect on lipol:.:sis. The increased
availability of FFAs leads to their oxidation b\' muscle
tissues :l~d in turn causes a concomit:mt di~inution
in the rate of glucose oxidation,30 Although FFAs on­
not be direcdv convened ro glucose, they promote h~-.
perglycemia in'diabetes by providing the liver ",vith
energy-yielding fuel and the necessary cofacrors ro
support gluconeogenesis and b~' interfering with glu·
cose consumption by muscle,73 ' removal from the circul:uion"s--7
In r;.-pe II diabetes. the presence of endogenous in­
sulin secretion allows for sufficient le\'e!s of insulin in
the ponal vein to suppress ketogenic processes in the
liver. In the p:uiem with r:-pe [ diabetes, however, mo­
bilized FFAs are very readily convened to kerone bod·
ies, Lack of insulin in the porral circulation and the
presence of gluc:lgon suppresses fat synthesis in the
lh'er and thus intrahepatic Ie\'els of malonyl co-enzyme
A The latter together with increased availabilir:' of car­
nitine stimul::ues the activity of hepatic acylcarnitine
transferase, This enzyme facilitates the transfer of long
chain bttv acids inro mitochondri::l, where they are bro­
ken dO"l\:n \·iJ f3-oxidation and converted to ketone
bodies. 36 Bv ,'irtue of itS inhibitory effect on ketone
turnover, h;-poinsulinemia in the r;.-pe I diabetic indi­
vidual enhances the magnitude of the ketosis for an~'
given level of increased ketone production.''; As are·
suit. blood kerones are generally ele":ared in r:-pe I
diabetic patientS (Fig, 4·10). although usually not ro
the extent that acid-base balance is affected,
Finally', patientS with diabetes commonly exhibit ele­
vated fasting concentrations of lipoproteins, Most strik­
ing is the elevation in \-err low-demir:' lipoprotein
(v1.DL) triglyceride, -,;\'hich m:1y be seen in milder
forms of ty-pe II diabetes as well as in insulin-deficient
patients, It would appear th:lt the mech:lr'lism responsi­
ble for h:-penriglyceridemiJ vJries in these groups, In
the former situa<ion, elevated portal insulin le\-els rna\'
promote \ l.DL triglyceride symhesis, and in the I::me~
Circumstance, lipoprotein lipase, an insulin-sensitive
enzyme. is deficient. leading to decreased triglyceride
Glucose Ingestion
The ingesrion of glucose triggers a varier::' of homeo­
st::ttic responses in nondiabetic subjeCts (see above)
that are directed to-,;\'ard minimizing the rise in blood
glucose concenrrations_ Ther include suppression of
endogenous glucose production, as well as the uptake
of the exogenous glucose load. by splanchnic and pe­
ripheral tissues (nninlr muscle). Because these re­
sponses are brgely dependent on insulin. diabetes,
e\'en in its mildest forms, is invariably accompanied
by postprandial h}-perglY'cemia,
Patients with impaired glucose tolerance a.ppear to
have relari\-e1y intact insulin secretory responses [0
glucose but demonStrate reduced sensith'it\- to insu­
lin,13 Postprandial hy-pergl}-cemia. in thes~ patients
mainly deri\-es from a reduction in glucose uptake by
peripheral tissues, .-\similar partern is obser,ed in r:pe
II di::tberic subjecrs with fasting h:-perglycemia.. al·
though the magnitude of the pancreatic defect is more
pronounced.-a This is because (l) insulin secre[o~­
response is markedly reduced in these patients and

ADIPOSE
TISSUE LIVER
MUSCL '/f'.
£/J;
.i~
~0ii /',j

~KETONE­
+ KETOGENESIS~ UTILIZATION

HYPERKETONEMIA
)
Fig_ 4-10, The development of hyperketonemi:l in diabetes is a consequence of three distinct merabolic ev<.!ms;
(1) :lCcelerated delivery of free fat~ acids (FFAs) from adipose tissue, (2) augmented ~·o:\idation of FFAs to ketones
as a result of elevated cminine levels and reduced concentrations of mJlonyl co-enzyme A. and (3) :l reduction
in ketone use in muscle. Each of these processes is reversed by the action of insulin.

"

:;.: ..
------------------------~~
CARBOHYDRATE, LIPID,
(2) the magnitude of the defea in insulin aaion on
peripheral lissues is greater (these patienlS can no
longer overcome the defea with larger amounlS of
insulin and t.'1us presumably have an impairment in
postrecepcor processing of the insulin signal),}} How­
c:\'er, patienlS with type II diabetes have sufficienr levels
of insulin in their portal 'circulation to allow the rising
glucose le\'el t9 suppress glucose production and
promote glucose upt:1ke by the liver. This tends co re­
duce the postprandial glucose excursion somewhat, at
ie:l5t as compared with insulin-deficient I:}pe I diabetic
patients, The type I di3betlc individuJ.l characteristr:
calk shows the mos, marked and prolonged elevations
in blood glucose concemrJ.tion after ingestion of car­
bohvdrate, These individuals, because ther fail to se­
cret~ insulin e\-en in the postabsorpth'e state, have con­
Siderably lower portal insulin levels than patienlS with
type II diabetes. This loss of the porol-peripheral insu­
lin gradient is not readily re,'ersed by conventional
subcutaneous insulin therapy, Consequently, the insu­
lin-deprived liver bils to reduce its glucose production
or take up glucose in response to a rising circulating
glucose level.6~ In addition, glucose uptake by periph­
eral tissues is grossl~' impaired beclUse of the lack of
an insulin secretOry response and the de\'elopmem of
insulin resistance at the postreceptor level after
chronic insulin depriv:1tion,ls The net result of chis
mulrifaceted disturb:mce is a gross defect in metabolic
glucose disposal that is only partially compensated for
by increased renal gl:'cosuria (Table 4-3).
In normal subjects, the rise in pl:l5ma insulin caused
by glucose ingestion also inhibitS Hpot:-sis, which in
t:.:rn decreases the a\'aiIabilir:- of FFAs for oxidation in
muscle. This facilitateS glucose upt;Li.::e and oxidation
because the oxid:ltion of FFAs interferes with glycolysis
Table 4-3. Homeosca(ic Response to Glucose
to rele:l~e insulin in response to systemic h:.perami­
Ingescion in Diabetes
noacidemia is commonlr inmct in patients witb type
Impaired
It diabetes,5 it is unlikely that comparable defects in
Glucose
protein disposJ.1 would occur in such pJ.tiems, This,
Suppression of gluco»e
production
Scimubtion of $pbnchni<.:
glucose uptake
Stimublion of peripherJl ! ! ! !
-.?!ucose upoke
Abbre\'[:1liOn5: :-'1., norr;ul. ,,'I.. !, norml! or belo"" normal.
A~D A.\IIi':O ACID METABOLIS~I 49
and the movement of glucose-derived pyru'(ace into
the Kreb's cycle,73 In type It di3betic subjectS, despite
the J','aibbiliry of some insulin. there is much less
suppression of lipolysis during glucose ingestion be·
cause of insulin resistance?:! Simil3r changes are ob·
served in l:}'Pe I diabetic p:1tiems, brgely beclUse of
h~poinsulinemia (although resist:mce to insulin m,1\'
also contribute). The failure of diabetiC patients to sup.
press bt oxid1cion during consumption of glucose
contributes to the peripheral insutin resist:lr.ce of dia·
betes and actS to block the oxidation of glucose that
enters muscle tissue.
Protein Ingestion
In addition to the increased use of amino J.cids for
gluconeogenesis and release of branched chJin amino
acids in the posw.bsorptive state, repletion of muscle
nitrogen is impaired in the cype I diabetic patient After
ingestion of a protein meal, the net splanchniC reie:lse
of indi\'idu:l1 amino acids in insu[in-dependem di:t­
hetic subjects is simiklr to that observed in he:tlthv
comrols,":- Although the systemic delIvery is nm ai.
(ered, postprandi:ll elevations in arterial amino acids
are exaggeratedY This protein-induced hyperamino­
acidemia is solely accoumed for bY the branched chain
::Imino acids (Fig, 4-9), In comr(lS'( to the ongoing ner
upta.l.(e of branched chain amino acids bv muscle tis·
sues seen in normal subjeclS, in di:lbeticlndi\'idu::t!s a
net uptake is only transiemlr obsef\'ed."7 As a conse­
quence, the total uptake of these amino acids bv mus­
cle is decreased, resulting in their accumul:.!c'ion in
plasma, T}pe 1 diabetes thus may be \-iewed as a disor­
der of prOtein tolerance as well as glucose tolerance,
This \'iew is in keeping with the kno""n c:1p:lcicy of
insulin to inhibit: the net rele:l5e of branched chain
amino acids from muscle tissue,~9 Because the capacity
however, has not been full:' in\'estigated.
Protein feeding also produces abnormalities in glu­
cose regulation in the insulin·deficient di;tbetic sub­
jects, In norm:ll subjects, protein ingestion induces a
modest rise in insulin secretion, which offse[s the stim­
ubtory effects of glucagon (and the amino acid IO:ld
itself) on hepatic glucose production_~-;' As a result,
 50 DIABETES MEIlJTIJS IN PREGNAt'iCY

BLOOD GLUCOSE LEVELS

PROTEIN INGESTION

DIABETICS

200

0~
0'
E

100
c 0- 0 t:i- a
-<5 '0
NORMALS
I
I 90
30 60 120 150 18Q"
MINUTES AFTER INGESTION

Fig,4-11. Hyperglycemic effec( of protein feeding in patients with type I diabetes, (Based on unpublished d:Ha.)

blood glucose levels remain at basal values, B~- con­
trast, in diabetic subjects protein ingestion produces
a large (albeit transient) incr~e in 'hepatic glucose
production due to the rise in glucagon in a selling in
which insulin is deficiemf7 Consequemly, there is a
substantial increase in blood glucose (Fig, 4-11). This
exaggerated glucose response in this setting also partly
reflects the failure to metabolize the glucose released
by the liver due to the failure of insulin secretion.
Fat Ingestion
Consumption of fat-containing foods leJds to the for­
mation of chylomicrons. which provide a means of
transferring triglycerides from the gut to adipose tis­
sue. The ultimate disposal of exogenous triglycerides
(like endogenous triglycerides) is regulated by the ac­
tivity of insulin-sensitive lipoprotein lipase. Conse­
quem!y, postprandial elevations of plasma triglycer­
ides may be increased or prolonged in insulin­
deficient diabetic patients because of deficient triglyc­
eride removal. This situation is most evident during
ingestion of carbohydrate-comaining mb:ed meals,
when the discrepancies becween insulin levels in non·
diabetic and diabetic individuals are most pronounced.
Exercise
The rapid fall in blood glucose levels commonly ob­
served in diabetic patients after vigorous exercise has
traditionally been the basis for recommending exer­
cise to diabetic patients. This acute glucose-lo,,-eriog
action is much more pronounced in insulin-treated
diabetic subjeCts and occurs only if insulin. merapr is
sufficient to prevent marked hyperglycemia (Le., >300
mgldl) or ketosis. so The importance of insulin avail­

'J

, 1
 CARBOHYDRATE, LIPID. At'ID A,.\IlNO ACID ~IETABOLIS;\f 51

abili"l in mediating the exercise-induced £:Ill in glu­ NOR.'AAL

cose levels is underscored by two observations in insu­
lin-treated patients. First, it is well recognized that the
magnirude of the decline in blood glucose is increased
if coincides with the time of the peak action
of the insulin preparation used. Second, exercise may
accelerate insulin absorption from its injection site,
and when this occurs, the fa!ling blood glucose is more
INSULIN-TREATED DIABETIC
pronounced. 81 .' .
Recently-. swdies using regional catheters and radio­
labeled glucose ha\'e helped elucidate the mechanism
of the glucose-lowering effect of acute exercise in dia- ­
betes, Normally. physical exercise causes a marked in­
crease in glucose uptake by muscle. 38 Blood glucose
levels nevertheless remain suble, because hepatic glu­
cose produGion incre3.5es to match exactl;: the rate of
glucose consumption. This process is mediated by a
decline in circulating insulin and by an acth'ation of
the sympathetic nerY'ous system 3.5 well as counterreg­
uhHory hormone release:iO In the diabetic individual
receiving insulin exogenously, the circulating level of Fig.4-12. Mechanism of exercise-induced hypoglycemiJ in
the insulin may, at times, be inappropriately high and insu!in·tre:lted di3bet[c patients. The f3Hure of insulin levels
fail to decline during exercise, Consequently, this 10 fall during exercise and the potential for insulin to rise
"finely tuned" homeostatic mechanism is disrurbed_ because of accelerated absorption pre\'ents the no~mal com­
Exogenous hypednsulinemia has been shown to po­ pensator;' increase in hep3tic glucose production and mav
tentiate the stimublOry effect of exercise on glucose potemilce glucose upt:l..l:e bv muscle, The net ef­
uptake,8~ Even more import:3.nt, the compensatory in­ fect is a reduction in blood'glucose le"e[s.
crease in glucose release from the liver is blocked
under these conditions, resulting in a fall in glucose
concentration (Fig, 4-12).
In poorly regulated ketotic diabetic individuals, ex­
The usefulness of the acme glucose-lowering effect
ercise accentuates hyperglycemia and mav increase ke­
of intermirtent exercise in rrpe I diabetes is limited.
tonemia as "'ell, particularly if exercise is·prolonged. s3
because the effect is reJarivelr short-lived (generally
This may be explained by the low levels of insulin in
se\'eral hours) after exercise is terminated. Unless ex­
these patients and because that poor control causes an
erCise is regular and of appropriate intensity and dura­
tion, there is Hrtle long-term "carry-over" effect that exaggerated release of counterregul:l.tory hormones in
can be expected to aid in diabetic care. Furthermore, response to exercise. s,; These hormonal changes (cou­
the magnitude of the fall is not easily titrated, so hypo­ pled with the diabetic's hyperresponsiveness to coun­
glycemia is a frequent complication of vigorous exer­ terregulatory hormones66 ) potentiate the exercise-in­
cise. The rapid rise in counrerregulatory hormones duced increase in hepatiC glucose production as well
that ensues, coupled with the increased responsive­ as lipolysis and ketone production by the li\'er (Fig, 4­
ness of the diabetic individual to these hormones 66 and 13). Because the stimulation of glucose upta.l::e in mus·
a tendency to overeat when hypoglycemic symptoms cIe occurs independent of insulin (namely, local [3C­
occur, often leads to a rebound increase in blood glu­ cors, as described above), glucose consumption by ex­
cose to hyperglycemic levels, Thus, if the diabetic sub­ ercising muscle is relatively un:lifecred during poor
ject is unable to adjust her diet and insulin dose, acute control and thus does not contribute to a rise in blood
Intermirtent exerCise mav cause fluctuations in glucose le,"els.85
blood glucose levels rat'her than impro,'e glycemic The differences in the rate of gluconeogenesis be­
ControL tween nondiabetic and rype I diabetic are fur-


I NSUUN
DEFICIENCY
l' Counrerregulatory /
Hormones
\: t Hepatic Sensitivity
to Counterregulatory
Hormones
Fig. 4-13_ ~lecb:mism of exercise-induced h~:rerglrcemiJ md ketosis in poorl)' comrolled type I diabetic parien""
ther increased during exercise. During short-term ex­
erCise, the compensatory elevation in hepatic glucose
production in nondiabetics is mediated by an accelera·
tion of glycogenolysis; gluconeogenesis remains un­
changed. 38 By contrast, the diabetic individual demon­
strates a rapid increase in gluconeogenesis that is onl}'
seen in normal subjects when exercise is extended for
prolonged periods (2 to 4 hours).8o Thus, the effect
of exercise in insulin-deficient diabetic patients is to
exaggerate [he excessive rate of gluconeogenesis that
characterizes di::lbetes.
Glucose Counterregulation
The main risk of insulin therapy in diabetes is hn)og!y­
cemia. It is now appreciated that patients with diabetes
are more vulnerable to hypoglycemia, not only be­
cause they are unable to normally- synchronize insulin
delivery with meal ingestion and activity but also be­
cause the hormonal responses that normally protect
against hypoglrcemia are defective. In normal subjects,
insulin administration produces a rapid decline in
plasma glucose concentration. The glucose fall is due
to a suppression of hepatic glucose production and a
rise in peripheral glucose uptake.s6 The former pro­
cess is more sensitive to insulin (see above). and this
is mainly responsible for hypoglycemia when insulin
elevations are relatively smal1.87 Glucose recovery re­
quires the re\'ersal of these responses-most impor­
tam. a stimulation of hepatic glucose production. Once
circulating glucose levels fall below 60 (0 70 mgtdl.
secretion ofglucagon and epinephrine is triggered and
endogenous insulin secretion is suppressed. These
/ HYPERGLYCEMIA
) l' Glucose Production
l' Hepatic Ketogenesis
/
I ~ KETOSIS
hormonal changes combine to promme glucose pro­
duction and return the plasma glucose level w>'."::lrd
normal. 88
In type I diabetes. insulin levels are incapable of
responding to phrsiologic signals and the glucagon
response to hypoglycemia is lost.89 Although some pa­
tients retain the ability to release glucagon du:-ing hy"
poglycemia early in the COurse of their disease,90 the
ultimate failure of glucagon secretion to'this panicular
stimulus is a consistent finding in patients who have
had rype I diabetes for several years. 89•91 .A..:s a result,
such patients :.Ire largely dependen'[ on epinephrine
for acute glucose counterregulation (Table 4-..f) Con­
sequently. they may show impaired glucose recovery
when f3-adrenergic blocking agents are adminisfered v2
or when there is coexisting autonomic neurop:lth~·.93
Some long-standing diabetic patients show defective
catecholamine secretion in response to hypogl:,.·cemia
without overt clinical evidence of diabetic neuropa.
thy.94 and more important, intensive insulin therapy
aimed at normalizing blood glucose levels mJ.:; itseti
diminish epinephrine responses to hypogl~·cemia.95
The latter may be especially important during preg­
nancy. when such treatment regimens have become
standard clinical practice.
Table 4-4_ Hormonal Defense Mechanisms Against
Acute Hypoglycemia
Hormone Secrerion I"ormal
Insulin
Epinephrine i
Glucagon
 O.REOHYDRATE, UPID, A'iD A.\U:\O ACID r\[ETABOLlSM 53

Effect of Intensive Insulin Therapy With respect to other insulin-se:15iti\'e fuels, the ele­
on Body Fuel Metabolism vated basal concentrations of branched chain amino
acids are reduced to nomul in conjunction with im­
described above, poorly controlled diJbetes is ch:lr­
.l,.$
pro\'ed glucose regulation (Fig, 4·9), Tracer studies
acterized by a variety of metabolic and hormonal ab­
hJ\'e demonS([Ilted th::u the accelerated leucine deliv­
normJ.lities that ma:' contribute [0 the long·term com·
ery into plasma observed during cOl1\'emiomI treat·
plicJ.tions of the dise'ase,. The introduction of improved
mem is decreased,-:-l accounting for the observed
methods for quantifying'blood glucose control and de·
a
li\'ering insulin in' more physiologic mJoner with
ch::mges in circubting amino acids, Furthermore, in­
rensi,'e treatment of r:-pe I diabetes reverses the exces­
multiple injections or pomble infusion pumps has reo
si\'e postprandial\e~'el:) of branched chain amino acids
cently allowed im'estig3tors to examine the extent to
after ingestion of mixed meals (Fig. 4·9) :lnd lh~ -de­
which these abnormalities mJ!, be reversed by sys­
cre:.lSed clearance of intravenoush' Jdministered leu·
temic insulin delivery, cine seen in convemionally tre::ued p3rients.100JO~ Sim­
~IJny studies h:t\'e shown th:1t imensi\-e insulin tre:.!,­
ilarly, increased levels of FF..-\s and triglycerides are
mem restores blood glucose ie\'e\s to near-normJl val,
reduced tow:lrd normal. 100.101
ues,96-98 Because these regimens pro\'ide a relati\'ely
E\e\'ations in growth hormone and glucagon con­
constam bJ5ai \e\'el of insulin throughout the night in
centrations observ'ed during 24-hour monitoring in p::t­
amountS sufficient to restrain hepatiC glucose produc­
tiems with poorly controlled diJbetes are diminished
tion, they normalize posrabsorpcive glucose concemrJ­
afrer instirution of StriCt gl:'Cemic COntro1. 65,103 In addi,
tions. postprandial glucose eb'ations are also dramati,
tion, excessive incrementS in CJtecholamines and
cally reduced but not conSistently normalized, In
gro\\l:h hormone during mild exercise are re\'ersed 9()
nondiabetiC patientS, fluctuations in blood glucose are
(Fig. 4-14). It follows, therefore, thar some of the mera­
minimized by the concomitant suppression of endoge,
bolic benefitS of intensive insulin regimens mav be
nous glucose production from the !i\·er. 46 This fails to
derived from their coumerregubror.· hormone'lo~ver­
occur in convemionally treated ry-pe I diabetic subjecLS
ing effectS. This may be particubrh: true with regard
because, in this siruarion, the liver is less sensitive to
to grov.m hormone. When g[O,\th' horm'one w~ in­
small increments in circulating insulin99 and unable
fused as hourly intravenous pulses to a grooD of dia­
to respond to the inhibitory effects of hyperglycemia
betic subjecrs who were intensi\'el~' treat~d uSi~g a por­
per se on glucose production 67 After intensive insulin
table insulin pump, serum grmnh hormone was raised
tf}erapy, these abnormalities are corrected;e.99 and
to le\'els similar to those observed in poorly comrotled
therefore the endogenous contribution to circulating
diabetes. Under these conditions, glycemic control·
glucose levels can be effecti\'ely suppressed, In addi­
m:1rkedly decerioratcd while circubtor.· b[tY acids, ke­
tion. the premeal bolus doses of insulin allow for ade·
tOnes, and branched amino acids al~o i~creJ5ed.65
quare portal insulin levels to promore glucose uptake
Thus. gro\\th hormone elevations can themselves re­
by splanchnic tissues. As noted above, this process reo
quires some insulin but is mJinly driven by the magni­ produce the entire spectrum of poor diabetic control
tude of hy-perglycemia:H The anticipated result is the despite previously optimized insulin treatment, This
restoration of the liver's capaciry to handle adminis­ serves to emphasize the multifaaorial nJture of the
tered glucose, Howe\'er, the rise in circubting insulin met:1bolic disturbances of diabetes as well as the pri­
after subcutaneous hormone injection is debyed, and mary role of insulin deficiency ill initi:l.ting them.
peak levels are lower as compared with normal sub,
jects.lOO Furthermore, peripheral resistance to the ac, Role of Insulin~like Growth Factor 1

tion of insulin is only p:.mi:l.lly reversed by imensi\'e Deficiency

insulin therapy,lOl It is, therefore, unlikely that periph,

eral glucose uptake in response to glucose ingestion
is restored to normal. Because this is the m:1in site of
exogenous glucose disposaV 5 it is not une:-:pected th::u
postprandial glucose levels commonly exceed normal
values.
The classical studies of Froesch and colleagues demon­
strated thar somatomedin C. the put:uj;-e mediatOr of
gro\\th hormone's somatOtroDhic acrio,b, exerted
metJbolic effectS in vitro that closeh' resembled those
of insulin, Hence, itS redesignilti;n as insuHn-fike
1 G
30 G PUMP DAY i
SERUM GROwTH
1 20
HORMONE
nqlmi
10 *
~ .\ . PRS-EXERCISE
150
PLASMA EPINEPHRINE
pg/ml
PRE-EXERCISE
1500
PLASMA NOREPINEPHRINE
1000
pg/ml
500
PRE'EXERCISE
Fig. 4-14. Resting levels and exercise·induced increments of grov,w hormone. epinephrine, and'norepinephrine
in diabetic and healthy control subjects. The diabetic patients were studied before (during poor control) and a.'i:e,
7 and 14 days of intensive insulin treatment using a portable pump. (Based on the daca of Tamborlane et al. 8 ")
I nsulin Deficiency
I
Fig.4-15. Hypothetical role of insulin-like gro....w factor-I (lGF-I) deficiency in the pathology of insulin-depen­
dent diabetes mellitus. GH, grov.th hormone.
CARBOHYDRO\TE, UPID, Ai'W A..\UNO ACID ;V1ETABOUSM
ro"Lh faCtor 1 (rGF-1). Later studies ofZapf and Guier
gtearlv established IGF-l's unique position as the only
~:J.(ur~l!;: occurring hypoglycemic hormone besi~es in­
sulin. The buLLe of data indicates that convenuonally
treated insulin·dependent diabetes mellitus (lOOM)
p:ui.entS have subnormal levels of IGF·1,104.105 ~pe·
clalh- during puberty, It has been suggested that raised
gro~Lh hormone. levels in IDOM ar~, .in pan:, a com·
pensatoryacrempt to overcome a blOCK In IGF-l synth~.
sis caused by insulin deficiency and poor me(:lbotlc
controL 6 5 Although it is uncertain whether IGF-l d~fi.
ciencv has direct adverse metabolic effectS in IDO.\t,
to th~ extent that it contributes to gro';'.th hormone
hypersecretion, it undoubtedly conrribuce: ~o diabe:ic
hyperglycemia (see above). Furthermore, It IS COnCel\"
able that IGF·l deficiency plays a role in the hyperglu·
cagonemia of poorly controlled IDO:'L Thus, [( is in­
triguing to speculate that insulin resistance associated
with poorly controlled IDOM may, in part, be due to
IGF·1 defiCiency, which in turn promOtes gro';'.th hor·
mone and glucagon hypersecretion (Fig. 4·15).
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PRE;-PUMP c::J PUMP DAY 14
EJ CONTROLS
* p<O.OI
*
**p<0.025
"T" _
A EXERCISE
**
A EXERCISE
**
t:. EXERCISE
Hy~rglycemia
'.
55
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sh'eness to cortisol. epinephrine. and glucagon in insu·
lin.infused ju\·enile·onset diabetics: a mechJnism for
dilbetic instabilirr Diabetes 29:284. 1980
67. \X·ahren]. Felig p. Cerase E. Luft R: Spbnchnic and pe­
ripheral glucose and amino add metJ.bo\ism in diabe·
tes mellitus. J Clin Invest 51:1870. 1972
68. Shulm:m Gl. Rothman DL. Jue T et al: Direct quantit:!­
tion of muscle glycogen syntheSiS in nom13l men and
non insulin-dependent diabetics by I.lC nucle:lr mag­
netic resonance spectroscopy. N Engl] Med 322:223.
1990
69. Chi'J$SonJL. LiTjenquistJE. Finger FE. LaC; \Y,r.:t,': Differen­
t!;]l sensitivity of glycogenolysis Jnd glucogenogenesis
to insulin infusion in dogs. Di;lbetes 25:283. 1976
70. Nikou D. Philippi dis H, Palaio!ogos G: Serum abnine
conct:ntfation in di:.lbetic children unuer insulin treat­
mt:nt. Horm Metab Res 7:207, 1975
i1. Gertner J, Press M, M:uhews D, Tamborbne \W: 1m·
pro\'ements in leucine kinetics with continuoll~ subcu­
t:.lneOUS insulin infusion. Di:lhetes. suppl 1. 33:2A, 198-*
72. Greenfidd M. Kolterm:m O. Otefsh:y ). Re-Jven GM:
Mech:lf1ism ofhypertriglyct:ridemia in diabetic patients
with f:!Sling hyperglycemi:L Di:lbt:tologia 18:441. 1980
73. Ferr:mnini E, Barren EJ. Bcvibcqu:.t S. DeFrom:o R.-\:
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57
Effect of fatt}' :lcids on glucose producCion lnd utiliw­
lion in man.] Clin Im'est 72:1737, 1933
74. Sherwin RS, Hendler R. Felig P: Effect of diabetes melli­
tuS and insulin on dle turnO\'er Jnd met:Jbolic response
to ketones in m3n_ Di:lbetes 26:776, 1976
75. BagdJd )D, Porte D )r, Bierm:m EL: Acute insulin wim·
dr3w3l :lnd me regulation of pl:!Sma triglyceride reo
rr:oval in diJbetic subjecrs. Di:lbetes 17:127, 1968
76. Nik.~!a EA. Huctunen )K, Ehnholm C: Pasu'1ep:lrin
p!:!Sm:l lipoproreinlipase and r.ep:ttic lip:!Se in di:toetes
mellitus: rebtiOnship to pbsma triglyceride meobo·
Itsm. Di::tbetes 26:11,1977
7/. Tobey TA, Greentield "I. Knemer F. Re-.lVen G)'!: Rela·
tionship between insulin res is t:mce. insulin secretion.
n~r,:, low density lipoprocein kinetics. Jnd r;l:i.sma [rio
glyceride levels in normmriglyceridemic mJn. ,\!et:lbo­
Itsm 30:165.1981
78. DeFronzo RA. Gunnlrsson R. Bjorkman 0 e: at: Effe::rs
of insulin on peripheral and spbnchnic glucose metlb·
olism in non-insulin-dependem (I:)pe ![) di:lbece5 me!·
litus. J Clin Im'es[ 76:149, 1985
79. Pozefsk;: T. Felig P, Tobin Jet :tl: Amino add bliance
across the tissues of the forearm in pos[:1bsorp:ive m:ln:
effecrs of insulin at two dose levels. J Clin bn:s[ -is:
2273,1969
SO. \X·Jhren.L H::tgenfeldt L. Felig P: Spbnchnic :1;,d kg ex­
ch:lnge of glucose, 3mino acid.:;. and free f:my adds dur­
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1975
81. Koivisto \'A. Felig P: Effecrs of leg exercise ore insulin
absorption in dbbetic parenrs. N Engt J ~led 298:79.
19::8
82. DeFronzo R. Feiig P. Ferrannini E ec al: Synergi5~ic imer­
action between exercise and insulin on peri?:-,erJ.I glu­
cose up(:Ike.J Clin lnvesr 69:1-168. 1981
83. Ber-ger:-'1. BerchtOld P. (iJpper~ HJ et ll: ~!e,o::;oHc and
hormon:!1 effects of mllscui:lr ext:rcise in juvenile r;.pe
di:1betes. Di:!be!ologia 13:355. 1917
84. Tamoorbne WY. Sherwin RS, Koi\'tsto V et J!: :iorm::d­
iDtlon of the grc\'>."th hormone and otecholamine re­
sponse to exercise in juvenile·onset diabetics tre:lled
,I
with portable in~ulin infusion pump. Diabetes 28::55.
1979
85, \·(':.lhren J. Felig P. Hagenfddt l: Physic31 t:xe~ci$e :lnd
fwd homeos[:!Sis in diJberes rr;dlitus. Diabe~ologia 14:
213.1978
86. G;1rber :\1. Cryer PE. SJntiago]',' elll: The role of Jdren­
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In':e:;c 58:7. 1976
87. Sacd L Shen.vin R. Hendler R. Felig P: 1nf::.:ence of
continuous ph\'siQlogic hyperinsulin~mi:l 0" glucose
"
58 DIABETES M.EI.1..ITUS IN PREGNA.:.'-;CY
kinetics and coumerregul:nory hormones in normal
and di:lbetic humans.) Clin Invest 63:849. 1979
88. Rizza RA. Cryer PE. Gerich lE: Role of glucagon. cate·
chobmines and growth hormone in human glucose
counterregulation. J Clin Invest 64:62. 1979
89. GerichlE, Langlois M, Noacco C et al: Lack of glucagon
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90. Colli G; 'De Feo p. Compagnucci P et al: Abnormal glu.
cose counterregulation in insulindependem diabetes
mellitus: interaaion of anti·insulin antibodies and im­
paired glucagon and epinephrine secretion. Diabetes
32:134, 1983
91. Bolli G, De Feo p. Compagnucci Pet aI: rmporranr role
of adrenergic mechmisms in acute glucose counterreg­
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r diabetes: evidence for an effea mediated by betl-adre­
noreceptors. Diabetes 31:641, 1982
92. Popp DA. Shah SD, Cryer PE: Role of epinephrine·me.
diated l3·adrenergic mechanisms in hypoglycemic glu.
cose coumerregulation and post·hypoglycemic hyper·
glycemi:l in insulin--dependem diabetes mellitus. J Clin
Invest 69:315. 1982
93. HoeJdtke RD, Boden G. Shuman CR, (fi<.·en OE: Re­
duced epinephrine secretion and hypoglycemia un·
awareness in diabetic autonomic neuropathy. Ann In­
tern Med 96:459,1982
94. Kleinbaum), Shamoon H: Impaired coumerregulation
of hypoglycemia in insulin--dependent diaberes melli­
tus. Diabetes 32:493. 1983
95. Sil)1onson DC. Tamborlane WV. DeFronzo RA, Sherwin
RS: Intensive insulin therapy reduces counterregularory
hormone responses CO hypoglycemia in patients with
type I diabetes. Ann Intern Med 103:18-i. 1985
96. Pickup)C, Keen H, Parsons)A et al: Cominuous subc:
neous insulin infusion: improved blood glucose:
imermedi3try metabolite comrol in diabetics. lance
1255. 1979
97. Tamborlane VJ.V, Sherwin RS, Gene! M. Felig P; Rec
tion (0 normal of plasma glucose in jm'enile diabetes
subcutaneous adminis:ration of insulin With a pord
infusion pump. N El1glj Med 300:573, 1979
98. Champion .MC, Sheph3rd GAl,.., Rodger N~·. DUD~c
Continuous subcuCJ.'leous infusion of insulin i~ ~
management of dilbe,es mellitus. Diabetes 291
1980
99. Arnie! SA, Tamborlane \~V, Simonson DC, Shef".-in
Defeaive glucose counterregularion after strict I:
cemic comrol of insulin-dependent di:lbetes melli~
N Englj Med 316:13'i6, 1987
100. Verdonk C, Tamborl:lne W, Hendler R et at: Does ir.o
lin treo.rmem of di3betes cause hmednsulinemia a.
hypoaminoJcidemia? Clin Res 29:425A, 1981
101. Simonson DC, Tamborbne '\I;V, Sherwin RS et al: l:
proved insulin sensir!\ity in patients with type I di:lbe:
mellitus after csrr. DiJbetes, suppl. 3,34:80, 1985
102. Tamborbne 'Ii.'V, Sherwin RS, Genel ~I, Felig P: RestG~
rion of normJI lipid and amino-acid metabolism in c
betic pJtients treo.red with a por[Jble insulin-infus!:
pump. Lancet 1:1258. 1979
103. Raskin P, Pietri A, Unger R: Changes in gluogon Ie';"
after four to fh'e weeks of g!ucoregulation by' pore:!'::
insulin infusion pumps. Diabetes' 29:1 033, 1979
104. Arnie! SA, Sherwin RS, Hintz RL et alt EffeCt of diabe:;
and its control on insulin-like growth factors in lC
young subjects with r~"pe I diabetes. Diaber!cs 33:1 1-:­
1987
105. Tan K, Ba:\,er RE: Se:um insulin-like grov..--m f:lao:
levels in adult diabetic patients: the effect 0: age'.) c:
Endocrinol Met:lb 63:651, 1986
 ....-
•

Ii Serono Symposia USA

Norwell, lVlassachusetts

Marc R. Blackman S. Mitchell Harman

Jesse Roth Jay R. Shapiro
Editors

GHRH, GH, and IGF-I

Basic and Clinical Advances
1
With 54 Figures
1
I

j
j
I Springer-Verlag
New York Berlin Heidelberg London Paris
Tokyo Hong Kong Barcelona Budapest
I

-.

Contributors

\VILLlA~1 H. ADLER. Clinical Immunology Section. :\ation:;11 I;btilute '0:1

Aging. National Institutes of Health. Baltimore. Maryland. USA.

JOSEPH A. ALOI. Di\'ision of Endocrinology and i\.kraDolism. Dep:mment

of l\[edicine, University of Virginia Health Sciences Center.
Charlottesville. Virginia. CSA.

MICHELE F. BELl.... :-.:TO:-.:1. Department of Medicine. Johns Hopkins

University School of Medicine. Baltimore. i.\!arylo.nd. USA.

BARRY B. BERClJ. Section of Pediatric Endocrinology. Department of

Pediatrics and Department of Pharmacology and Therapeutics. Unh'ersity
of South Florida. College of i-.fedicine. Tampa. and All Children's
Hospital. SL Petersburg. Florida. USA.

MARC R. BLACK~I.-\:-;. Division of Endocrinology and ~letaboli:>m. Francis

Scott Key 1>.!edical Center. Department of Medicine. Johns ""Hopkins
University School of r.!edicine. Baltimore. Maryland. USA. '

WALTER P. BORG. Department of Internal Medicine. Section of Endo­

crinology, Yale University School of Medicine. New Haven. Connecticut.
USA.

SUSAN D. BOULWARE. Department of Pediatrics. Section of Pediatric

Endocrinology. Yale University School of rvledicine. New Haven. Con­
necticut. USA.

J.... N BUSBy-WHlTEHE.... D. Di\'i5ion of Geriatric Medicine. University of

'North Carolina School of Medicine. Chapel Hill. Korth Carolin'l. USA.

GArl BUTIERFIELD. Geriatrics Research. Education and Clinical Cemer.

VA Medical Center. Palo Alto. California. USA.

GrAN PAOLO CEO..\" University of Parma. G. Sruard Hospital. Parmn.

Italy.

XIII
 •
I

I
I
t I 18
I,
!
Metabolic Effects of IGF-I:
Implications for the Therapy of
Diabetes Mellitus
ROBERT S. SHERWI:". W.-\LTER P. BORG. AND SUSAN D. BOCL'.I,',.l3;:

When the radioimmunoassay for insulin was developed. i[ Oe:::m:.c

apparent that serum contained far more insulin-like biologic :!ccj\'[,:
than could be accounted for simply by its content of immunore:;':cl\e
insulin (1). This insulin-like activity was initially termed by Froes:h e:
al. IlOllStippressible insutin-like activity (NSILA) (2). Later. the ~e;m
somaromedill was imroduced to denote the uncharacterized bet.)r lh~H
displayed insulin-lik<; activity and mediated the action of G H i:1 tee
stimulation of somatic growth (3). Further studies of Froesch a:1::! C('11­
leagues demonstrated that somatomedin C exerted metabolic e(fe:ts :n
vitro that closely resembled those of insulin (4-9); hence. its redesig,:,,:}[t\.)n
as insulin-like groll'th factor I (IGF-I).
More recently. the availability of recomoinanr hllman IG F-l (rhIGF- Ii
synthesized by recombinant DNA techniques has pro\'ided the im?ecus
for a systematic assessment of rhIGF-rs metabolic actions in \'j''-o. Zao:
et al. (10) were the first to show that rhIGF-I had hypoglycemic e;:ec[s if:
normal rats that were not inhibited by anti-insulin antibodies. Guk~ et at.
(11) subsequently demonstrated a similar acute hypoglycemic e(rect in
healthy human volunteers. These studies clearly established IGF-I's unique
position as the only other naturally" occurring hypoglycemic hormone
besides insulin. It is noteworthy that rhIGF-Ihas been used successful!\'
to improv'e protein balance in hypercatabolic:states associated \\'ith iosufi;
resistance (12). suggesting that rhIGF-I may be useful in impro\'ir:g body
fuel and metabolism in other conditions associated with defecti\'e insulin
action. such as diabetes mellitus (13).

".

1
 196 R.S. Sherwin et al.

Potential Role of IGF-I in the Pathology of

Type I Diabetes Mellitus
The bulk of data indicate that conventionally treated ins(I/in.depelldem
diabetes mellillis (IDD~1) patients have subnormal levels of lGF-l (l-l.,
15). especially during puberty. This may not be the case in pariems with
advanced retinopathy (16). although this finding has been disputed (17)
This issue will need to be resolved if rhIGF·I is to be used as a thei;:;peutic
agent in diabetes. Moreover. low-molecular weight IG F-/ binding protein
(IGFBPs) (Le., IGFBp·l) h,l\'e been reported to be increased in exper­
imental diabetes in rodents (1S) and in patients with IDDr.[ after insuliil
has been withdrawn (19). Since low-molecular weight BPs h:l\e acceS5 to
the extracellular fluid bathing lGF-I-responsive tissues. this might rurther
limit the availability of biologically active IGF-I in patients with 1DD:--1.
We have previously suggested that raised GH levels in IDD\l Qre. in
part. a compensatory attempt to overcome a biock in IGF-I synrhesis
caused by insulin deficiency and poor metabolic control (10). Although i~
is uncertain whether IGF-I deficiency has direct adverse metJboiic effects
in IDDM. to the e:\L\~nt that it contributes to GH hypersecre;lon. i,
undoubtedly contributes to diabetic hyperglycemia. E\'en til;: modest GH
elevations seen in poorly controlled diabetes have been shown to p~'Jdu;;e
J
marked hyperglycemia and metabolic decompens:ltion in IDD:-..r patient;
in the face of intensiye treatment with the insulin pump C21). Further·
more. IGF-I deficiency may play ;.\ role in the hyperglucagone:nia 0:
poorly controlkd IDD~f as well. Therefore. insulin resistance associ:Hd
with poorly controlled IDDM may. in pan. be due to fGF-I ddc:e:lc:.
and its stimulatory effect on GH and gluc;.\gon secretion (Fig, 1S.'),
r
j
IGf-1 Deiiciency

.,
I

t Glucagon & ~ GH

1
Insulin Deficiency

J
Insulin Resistance
I

I
"
Hyperg Iycemia

FIGC"RE IS.1. Hypothetical role of IGF·I deficiency in the IMr.Ophy,:,~ingy '):

IDD:VL Imulin resiswnce associated with poorly cOrl;rol!ed IDD\I may r:: In po'::

I
due to IGF-I deficiency and its stimu:<lrory cikct on GH and gil.l'::lgL)1l :::;:>:n:lio::,

I
 18. Metabolic Eff:::cts of IGF-I 197

Despite IGF-l's potential for improving metabolic control in IDDM.

little is known about its effects in IDDM. In the BB rat, a model of
spontaneous rDD\L we have reported that acute administration of
rhIGF-I exerted a potent stimulatory effect on glucose uptake that was
indistinguishable from that seen in nondiabetic controls (22). This Occurred
in the face of insulin resistance; insulin-stimulated glucose uptake in the
diabetic animals was reduced -30%. These findings imply that rGF-I
might be effective in human diabetes. For example. administration of low
...., . doses of rhIGF-I sufficient to restore basal IGF-I k\els to normal in
IDDM might lower glucagon and GH levels. as well as improve cellulJr
metabolism in muscle. As a result. insulin might become more effective.
thereby ameliorating insulin resistance in IDD;"!. It is noteworthy that
administration of insulin may in a similar fashion the metabolic
effect of IGF-I. Insulin rapidly lowers IGFBP-I and. therefore. may
increase tissue access to free IGF-I (23). Such complementary effects
of IGF-I and insulin might facilitate restoration of normal substrate
me tabolism in ID D:-'L

Ivletabolic Effects of IGF-I Under Different

Glycemic Conditions
The potenEial role of IGF-I on the pathophysiology of lDDM !ed us ro
initiate studies designed to define more precisely [he mechanisms for
IGF-l"s effects. In our preliminary studies we administered rhIGf-l to
awake. chronically catheterized. 2-l-h-fasted rats using the eugiycemic
damp technique (2-+). Effects of rhIGF-I were compared to rhose of
insulin using doses of each hormone that produced compilrable stimulation·
of glucose uptake (i.e .. that were biologically equi\·alent).; Although
rhIGF-I and insulin increased glucose uptake to a similar extent (by
design), in the rat their effects on hepatic glucose production (as measured
by 3-3 H-glucose) were strikingly different. In contrast to insulin. rhIGF·I
failed to suppress hepatic glucose production Or lipolysis. In further
studies. to avoid the potential limitation of species differences in the
response to the hormone. we examined the metabolic effects of rhIGF-I
in normal humans under various glycemic condirions.

Euglycemin
To examine rhIGF-I's actions withom the confounding changes pro­
duced by hypoglycemic counterregulation. \ve studied 9 healthy human
volunteers (aged 19-34) during a primed-continuous IV infusion of
rhIGF-I for 3h (prime. 20llg/kg; continuous rate. O.-l~tg/kg/min) (25).
Plasma glucose was damped at euglycemic levels (90 mg/dL) using a
variable infusion of exogenous glucose. During the IGF-I infusion total
 198 R.S. Sher."'in et al.

IGF-I increased 3-fold. and free IGF-I levels rose from undetectable to
-70 ng/mL. There was marked suppression of islet hormones; plasma
insulin fell by 32%, C-peptide by 58%, and glucagon by 40% (P < 0.01).
Glucose uptake (measured by 3- 3H-glucose) increased 2- to 3-fold over
baseline (P < 0.001), glucose oxidation (measured by indirect calorimetry)
increased by 50% despite the decline in insulin secretion, and amino acid
concentrations feU by 40%-60% (P < 0.05). Unexpectedly. IGF-I
also suppressed hepatic glucose production (P < 0.01) (Fig, 18.2) and
,>
circutating FFA levels by 70% (P < 0.001). Indirect calorimetry showed a
shift in fuel oxidation from lipids to carbohydrate,
The overall pattern of response to IGF-I seen in these studies is
remarkably similar to that seen with insulin. The similarity of the pattern
of mewbolic response to IGF-I and insulin suggests that either hormone
may act via binding to the insulin receptor (or hybrid insulinflGF-I
receptors) and/or that both hormones activate a similar cascade of post­
receptor events after e:lCh binds to its own specinc receptor.

30

20

GLUCOSE UPTAKE
(mg·kg- 1 min- 1 )
10

30
o Basal
o IGr-l Infusion

20
HEPATIC GLUCOSE
PRODUCTION
(mg·kg- 1 min-' )
10

....

FIGURE 18.2. Effect of rhIGF·I on glucose uptake and h:!patic glucose production,
During this study plasma glucose was damped at eugfycemic (e\'els (90 mgiJLl
using a \"ariable infusion of exogenous glucose. The asterisks denote a significant
change as compared to basal values: • P < 0.001 and" P < 0.01.
 J

18. Metabolic Eff~cts of IGF-r 199

Hyperglycemia
j To determine whether IGF-rs inhibitory effect on insulin secretion (see
above) persists during glucose-stimulated insulin secretion. healthy.
nonobese subjects received either rhIGF-I (OA ~lg:kgimin) or saline for
3 h (26). After an initial euglycemic phase. plasma glucose was raised to
two different levels of hyperglycemia (clamp technique) to evaluate insulin
., responses to a standard stimulus. In one group. glucose was raised
: +50 mg!dL (n = 6). and in the other. + 125 mg!dL (II 8) above baseline.
At the +- 50-mgdL step. C-peptide levels we re suppressed by -W%
during rhIGF·I infusion. while insulin levels were suppressed by 30o~
(P < 0.05). Despite the reduction in insulin secretion. the rate of glucose
metabolism was ]·fold higher in the IGF·r·jnfused group (P < 0.00l) . .-\5
depicted in Figure IS.3. at the higher glucose stimulus (+125mgidl).
rates of glucose metabolism were 30% -35% higher during IGF·I infusion
(P < 0.01): suppression of insulin secretion by IGF·I was also noted. bu~
it was less remarkable than with the +- 50·mg/dl step.

j ao 0
W
Insulin
rhlGF·l

60

INSULIN 40
(I1U!mL)

20 "'.­

M VALUE
(mg'kg- 1 min- 1 )

J
F,GURE l8.3. Effect of rhlGF·[ on glucose-stimulated insulin release and the rate
of glucose me[aboli~m (M) during + 125·mg/dL hypergl;cemic clamp. Rates of
glucose mewbolism were 30% -35% higher during IGF·L and suppression of
insulin secretion by [GF·I was noted.
 ~oo R.S. Sherwin et a1.

These data demonstrate that rhlGF-rs inhibitory effect on glucose­

stimulated insulin secretion is subst,:mtially overcome by increasing the
hyperglycemic stimulus. Despite the decrease in insulin secretion. glucose
disposal is actuatly accelerated by IGF-I's ability to stimulate glucose
metabolism. These findings suggest that the insulin-lowering effect of
IGF-I is not likely to limit its usefulness as a glucose-lowering agent in
patients with preexisting capabilities for insulin secretion.

Hypo glycem fa
To determine if the effeCts of rhIGF-I on hormonal counterregulation
were distinguishable: from those of insulin. we compared infusions of
rhIGF-I (O.7mg!kglmin) and insulin (O.SmUfkgfmin) for 120min in 10
healthy volunteers (plasma glucose allowed to fall freely) (27). Despite
similar plasma glucose nadirs (2.6 = 0.1 vs. 2.7 ± 1mr-.r). glucagon and
GH responses to hypoglycemia were clearly lower with rhIGF-I than with
insulin. while epinephrine rele:lse was unaffected (Fig. 18.4). In conrrast.
the norepinephrine response was enhanced by rhIGF-I (data not shown).
When the IGF-I and insulin iniusions were discontinued. the rebound
increase in plasma glUCOSe was delayed with IGF-I as compared to insulin.
This delay in glucose reco\ery was mainly due to persistent suppression of
hepatic glucose production. as leas! in part because of the failure of
glucagon levels to rise significantly.
The absent glucagon response to hypoglycemia observed during the
free-fall study was also confirmed when we used the glucose damp tech­
nique to produce a sustained. standardized. hypoglycemic stimulus
(50mgidL). Surprisingly. the magnitude of the inhibitory- effect on
glucagon release was substantially greater than that see.f), for GH. Once
again. IGF-I generated a more pronounced rise in circulating norepineph­
rine as compared with toe insulin study. IG F-I also caused a greater
increase in heart rate than insulin. as well as greater awareness of hypo­
glycemia. findings that suggest enhanced stimulation of sympatheric
activity.
These data suggest that the clinical use of rhIGF-I may be limited by
its ability to cause hypoglycemia and diminish glucose recovery due to
inhibition of glucagon secretion. Paradoxically. a\I;areness of hypoglycemia
is enhanced with rhIGF-I. presumably due to more pronounced stirr.u­
lation of sympathetic nervous system actidty. It is interesting to speculate
that this pattern of response to rhlGF-I could be advantageous in lOOM
patients with hypoglycemia unawareness syndrome and defecti\e sym­
pathetic responses to hypoglycemia. The inhibitory effect of IG F-I on
glucagon secretion is minimized in such patients since their capacity £0
release glucagon during hypoglycemia is already lost.

·t"
 18. Metabolic Effects of IGF·I 201

so
40
GROWTH HORMONE
(pg/L)

200

150

GLUCAGON 100
o Insulin
~ rhlGF-l
(og/L)
so

6000
5000

4000
EPINEPHRINE 3000
(pM)
2000

lOCO

BASAL HYPOGLYCCM1A

FIGt:RE 18.-1-. Glucagon. G H. and epinephrine responses to hypoglycemia produced

bv rhIGF·L The asterisk denotes a significant cham,e in hormoneleve! as com­
p~red to basal values (P < 0.05). whereas the d-;gger indicates a significant
difference between the hormonal response to hypoglycemia achieved by insulin or
rhIGF-I infusion (P < 0.05).

Concluding Remarks
Taken together. our studies in normal human subjects support the vie'.v
that IGF-I might be effective in human diabetes. especially when used to
restore to normal the typically low basal IGF-Ilevels seen in IDD~L This
might be particularly true during the pubertal period. when the magnitude
 202 R.S. Sherwin et al.

of IGF-I deficiency is most pronounced. In this setting IGF-I replacement

might lower glucagon and GH levels and act directly to improve cellular
fuel metabolism. thereby overcoming the profound insulin resistance of
100M and making it easier to optimize metabolic control.

A ckno wledgmef!(s. This work was supported by grants from the U_So
Public Health Service (DK-20~95 and DK-~5735) and a fellowship grant
from The JU\'enile Diabetes Foundations International (\V.P.B.).

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Re\' 1990:70:591-61-1.
2. Froe::sch ER. Burgi H. Ramseirer EB. Bally P. Labh:lrl. Antibody supre~sible::
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6. Poggi C. Le:: :--'1archand-Brustel Y. Zapf J. Froesch ER. Freyche; P. Effects of
binding of insulin-like growth bctor I in the isolated soleus rr:~sde or iean
and obese mice: comparison with insuiin. Endocrinology 19.79:10-1:723-30.
7. Zapf J. Froesch ER. Humbel RE. The insulin-like grov.:th factors (Gr) of
human serum: chemical and biological ch:lracteriz:!tion and aspects of their
possible physiological role. Curr Top Cell Regul 19S1:19:257 -309.
8. Rechler \1:'.1. ~issley SP. King GL. e::t ::ll. :vrultiplic:lrion stimulating :lci\'ity
(SA) from BRL3A rat liver line: relaxation to human somatomedins :lnu
insulin. J Supramol Struct Cell Biochem 1981:15:253-$6.
9. Guenther HL. Guenther HE. Froesch ER. Fleisch H. Efkcts of insulin-like
growth factor on collagen and glycosaminog~ycan synthesis by rabbit :1rticuiar
chondrocytes in culture. Experientia 1982:38:979-80.
10. Zapf J. H~uri C. Waldvogel M. Froesch ER. Acute metabolic effe::cts and
half-lives of intr::lvenously administered insulin-like growth factors I anu rr in
normal and hypophosectomized rats. J Clin Invest 1986:77: 1763-75.
II. Guller HP. Zapf J. Froesch ER. Short-term me::t::lboiic effects of recombinant
human insulin-like growth factor I in he::llthy adults. ?-.: Engl J !\led IYS7:3 17:
137-40.
12. Ross RJM. :V1iell JP. Buchanan CR. Avoiding au[Oc::lnnibalism. Sr .'.fed J
1991 :303: 1147-8.

"

18. Metabolic Effects of IGF-f 203

13. Froesch ER. Guier HP. Schmid C. Binz K. Zapf 1. Thtrapcucic potential of
insulin like gro\'th factor 1. Trends Endocrinol Mdab 1990:l:25~-60.
14. Amiel SA. She:r\\ln RS. Hintz RL. Ge:rtner JM. Press CM. Tambor!anc \\'V.
Effect of diabetes and its control on insulin-like i!rowth factors in the: \'Qun"
subjects with type I diabetes. Diabetes 198-1:33:1175-9. -"
15. Tan K. Ba:<ler RE. Serum insulin-like growth factor I Ie:vels in adult diabetic
patients: the df~ct of age. J Clin Endocrinol Met:lb 1986:63:651- 5.
16. Merimee Tl. Zapf J. Froesch ER. Insulin-like growth factors: scudies in
diabetics with :!;,\c without rerinopathy. ~ Engl J :'Ied 1983:30-k527-JO.
17. Arner P. Sjo~e~g ~1. GjOlterberg M. Skottner A. Circui;Hing i<lsulin-like
growlh facror I in type I diabetic patients \\ith retinopathy. Oi:!oe:tologia
1989:32:753-8.
IS. Unterman TG. Patd K. 1\:umJr Mahathre \'. RJjamuhan G. Oehler OT.
Becker RE. R;:;:ularion L)t 10\\' molecubr weight insltlin-Itke growth factOr
binding prottin:, in ex;:aimentJI diabelts me:l!iw>. Endc)crinotogy ['-)'11):126;
2614-2-L
19. Holly J:'IP. BiG,,;i::'::ombe RA. Ounger DB. tt ,,/. Circldian \ariation of GH­
independent IGF-Qli1dii1g protein in diaberes mellitus lnd it::; rd:Hionship to
in5ulin: a new [G[c: (or insu!in'? Clin EndocrinollOxfl [()SS:~9;667 75.
20. Tamborfane: \\Y. Hintz RL Bergman :'1.1. Gene! :'1. Felig P. Sh;:f\\in RS.
Insulin infusion pump trelement or diabetes: inftuem:e or im;:ro\'ed metabuli.:
control on plasmJ. sOnlJ.tomedin Itvels. N Engl J \led 19S1:305:303-7.
21. Press M. Tamboriane \\·Y. Sherwin RS. Importance t)t r:tised grou'lh hormone
lends in mediat:n~ ,he metabolic derangemcms or diabetes. ~ J :'\[ed
1984:310:010-5
")") Jacob RJ. Sherwi:1 RS. Bowen Let aI. :\letabolic eff~-::s of IGF· [ :wd insulin
in spontaneously ,jiaveric BB \\ [illS. Am J Physioi 199t:2bO:E21)2-",
23. Smder OK. Cle:::-,;non OR. Insulin-dependent re!lubtion or in:iuHn-like ,zrowth
f;ctor-binding FO[~in- L 1 Clin Endocrinol Met;b 199U::-l:i6':;2-I)~ ~.-
2-1. Jacob R. Barre:: E. P!ewe G. Fagin 1\:0. Sherwin RS. ACute effects ot
insulin-like gro";n factor I on glucost and amino acid mer::bolism in the
awake fasted rJ[: ,;omp:Hison with insulin. 1 Clin Invest! 9S9:S3:'lil -;- - 2:;.
25. Boulware SO. TJmboriane \\Y . .'.fanhews LS. She:rwiD RS. Di\'e~se eifec:s
of ins.ulin-like :!~~'wrh factor I on glucose_ lipid ilnd ;tmi:lO :lcid m;:[:lQoiism.
Am] PhvsioI19 0 2::::5:EI30-3.
:!6. Rennert ·N). C<!,nio S. Sherwin RS. Insulin-like growth r'acwr t inhibits
glucose stimulated insulin secretion but does not imp~ir glueD,e me:abolism
in normal humans J Clin Endocrinol MetJb 199}:76:S0~-6.
27. Kerr D. Tamborbne \\'\'. Rife F. Sherwin RS. Effect of insuiin-like \l.rowth
faccor I on the response to and recognition of hypoglycemia in hu;ans: :!
comparison wilh insulin. J Clin Invest 1993:91: 141- 7.
 1
1·

Tlte: Diabetes Atlntwll9

S.H i'.\:ll'<;h:lti. P.O. Home. RA. Rizz:l (editors)
© 1995 ElscvierScicnce 8.V. All rights resC[vd 57

3 Metabolic effects of insulin-like

growth factor 1

WALTER P. BORG /\ND ROBERT S. SHERWIN

Introduction

Insulin-like growth factor I (lGF-l) is a 7649 Da polypeptide hormone chaf<lc­

terized by high structural homology \vith insulin (I). Its existence was first sug­
gested by the discovery that serum cont<lined much more insulin-lik-e,bioiogic<ll
activity than conld be accounted for by the level of immunoreacti\'e insulin
alone (1). It is now appreciated that this "additional" or "non-suppressible" in­
sulin-like activity (2), is largely, if not exclusively, mediated by two members of
the family of growth-promoting hormones, termed somatomedins. Because these
polypeptide hormones exerted both insulin-like and growth-promoting effects.
they are currently designated as IGF- [ (formerly called somatomedin A) and
IGF-2 (formerly called multiplication-stimulating activity or MSA) to emph<l­
size their dual biological actions.
In this review we focus on IGF-I, the growth hormone responsive IGF. The
recent availability of recombinant human IGF-I has paved the way for numerous
I studies that have provided new insights inco both the scope of its metabolic ef­
j fects and how they might potentially be used in the treatment of diabetes melli­
tus.

1
Pharmacokinetics ofIGF-l

In a contrast to insulin. which is synthesized and released into the bloodstream

exclusively from the pancreatic B-cells, IGF-I has many sites of production.
Although the liver is the major source of the circulating IGF- I (3), this peptide is
also locally produced in many other tissues of the body (4-7). Consequently
IGF-\ exerts its physiological actions in two ways: as a classical endocrine hor­
mone and also as an auto-paracrine factor.
IGF-I is further distinguished from insulin by its association with specific
binding proteins (8). There are six majorIGF binding proteins (IGFBPs) recog­
nized, among which IGFBP-3 is dominant within the circulation (9). This pro­
'.­
1

1
..
58
tein plays a pivotal rok by virtue of its ability to maintain a resen'oir of IGF-I in
the vascular space. IGFBP-3 forms a complex bet\veen its acid labile subunit
(ALS) and the IGF-l molecule producing alSO kDa heterotrimer. which is ~
biologically inactive "storage" form of IGF-l (9). Interestingly, while IGFBP-3
is produced mostly by endothelial cells, ALS is synthesized in the liver under the
control of growth hormone (GH), much as IGF-l. For [his reason, a decreJ.sed
level of GH diminishes hepatic production of both IGF-I and ALS. This leads to
a reduction in IGF-I bound to [he 150 kDa complexes and the 50 kDa complexes
(consisting of IGF-! combined with BP-2 and BP-3) which facilitate passage of
IGF-l to the extracellular compartment. The net effect of these changes is a
transient increase in IGF-I availability, followed ultimately by depletion of the
total circulating IGF-I. The biological actions of IGF-l are further complicated
by the fact that IGFBPs are synthesized and released locally by the various tis­
sues. In this setting. IGFBPs may play an important role not only in storing bu.;
also in inhibiting, enhancing ;lnd/or targeting the IGF-l to the specific receptors
(10-12).
Clearly. IGF- I is a hormone characterized by unusually complex pharma­
cokinetics. Because it has the capacity to modify the IGF-lIIGFBP system
through direct and indirect (via GH) effects on the levels of IGFBP, and to exe"
dual endocrine and paracrine effects on responsive tissues, its actions may
change over time. thereby complicating attempts at defining its biological role
and possible pharmacological use.

i Physiological actions of IGF·l in animals

Early in vitro studies demonstrated that IGF-I can mimic the capacity of insulin
to promote glucose uptake and metabolism in isolated muscle and adipose tissue
J (13-16), stimulate glycogen synthesis in rat he~lIT and diaphragm muscle (15.
17), increase amino acid transport in fibroblasts (17), and increase net protein
synthesis in cartilage (18). Initial in vivo studies using partially purified IGF-I
I showed a glucose lmvering action, in hypophysectomized and adrenalectomized
rats (19, 20). More recently, the availability of human IGF-I synthesized by re­
combinant DNA techniques has made a more extensive analysis of IGF-l's ef­
I fects on fuel metabolism possible. Zapf and colleagues (2 J) were the first to
show that recombinant IGF-I had hypoglycaemic effects in normal rats that
were not inhibited by anti-insulin antibodies. In addition, medium-term infusions
of IGF-I were shown to stimulate growth in hypophysectomized rats (22), im­
plying that IGF-l may exert protein anabolic effects as well.
To examine the mechanisms underlying its glucose lowering action, we gave
a primed-continuous infusion of human recombinant IGF-l to consciolls, long­
term catheterized 24-h fasted normal rats (23). IGF-l produced a sustained fall
of plasma glucose (from -6.2 to 3.4 mmoll- I ) which was due to a rise in glucose

 59

uptake; hcp:1tic glucose production changed littk. if at all. To further aSSeSs IGF­
I effects in the absence of hypoglycJ:emic counterregubtion. we comp:lrt~d IGF­
I with insulin using the euglycJemic clamp technique. Doses of IGF-I :1Od insu­
lin were specifically chosen to produce a comparable twofold stimulation of glu­
cOSe uptake. Although IGF-I and in5ulin h3d similar effects on glUCOSe uptake,
IGF-I was less effective suppressing hep:Hic glucose production. IGF-I also had
no detectable effect on non-esterified fany acids (NEFA) levels, a feature thot
further distinguished IGF-l from insulin.
The disparate effects of IGF-I on glucose uptake vis-a-vis other insulin­
sensitive processes, implies that IGF-l may be acting through its own specific
recepwr. However, the in vivo effects of IGF-l on circulating substrates and
hormones may themselves have contributed to the unique pattern of response to
IGF-1. For example, IGF-I produced a marked decline in circulating insu! in
concentrations. even when euglycaemia was maintained, and this may have
contributed to IGF-l's failure to reduce hepatic glucose production or l\EFA
levels in normal rats. These data rJised the possibility that IGF- I met:lbolic
effects might be quite different in people with insulin-treated diabetes.
In contrast to the disparate effects of IGF-I and insulin on hepatic' glucose
production and NEFA concentration, IGF- I '5 effects on plasma. amino acids.
leucine kinetics. and leucine incorporation imo protein closely resembled those
of insulin (23). IGF-I, like insulin. cJused generalized hypoaminoacidaemia and
suppressed leucine flux. whereJs bbelled leucine incorporation into he:1rt,
skeletal muscle, and liver proteins declined. These datJ suggest that the amino
;)cid lowering effect of both IGF-l Jnd insulin results from a diminution in pro­
teiQ breakdown rather than an incre:lse in protein synthesis. It should be empha­
sized that the failure to observe :In effect of IGF-l on protein synthesis may be
due to the concomitant decrease in tissue availability of amino acids, since we
have observed stimulation of protein synthesis by IGF- I in the normal rat when
hypoaminoacidaemia is prevemed by exogenous amino acid infusion
(unpublished data).
Despite IGF-I's potential for improving metabolic control in insulin-treated
patients, little is known about its effects in diJbetes. ScheilwiUer and colleagues
(24) reported that medium-term low dose infusions of IGF-l restored growth,
but had negligible glucose-lowering effects in young streptozocin diabetic rats,
To further examine the influence of diabetes on the metabolic response to IGF-I,
we recently administered "bioequivalem" doses of IGF-I or insulin to awake
chronically catheterized diabetic and non-diabetic BB rats under "clamped"
euglycaemic conditions (25). Again doses of IGF-I and insulin were titrated to
produce equivalent increases in glucose uptake in non-diabetic BB rats. As
shown in Fig.!, insulin resistance was observed in these BB rats with spontane­
ous autoimmune diabe~es, with insulin-stimulated glucose uptake reduced by
-30% (P < 0.05 versus non-diabetic rats). In contrast, IGF-I's capacity to pro­
'.

J.

60

• IGF·l
Insulin

10

GLUCOSE
UPTAKE
(mg/Kg/mln)

NON·DIABETIC OIABETIC

1 FIG. 1. IGF-/ and insulin slinllllared glucose uptake in non·diaberic and ciialx[ic BB
rars. *p < 0.05 versus lIon·diabetic rats.

mote glucose uptake was identical in diabetic and non-diabeYic BB rats. Fur­
thermore, in diabetic BB (but not normal) rats IGF-I suppressed hepatic glucose
production as well as ketones by -75% (Fig. 2). These observations indicate thal
the in vivo metabolic response to IGF-l is not diminished, and may even be en­
hanced, in insulin-dependent rats that are insulin resistant. The findings of a
more diverse action of IGF-l in IDDM rats is consistent with the hypothesis that
IGF-l' s metabolic actions in normal rats had .been offset by suppression of insu­
J lin secretion.
The demonstration of potent acute effects on glucose and ketone metabolism
I in IDDM rats prompted us to undertake further studies using medium-term sub­
cutaneous infusion of IGF-I (-I mg/day). In these experiments diabetic BB rats
(n = 8) were given low doses of insulin (-1.5 Ufday) adjusted to maintain

I chronic hyperglycaemia for 1 week, and then subcutaneous IGF-l infusion was
superimposed for 1 week. Mean plasma glucose levels fell from -235 to
-12.0 mmolfl and nitrogen balance improved by -15% following IGF-l (26).

I These findings imply that IGF-I might be effective as adjunctive therapy in

Type 1 (insulin-dependent) diabetes.

Physiological actions ofIGF·l in humans

Hypog/ycaemia

In a preliminary study Gu ler and colleagues (27) demonstratfd that the acute

 61

NON·DIABETIC DIABETIC
IS ;6

12 12
• IGF·1

Glucose
= Insulin

Production
(mg/kg/min)

e..... ~ru:uQn InfusIon a.aal InfuSIOn 8a5oa1 TntuSlon

~·hydroxy­
butyrate
!
(mM) ,i..
­

0
I I
SaMI :rttus,ora
! i

B.l:w:1 InfuSion

FIG, 2. Comparison of rhe effects of lGF-l and insulin infw;ior! on the hepatic glucose
production and {3.hydroxybutyrate levels in non-diaberic and diabeti,c BB rats.

1
administration of IGF- [ rapidly lowers blood glucose levels in healthy human
i volunteers. To more precisely compare the effects of recombinant, human IGF- I
(rhIGF-l) on hormonal counter-regulation with those of insulin, we infused
rhIGF-I (0.7 pglkg per min) and insulin (0.8 mU/kg per min) for 120 min inro
10 healthy volunteers (plasma glucose allo';ved to fall freely) (28). Both hor­
mones produced a prompt fall in plasma glucose due to a simultaneous decrease
in hepatic glucose production and increase in glucose uptake. Despite similar
plasma glucose nadirs (2.6 ± 0.1 versus 2.7 ± I mmolll), glucagon and gro\'·(th
hormone (GH) responses to hypoglycaemia were clearly diminished with rhIGF­
I compared with insulin, while epinephrine release waS unaffected. In a contrast.
the norepinephrine response was enhanced by rhIGF-l (Fig. 3), When the IGF-l
and insulin infusions were discontinued, the rebound increase in plasma glucose
was delayed with IGF-l'as compared to insulin. This delay in glucose reco\:ery
was mainly due to persistent suppression of hepatic glucose production. at least
in part because of the failure of glucagon levels to rise significantly .
•
I
1

62
GROWTH HORMONE GLUCAGON NOREP;UE?HRlfIE
(;.IgIL) (ngIL) 101.11

200 .' Insulin

rhlGF·1

FIG. 3. Comparison 0/ the changes ill glucagon. growth hormone wid norepinephrine
levels caused by hypoglycaemia produced by rhIG F-l. or insulin. The as[erisk I ~) indio
cates a sigl!ificant difference between the hormonal response 10 hypog/ycaemia acilit'l'ed
by insulin or rhIGF-l ill/usion (P < D.DJ).

The absent glucagon response to hypoglycaemia was also confirmed when \Ve
used the glucose clamp technique to produce a sustained standardized hypogly­
caemic stimulus (2.8 mmolll). Surprisingly, the magnitude of tbe inhibitory ef­
fect on glucagon release under these conditions was substantially than
that seen for GH. Once again IGF-l generated a more pronounced rise in circu­
lating norepinephrine as compared with the insulin study. IGF-I also caused a
greater increase in heart rate than insulin as well as greater awareness of hypo­
glycaemia. findings suggesting enhanced stimulation of sympathetic activity.
These data suggest that the clinical use of rhIGF-1 may be limited by its ability
to cause hypoglycaemia and diminish glucose recovery due to inhibition of glu­
cagon secretion. Paradoxically, awareness of hypoglycaemia is enh;:mced with
rhIGF-I, presumably due to more pronounced stimulation of sympathetic nen'­
ous system activity. It is interesting to speculate that this pattern of response to
J
rhIGF-I could be advantageous in insulin-dependent diabetic (lOOM) p:ltients
with hypoglycaemia unawareness and/or defective sympathetic responses to hy­

I
poglycaemiu. In such patients the inhibitory effect of IGF-l on glucagon secre­
tion is minimized since their capacity to release glucagon during hypoglycaemia
is already lost.
1

• Euglycaemia

To examine rhIGF-I' s actions without the confounding changes produced by

hypoglycaemic counter-regulation, we studied nine healthy human volunteers
(aged 19-34 years) during a primed-continuous intravenous infusion of rhIGF-l
for 3 h (prime 20 .uglkg, continuous rate 0.4 .uglkg per min) (29). Plasma glucose
was clamped at euglycaemk levels (5 mmoll1) using a variable infusion of ex­
ogenous glucose. During the IGF-infusion total IGF-l increasfid threefold, and

I
1

63

fre.: IGF-l le\'els rose from undetectable to -3,9 mmolll. There was marked
suppression of islet hormones: plasma insulin fell by 329'c, C-peptid.: by 580(.
and glucagon by 409c (P < 0.01). Glucose uptake (measured by [3- 3 HJglucos.:)
increased two- [Q threefold over baseline (P < 0.001), glucose oxidation (meas­
ured by indirect calorimetry) increased by 50% despite the decline m insulin
secretion and amino acid concentrations fell by 40-609c (P < 0.05). Cnexpect­
edl;;, IGF-I also suppressed hepatic glucose production (P<O.OI) as well as
circulating NEFA levels by 70% (P < 0.001). Indirect calorimetry showed a shift
in fuel oxidation frorr, lipids to carbohydrate. This study demonstrated that in
humans as compared to rodents the pattern of IGF-I metabolic actions is much
closer to that of insulin.
The above findings prompted uS to compare the metabolic actions of rhIGF-1
and insulin in 21 healthy young subjects (2..+ ± 1 years) and 14 healthy middle­
ag.:d subjects (48 ± 2 years) during euglycaemic clamp studies Llsing: one of
three doses of rhIGF-l (0.2,0.4, 0.8,llg/kg per min) or insulin (0.2, 0.4.0.8 mUi
kg per min) on separate days (30). These doses of the rhIGF-I and iosulin v"ere
cha;en to induce equivalent increases in gluca;e uptake and to compare '[he meta­
bolic actions of the hormones in the low end of the insulin dose-response curve.
As anticipated, these doses of IGF-I and insulin produced an equivalent in­
crease in glucose uptake. However, these hormones also had remarkably similar
effects on a variety of other metabolic processes. Both hormones (in these doses)
increased non-oxidati\'e and oxidative glucose metabolism identically and also
suppressed glucose production. NEFA, and fat oxidation similarly. In contrast.
rhIGF-I had a more pronounced inhibitory effect on islet function and produced
a greater decline in plasma amino acids than did insulin, despite the presence of
hypoinsulinaemia. implying that IGF-I may have a more potent protein anabolic
effect than insulin. The finding of a similar inhibitory effect on hepatic glucose
production was also unexpected, since human hepatocytes are virtually devoid of
IGF-I receptors. Possible mechanisms for this effect include a spillover effect of
rhIGF-l leading to stimulation of the insulin receptor, rhIGF- I stimulation of
IGF- Iiinsulin hybrid receptors or an indirect effect due to reduced circulating
glucagon.
Remarkably, basal IGF-I concentrations in the middle-aged subjects were
only one-half of those measured in the younger subjects, while insulin and C­
peptide levels were 25% higher in the middle-aged compared to younger sub­
jects. The response to rhIGF-l infusions in the older subjects was no different
from that seen in the younger subjects, glucose uptake and inhibition of glucose
production were similar. However, there was blunting of these responses to in­
sulin. These data suggest that middle age is characterized by basal IGF-l defi­
ciency and hyperinsulinaemia, but normal rhIGF-I responses and blunted insulin
action. IGF-l deficiency, as well as insulin resistance, may thus be responsible
for some of the adverse metabolic changes accompanying the aging process.

i
I
l

..

6-f
f-lipe rglvcaemia

To determine \vhether IGF-l's inhibitory effect on insulin secretion (see :lbove)

persists during glucose-stimuLlted insulin secretion, he:llthy non-obese subjects
recei\'ed either rhIGF-I (OA per min) or saline for 3 h (31). After an initial
euglycaemic phase, pl:lsm:l glucose W<lS raised to two different levels of hyper­
glyc<lemia by the cbmp technique to eV:lluate insulin responses to a Standard
stimulus. In one group, glucose was mised -2.8 mmoi/l (11 == 6) and in the other
-7 mmol/l <lbove baseline.
At the -2.8 mmolll step, C-peptide leve!s were suppressed by 40% during
rhIGF-I infusion, while insulin levels were suppressed by 30% (P < 0.05). De­
spire the reduction in insulin secretion, the rate of glucose metabolism was two­
fold higher in the IGF-l infused group (P < 0.00 I). At the higher glucose
stimll [us (-7 mmolll), rates of glucose metabol ism were 30-35% higher duri ng
IGF-l infusion (P < O.Ol). Suppression of insulin secretion by IGF-I also was
noted, but was less marked than with -2.8 mmolll step. _
These data demonstmte that rhIGF-l's inhibitory effect on glucose-stimulated
insulin secretion could be partially overcome by increasing the hype'rglycaemic
stimulus. Despite the decreJse in insulin secretion, glucose dispoSJ! during hy­
perglycaemia was accelemted by IGF-I, findings in accordance with the obser­
varions of Zenobi and colleagues (32) who demonstrated that while rhIGF-1
suppressed fasting and meal stimu!Jted insulin levels, glucose tolerance did not
change. They suggested that IGF-I may improve glucose disposal by increasing
tissue sensitivity to insulin. however it is also possible that this phenomenon re­
nects the combined stimulatory effects of both IGF-I and insulin rather than a
direct change i'ninsulin action.
Regardless of the mechanisms involved, these findings suggest that [he insu­
lin lowering effect of IGF-l is not likely to limit its usefulness as a glucose low­
ering agent in patients with the pre-existing capacity for insulin secretion.

Role ofIGF-I in the pathology and therapy ofIDDM

It is now recognized that conventionally-rreated patients with Type I diabetes

mellitus (IDDM) are chJracterized by reduced levels of IGF-I (33.34), espe­
cially during puberty. Furthermore. experimental diabetes in rodents (35; nnd
insulin deficient patients with IDDM (36) exhibit increased levels of lov" mo­
lecular weight IGF-I binding proteins such as IGFBP-I which might further
limit the tissue availability of biologically active IGF-l in IDDM.
Indeed, the raised GH levels in IODM appear to be, for the most part, a com­
pensatory attempt to overcome a block in IGF-l synthesis caused by insLllin de­
ficiency and poor metabolic control (37). Thus, while it is uncertain whether
".
 65

IGF-I deficiency directly contributes to the ad\'ase metabolIC effects in IDDM.

to the extent th:lt it contributes to GH hypersecretion it undoubtedly contributes
to diabetic hyperglycaemia. Even the modest GH elevations seen in poorly con­
trolled diabetes have been shown to produce marked hyperglycaemia and meta­
bolic decompensation in IDDM patients in the face of optimized intensive insu­
lin treatment (38). Furthermore. IGF- I deficiency may play il role in the hyper­
glucagonaemia of poorly controlled IDDr.'L Insulin resistance associated with
poorly controlled IDDM may. therefore be. at least in part, due to IGF-I defi­
ciency. and in turn the loss of its inhibitory effect on GH and glucagon secretion
(Fig, 4). Theoretically. administration of low doses of I sufficient to re­
store basal IGF-I levels to normal in IDDM, might lower glucagon and GH lev­
els as well as improve cellular metabolism in muscle. As a result insulin might
become more effective. thereby ameliorating insulin resistance in IDDM.
It is noteworthy that administration of insulin may in a similar fashion aug­
ment the metabolic effect of IGF-I. Insulin rapidly lowers I. and there­
fore may increase tissue access to free IGF-I (39). Such complementaQ' effects
of IGF-l and insulin might facilitate restoration of normal substrate membolism
in IDDM. The potential therapeutic value of combined insuIin/rhIGF-1 admini­
stration in young patients with Type I diabetes has recently been ie'sted in ado­
lescence. Bach and colleagues (40) have compared the impact of short term IGF­
I administration on GH. IGF- I. and insulin requirements in nine IDDM adoles­
cent patients and six pubertal-stage matched healthy volunteers. Subcutaneous

r -_ _ _ _ .lnsulin Deficiency _ _ _ _ _~

IGF-l Deficiency

Insulin Resistance

t Glucose
t Amino Acids
t FFA, Ketones

FIG. 4. Potential role of the deficiency of fGF-} in the pathogenesis of insulin resistance
in poorly controlled fDDM. '.
1
66
infusion of IGF-I (20 u g/kg per h for the lO h) applied for two consC'cuti \'c da','s
resulted in a 60% dC'('rease in the insulin dose necessary to m::rimJin baseli~e
blood glucose level in diabetic patients. In addition a marked suppression of
spontaneous overnight and ::rrginine stimulated GH secretion \\(;15 noted. Simi­
larly, Cheetham and colleagues (41) using a double-blind placebo controlled
design. showed that a single subcutaneous injection of relatively small doses of
rhIGF-l (40pg/kg body \veight) in the evening, reduced nocturnJl GH levels
and insulin requirements throughout the night in pubertal diabetic p:l.tiems.
Although these results are encouraging, their clinical implications are limited
by the fact that IGF-I was administered by relatively brief periods. Whether
more long-term administration of IGF-l directed toward the replacement of the
depleted IGF-l in Type I diabetes might reduce the metabolic bbility com­
monly seen in Type I diabetic patients, especially during puberty reminds still to
be determined. Furthermore. [he potential risks of IGF- I. perhaps in accelerating
retinopathy, need to be examined before its long-term use can be recommended
for the management of diabetes mellitus.

IGF-l and the therapy of NIDDM

The potential value of IGF-I as therapeutic agent to control hypcrgl;cac:mia and

dyslipidaemia associated with Type 2 diabetes is suggested by short term studies
in NIDDM patients (32). Ie has been demonstrated that short term IGF- I treat­
ment in Type 2 diabetes results in decreased hyperglycaemia following mixed
meals, as well as decreased circulating levels of insulin, C peptide, total triglyc­
erides, VLDL-triglyceride. LDL-cholesterol and lipoproteina (32, 42). Consider­
ing that NIDDM patients are at particular risk for the development of the acce!­
er;ted atherosclerosis. the reduction in these atherosclerotic risk factors is par-"
ticularly noteworthy. Unfortunately, a subsequent study examining the thera­
peutic efficacy of I in obese NIDDM patients who had required insulin to
prevent severe hyperglycaemia had to be terminated because of the development
of adverse side effects of this therapy (43). In that study, which lasted from 4 to
52 days, two large daily doses of IGF-I (120 or 160,uglkg) were administered to
seven obese Type 2 diabetic patients who had been treated previously with high
doses of insulin. While the glucose control achieved with high doses of IGF-I
was similar to that accomplished during previous insulin treatment. side effects
of IGF-l administration appeared including facial and upper extremities oedema,
mild weight gain. dyspnoea, bilateral jaw tenderness, arthralgias, myalgias, fa­
tigue. tachycardia, flushing, orthostatic hypotension, and local burning in the
injection site. .
These studies indicate that obese, insulin resistant patients requiring insulin
for metabolic control also require large pharmacological doses of IGF-l if IGF-I
}
1

67
is to be used as a substitute for insulin. and that [his produces unacceptable side
effects. On the other h;:md, the use of smaller replacement doses mie:ht still be
potentially beneficial in 0.'IDDf.,L By virtue of its insulin and glucagon lowering
effects, its ability to reduce dyslipidaemia and increase leJn body mass and in­
sulin action, IGF-l could potentially serve a useful function in less obese. or
milder forms of NIDD~L

Conclusions

Current studies suggest that IGF-I might be an effective therapeutic agent in

various pathological conditions, especially when used [Q restore to normal ab­
normally low levels of IGF-l caused by relative growth hormone or insulin de­
ficiency, such as in diabetes, malnutrition, and catabolic states. In those settings
IGF-I replacement might lower glucagon and GH levels as well as act directly to
improve cellular fuel metabolism, thereby overcoming insulin resistl:Ulce. De­
spite the recent research on the actions of IGF-l, clinical experience with the
IGF-I is still quite limited. As a result, the therapeutic benefits and risks of IGF­
1 require further investigation before they can be appropriately defi'ri'ed.

Acknowledgements

This work was supported by grants from the U.S. Public Health Service (DK­
20495 and DK-45735) and a fellowship grant from The Juvenile Diabetes Foun­
dations International (W.P.B.).

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;~
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,~

Insulin-like growth factor r in healthy adults. N Engl J Med 1987; 317: 137-1-10.
28. Kerr D, Tamborlane WV, Rife F, Sherwin RS. Effect of insulin-like growth factor I
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29. Boulware SD, Tamborlane WV, Matthews LS. Sherwin RS: Di\'erse effects of insu­
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(Endocrinol,'.-fetab 25) 1992; 262 : E13O--E 133.
30. Boulware SD. Tamborlane WV, Rennert NI, Gesundheit N, and Sherwin RS. Com­
parison of the Metabolic effects of recombinant human insulin-like growth factor-I
:lnd insulin. J Clil! lrlt'esr [994; 93: 1\31-[139.
31 Rennert NJ. Caprio S. Sherwin RS: Insulin-li:-:e growth factor I inhibits glucose
stimulated insulin secretion but does not impair glucose metabolism in norma! hu­
mans. J Clin Endocrinol J'yfetab 1993: 76: 804-806.
.J '-. Zenobi PD. Jaeggi-Groisman SE. Riesen \VF. Roder ME. Froesch ER. Insulin like
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growth factor-[ improves glucose and lipid metabolism in type 2 diabetes mellitus. J
Clill lllres( 1992: 90: 1234-2241.
33. Amiel SA. Sherwin RS, Hintz RL Gertner JM. Press CM. Tamborlnne WV: Effect
of diJbetes and its control on insulin-like growth factors in the young subjects with
type I diabetes. Diabetes 1984; 33: 1175-1 179.
34. Tan K. Baxter RE: Serum insulin-like growth factor I levels in adul t diabetic pa­
1 tients: the effect of age. J Ciill EndocrinollVlerab 1986; 63: 651-655.
35. Unterman TG. Patel K. Kumar Mahathre V, Rajomohan G, Oehler DT. Becker RE:
Regulation of low molecular weight insulin-like growth factor binding proteins in
experimental diabetes mellitus. Endocrinology 1990; 126: 2614-2624.
36. Holly IMP. Biddlecombe RA, Dunger DB. Edge lA, Arnie! SA, Howell R. Chard T.
Rees LH. Wass JAH: Circadian variation of GH-independent IGF-binding protein in
diabetes mellitus and its relationship to insulin. A new role for insulin? Ciil! Ereda­
crinol (Oxford) 1988; 29: 667-675.
37. Tamborlane WV, Hintz RL, Bergman M, Genel M, Felig P, Sherwin RS: Insuiin
infusion pump treatmen~ of diabetes_ Int1uence of improved metabolic control on
plasma somatomedin levels. N Engl J Med 1981; 305: 303-307. .
38. Press M. Tamborlane WV. Sherwin RS: Importance of raised growth ho'rmone lends

1
]

1 "'(",
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in mediating the metabolic derangements of diabetes. N Eng! J AIed 198-1; 310: S 10­
815.
39. Synder DK. Clemmon DR: Insulin-dependent regulation of insulin-like growth fac­
tor-binding protein-I. J c/in EndocrinollHewb 1990; 71: 1632-1636.
40. Bach MA. Chin E. Bondy CA. The effects of recombinant insulin-like growth factor
I (IGF-I) on growth hormone, IGF-II, IGF binding protein and blood glucose levels
in normal and diabetic adolescents. Pediatr Res 1993; 33: 190.
41. Cheetham TD. Jones J, Taylor AM. Holly J. Matthews DR. Dunger DB. The dfects
of recombinant insulin-like growth factor I administration en growth hormone !evel
and insulin requirements in adolescents with type l (insulin-dependent) diabetes
) mellitus. Diaber%gia 1993; 36: 678-681.
42. Zenobi PD. Holzmann P. Glatz Y. Riesen WE Froesch ER. Improvement of lipid
protile in type 2 diabetes mellitus by insulin-like growth factor I. Diaberologia 1993:

I 36: 465.
43. Jabri N. Schalch DS. Schwartz SL. Fischer JS. Kipnes MS. R:ldnik BJ et al. Adverse
effects of recombinant human insulin like growth factor I in obese insulin-resistant
type II diabetic patients. Diabetes 1994; 43: 369-374.

j .~ '- .

1
1
 dt

Foui'rdecl
1991
ff
24
I
I
fi
rt
FOREWORI)
r"
It
tf
The AmericanAssociationof Clinical Endocrinologistsis pleasedto presentthe frfth edition ofthe AACE Endocrine
CodingManual.This manualwas desiped and compiledby clinical endocrinologistsfor clinical endocrinologists,
lil
d tlus creatinga resourcethat shouldbe higbly relevantto tle needsof our real-world practices.
I
trrl
tt Specificfeaturesof interestinclude comprehensivesectionsincorporatingall primary codesfor 15 categoriesof
endocrine-specificdisorders;formatting by diseasestates;a detailedindex; and a "coding quick referenceguide" for
t easyuse.

t In designingthe manual,the AACE Socioeconomicand MemberAdvocacy Committeereviewedthe entire

compendiumof CPT@,ICD-9-CM, andHCPCScodesfor their clinical relevanceto endocrinology.The Committee
II
quickly realizedthat all codesofpotential interestcould simply not be includeddue to spacelimitations, and
selectivelychosecodeswitl the greatestanticipatedclinical utility.
il

t: Diagnosticandtherapeuticadvancesoccur daily; therefore,periodic updatesof tlis resourcewill be madeavailable

regularly.Watch AACf, plilings or AACE Online (www.aace.com)for information on updates.
t
Y
This outstandingmanualcould not havebeencreatedandproducedwithout the hard work and dedicationof the
ill AACE Socioeconomicand MemberAdvocacy CommitteeandAACE staff. Particulargratitudeis extendedto R.
Mack Harrell, MD, FACP, FACE, Chair andA. Jay Cohen,MD, FACE, Vice Chair for their exemplaryleadershipof
E

n the Socioeconomicard MemberAdvocacy Committeein making this importantand valuabledocumentavailablefor

practicingclinical endocrinologists.
n
AACE welcomesfeedbackand suggestionsto makesubsequenteditionsofthe manualevenmore useful and
E beneficialto the practiceof endocrinology.

il Sincerelv.

:
f#"rffi
StevenM. Petak,MD, JD, FACE, FCLM, President
II

AACE 2006-2007Socioeconomicand Member Advocacv Committee

E R. Mack Harrell, MD, FACP. FACE" Chair
A. Jay Cohen, MD, FACE, Vice Chair Arthur N. Lurvey, MD, FACE
r
Walter P. Borg, MD Tilak Kumar Mallik, MD, FACE
William Conway, MD Eric A. Orzeck,MD, FACP, FACE
= Marc J. Laufgraben,MD, FACE S. SethuK. Reddy, MD, MBA, FACE
Bill Law Jr., MD, FACP, FACE SharonE. Selinger,MD, FACE
: Anne-Marie Lee, MD, FACE W. PatrickZeller, MD, FACE
I Elliot G. Levy, MD, FACE William D. Zrgrang,MD, FACE

=
il

til AACE Staff

Chris Welch, MBA, CPC, CMC, Deputy CEO
il
ft
Shelley Vandiver Garrett, CPC, CEC, Director of Socioeconomicsand Member Advocacy
Jennifer Carlin Young, CPC, CEC, PracticeManagementCoordinator
il
T

II
I
il
PROFESSIONAL REFERENCES:
YALE UNIVERSITY 1
PROFESSIONAL REFERENCES:
ACADIANA REGION 2
CURRICULUM VITAE
3
LIST OF PUBLICATIONS
4
EXAMPLES OF CITATIONS:
TEXTBOOKS & PAPERS 5
INFORMATION ABOUT
SELECTED JOURNALS 6
REVIEWS
7
CHAPTERS IN THE BOOKS
8
REVIEWS
9
ABSTRACTS
10
 PAGE 
FDA Takes a Stand on Bioidentical Hormones
Walter P. Borg, MD • Chair, Reproductive Medicine Committee
Continued from page 1
The FDA expressed explicit concerns about
those claims, since the above statements are
scientifically unsupported. The FDA is con-
cerned because those false statements can
mislead women and health care profession-
als. In fact, the FDA regards the use of the
term “bioidentical” as nothing more than a
clever marketing ploy that lacks scientific
substantiation and is used only to boost the
sales of the product. Therefore, the FDA is
encouraging patients to use FDA-approved
drugs for menopause- related complaints
whenever possible, instead of relying on
compounded drugs that are not reviewed
by the agency for safety and effectiveness.
It has to be noted that several major
medical societies, including AACE, have
recently published statements reflecting
their concerns regarding BHRT. The
statements are consistent with those
expressed by the FDA (4,5,6,7,8).
However, in its recent statement, the FDA
went further than expressing just a mere
criticism of the BHRT concept. Warning
letters issued by this agency clearly stated
that the specific pharmacy operations
violate federal law by making false and
misleading claims about BHRT.
There is a clear change in the attitude
to the issue of BHRT by the scientific
medical community and governmental
oversight agency. For many years after
its emergence, the concept of biodentical
hormones has been proliferating steadily
in the consumer market without being in-
dependently reviewed or debated. Even-
tually, it became so pervasive that it could
not be ignored any longer. Yet, despite all
the described initiatives, we are still far
away from the so much needed objective
approach to this important matter.
There are serious dangers of BHRT use
that have not been sufficiently evaluated.
The primary concern about bioidentical
hormone use is patient safety. These sub-
stances have not been shown to be clini-
cally effective. In addition, utilization
of these formulations may be associated
with various risks inherent to the com-
pounding process, including variability
in potency, high potential for contamina-
tion, and impurity of the preparations.
The issue of BHRT is no longer ignored.
However, additional initiatives are neces-
sary to help protect the health and safety
of the public. This should be approached
with utmost diligence and objectivity.
Both positive and negative biases have
The First Messenger • March/April 2008
no place in endeavors addressing public • Performance of reliable clinical tri- approach. The First Messenger.
safety issues. Moreover, as it was already als and basic research in the area of American Association of Clinical
pointed out by some legislators, issue of BHRT; and Endocrinologists. 2007;16(2):10.
public safety should always be balanced 4. AACE Reproductive Medicine
with the individual freedom to make in- • Formulation of the enforceable legis- Committee Position Statement on
formed personal choices (9). Obviously, lation to address the issue of BHRT. Bioidentical Hormones. The First
such informed, personal decisions should Such legislation and its enforcement Messenger. American Association
be based upon objective information that may become a model solution for of Clinical Endocrinologists.
addressing similar therapeutical con- 2007;16(5):14.
is not tainted by any commercial or doc-
troversies that are likely to follow. 5. American Medical Association. FDA
trinal bias. Therefore, those programs
oversight of bioidentical hormone
should include efforts on the part of med-
Last but not least, in view of the recent (BH) preparations. Resolution 706
ical community, legislature, enforcement
development - it would be most prudent (I-06). AMA House of Delegates
agencies (especially FDA), and public Meeting. 2006: Las Vegas, NV.
for any patient on bioidentical hormone
advocates, and consist of: 6. The Endocrine Society. Bioidentical
replacement therapy prescribed by a phy-
Hormones Position Statement.
• Performance of surveys for purity and sician to contact his/her doctor about the
dosage accuracy of all compounded safety and efficacy of this treatment. October 2006.
7. American College of Obstetricians
“bioidentical hormone” formulations; and Gynecologists Committee.
References:
Opinion #322: Compounded
• Requirements for mandatory report- 1. Borg W. “Bioidentical” hormones- bioidentical hormones. Obstet
ing by all drug manufacturers, includ- the need for an objective Gynecol. 2005;106(5 Pt 1):1139-40.
ing compounding pharmacies, of adverse approach. The First Messenger. 8. MacLennan AH, Sturdee DW. The
events related to the use of BHRT; American Association of Clinical ‘bioidentical/bioequivalent’ hormone
Endocrinologists, 2006;15(5):1,7. scam. Climacteric. 2006; 9(1):1-3.
• Creation of a registry of such adverse 2. Borg W. AMA calls for reality check 9. Senate Hearings: bioidentical
events; on bioidentical hormones. The First hormones: sound science or bad
Messenger. American Association medicine? United States Senate
• Requirements for inclusion of uni- of Clinical Endocrinologists. Special Committee on Aging. April
form patient information (warnings 2007;16(1):3. 19, 2007. FM
and precautions), in packaging of 3. Borg W. Comments to the author
compounded bioidentical hormones; re the need for an objective
Cardiometabolic Risk:
AACE
Seventeenth Annual
Meeting and
New Insights and Perspectives
Clinical Congress
Satellite Symposium
on the Management of Dyslipidemia, Obesity, and Type 2 Diabetes
A 1.5 AMA PRA Category 1 Credit™ activity in conjunction with the AACE Seventeenth Annual Meeting and Clinical Congress
Wednesday Evening, May 14, 2008 Goal
Walt Disney World Dolphin Resort To provide clinical endocrinologists who treat patients with
diabetes and its related conditions with an update on the
1500 Epcot Resort Boulevard Buffet dinner: 6:30 PM – 7:15 PM
Lake Buena Vista, Florida Symposium: 7:15 PM – 8:45 PM advancement of preventive and treatment strategies for
patients with multiple cardiometabolic risk factors.
Agenda Objectives
• Targeting Cardiometabolic Risk: A Pathophysiologic Overview and Update on Participants will be provided with clinically relevant,
Lipid Treatment Strategies evidence-based information. Upon completion of this activity,
• Adipose Tissue and Metabolism: Pathophysiology and Clinical Implications participants should be able to:
• Dysglycemia and Type 2 Diabetes: Targeted Interventions to Optimize Outcomes
• Identify metabolic risk factors such as obesity, diabetes, and
dyslipidemia, and describe the role of each in increasing
cardiovascular risk
Faculty
• Initiate interventions to prevent the development/progression of cardiovascular
Sergio Fazio, Osama B. Hamdy, Paul S. Jellinger,
disease, particularly targeting dysglycemia, dyslipidemia, and obesity
MD, PhD MD, PhD, FACE MD, MACE
Professor of Medicine and Medical Director PROGRAM CHAIR • Target recommended lipid levels for optimal cardiometabolic risk reduction,
including the full spectrum of lipid components, to optimally reduce residual risk
Pathology Obesity Clinical Program Professor of Medicine,
of end-organ impact
Co-Director, Atherosclerosis Joslin Diabetes Center Voluntary Faculty
Research Unit Instructor in Medicine University of Miami • Identify individuals needing weight-reduction interventions and initiate
Director, Lipid Laboratory Harvard Medical School Miami, FL interventions targeting abdominal adiposity that blunt its cardiometabolic impact
Vanderbilt University
Medical Center
Boston, MA Past President, American • Assess specific mechanisms leading to the dysglycemia of type 2 diabetes and
College of Endocrinology formulate management programs targeting those etiologic mechanisms to blunt
Nashville, TN
cardiometabolic risk.
Accreditation and Designation of Credit You must be registered for the AACE Annual Meeting to attend this symposium.
The American Association of Clinical Endocrinologists is accredited by the Accreditation Council for Please select Satellite Symposium #8 on the official registration form and mail or fax your form
Continuing Medical Education (ACCME) to provide continuing medical education for physicians. directly to AACE. If you need a meeting registration form, please visit the AACE website at
The American Association of Clinical Endocrinologists designates this educational activity for a www.aace.com or call AACE at 904-353-7878.
maximum of 1.5 AMA PRA Category 1 Credit™. Physicians should only claim credit This activity is sponsored by the American Association of Clinical Endocrinologists. Program
commensurate with the extent of their participation in the activity. management services provided by Joslin Diabetes Center. This activity is supported by an
educational grant from Merck & Co., Inc.
 Vol. 17, No. 2 • www.aace.com
Managing Medical Vendors
Walter P. Borg, MD • Socioeconomics & Member Adovocacy Committee Member
E
xcessive prices of indispensable
medical supplies contribute great-
ly to exponentially rising costs of
medical services. The rise in the cost of
doing medical business has occurred in a
setting of declining reimbursement. Med-
icine is the only industry in which a pay-
ment of 30 cents per one dollar charged is
considered acceptable. At the same time,
however, medical office managers tend to
pay exorbitant prices for medical supplies
without ever questioning the validity of
the bills. Many practices allow vendors
to mark up lab and office supply pricing
more than 20% without any protest. This
is well known as “price gouging” in the
rest of the business world. In medicine, it
is called “competitive pricing.” Under the
guise of “price differential,” identical sup-
plies are being sold to different physicians
at dramatically divergent prices. The of-
ficial explanation is that certain practices
are not eligible for volume discounts. A
close examination of these sale patterns
reveals that the excessive prices have
more to do with the naivete of unsuspect-
ing physicians than low order volume.
Clearly, most medical businesses are mak-
ing small change while costs of provid-
ing medical services run in mega dollar
sums. This discrepancy between the low
reimbursement and high costs of doing
medical business results in decreasing ac-
cess to quality medical care for patients.
Physicians take their vows seriously.
They want to serve all who are in need.
Ultimately, however, there will be no ac-
cess to medical services if well-meaning
physicians are bankrupt and their offices
are closed down.
Medical offices use large amounts of
various materials in daily operations.
Practices that provide ancillary services
(e.g., office laboratories, imaging) are
especially dependent on a steady flow
of quality supplies. Sadly, some unscru-
pulous vendors take an advantage of
this dependency. Survival and economic
well-being of any endocrine practice sim-
ply depends upon being able to properly
manage vendors.
Physicians who attempt to seek reliable
advice about proper management of ven-
dors are in for a big surprise. The literature
on this subject is full of boilerplate texts
written by self-proclaimed “management
consultants.” Despite their appealing
titles, such vendor experts provide physi-
cians with no basic framework or prac-
tical references on vendor management.
The purpose of this article is to introduce
the reader to the most basic aspects of
controlling costs through vendor man-
agement. From the practical standpoint,
this includes two critical elements:
• Understanding the duality of the vendors to mark up lab
medical practice
• Effective loss prevention policy
DUaLITY OF
MEDICaL PRaCTICE
Most clinical endocrinologists in the U.S.
have both professional and business re-
sponsibilities. Despite conventional wis-
dom, these responsibilities should not
“The purpose of this
article is to introduce the
reader to the most basic
aspects of controlling
costs through vendor
management.”
contradict each other. Physicians are en-
gaged in the special mission of healing.
In that calling, they have to lobby, first
and foremost, for the best interest of their
patients. Consequently, physicians have
an obligation to run efficient and suc-
cessful businesses – not for self-aggran-
dizement – but to serve the best interest
of their patients. This issue is frequently
misunderstood both by the public and by
physicians themselves. Professional self-
lessness is often confused with quixotic
self-destructiveness. Medical businesses
operate in the free market. Therefore,
they are subject to the economic laws of
free market. Doctors do not have a super-
natural power to override those laws.
It is important to distinguish medical eth-
ics from the professional business code.
Physicians should practice medicine as
ethical doctors, but run their medical
business as modern, efficient business-
men. The most important skill of a good
businessman is the ability to bargain.
Unfortunately, physicians are not trained
to negotiate. To the contrary, during their
long education, most physicians are con-
ditioned to accommodate others. From
medical school to fellowship training,
doctors are taught to obey their mentors.
They are also trained to respond prompt-
PAGE 
ly to patients’ needs. Consequently, phy-
sicians develop the mindset that con-
frontation should be avoided, otherwise,
they may be labeled as “difficult” and
“Many practices allow
and office supply pricing
more than 20% without
any protest.”
their medical reputation and career may
be jeopardized. Medical training also
nurtures a natural human tendency to be
liked. Such a tendency may be a blessing
in some clinical settings. However, it will
always be a curse in the negotiating pro-
cess, since business dealings are based on
confrontation between two parties.
Physicians should accommodate their
sick patients, but not pushy vendors. They
should not confuse the clever sales pitch
with a real concern for their patients’ wel-
fare. While interacting with salespeople,
physicians should be sensitive to any at-
tempts on the part of the vendor to ex-
ploit noble standards of medical ethics. In
fact, society should insist that, in the 21st
century, medical vendors should follow
“Physicians should
practice medicine as
ethical doctors, but run
their medical business
as modern, efficient
businessmen.”
a more stringent code of conduct. Sup-
pliers of medical products and services
must realize that the “good old days” of a
free ride at the expense of the healthcare
industry are over. Dishonest vendors do
not just damage physicians’ finances -
they cause injury to patients whom those
doctors serve. Clearly, the Centers for
Medicare & Medicaid Services (CMS)
is not amused by the over-inflated prices
of durable medical equipment and has
launched numerous investigations into
these abuses. There is no reason why the
private and academic sectors should tol-
erate similar practices.
LOSS PREvENTION POLICY
As we head down the road of accelerat-
ing Medicare cuts, private payors are
becoming very creative in decreasing
physicians’ reimbursements as well. Phy-
sicians’ cognitive services are severely
underpaid. Just maintaining compensa-
tion in accordance with their contracts
has become an ongoing challenge for
most doctors. In this setting, the need to
optimize the efficiency of business opera-
tions is critical.
Our professional viability ultimately re-
quires us to operate at a financial profit.
A profit is the difference between real re-
imbursement and the costs of running the
practice. Although very little can be done
to significantly increase reimbursement,
effective Loss Prevention Policy is abso-
lutely critical. This concept is so obvious,
yet it is usually overlooked by physicians
and office managers alike.
Physicians are supposed to supervise
their accounts payable. In reality, how-
ever, they are overwhelmed by direct pa-
tient care, compliance issues, and endless
reimbursement appeals. Most doctors
still assume that they should generate ad-
ditional revenue by seeing more patients
rather than “sweating the small stuff.”
Monthly charges under $100 are often in-
terpreted as “small stuff;” however, with
“While interacting with
salespeople, physicians
should be sensitive to
any attempts on the part
of the vendor to exploit
noble standards of
medical ethics.”
time, those “small charges” accumulate
to substantial losses. When managing ac-
counts payable, loss prevention should
be a guiding principle. All too frequently,
the main concern of the unsupervised
manager is to simply pay the bills “on
time” without questioning their validity
or understanding their significance. Most
doctors and office managers live in fear
of losing their good credit history. Such
fear is sometimes excessive, since it is
caused by ignorance. This mindset is
often exploited by clever vendors and
unscrupulous schemers. It is not uncom-
mon for a doctor’s office to receive a le-
gitimate-looking document that resem-
bles a bill for the product or services.
Closer inspection of such a document,
however, reveals that it is a not a real bill
for purchased goods or performed ser-
vices, but rather a clever solicitation at-
tempt. It is difficult to assess how many
medical offices have purchased unnec-
essary OSHA safety posters, paid for ad-
vertisements in obscure phonebooks, or
subscribed to useless publications. As in
clinical practice, the decision about the
accounts payable should be based upon
facts and not personal assumptions or
Continued on page 25
 Vol. 17, No. 2 • www.aace.com
Managing Medical Vendors
Walter P. Borg, M.D.
Continued from page 9
Most physicians do not think about
potential losses when considering
new capital investment. Unfortunate-
ly, there are many situations in which
the purchased equipment simply in-
creases overhead without increasing
income. As a rule, one should invest
in technological solutions that are di-
rectly reimbursable or result in a ma-
jor improvement of office efficiency
with immediate translation into in-
creased profits. Endocrinologists are
being frequently offered services or
products that actually produce mar-
ginal losses (not gains) for the prac-
tice. It is critical to perform a very
detailed cost-benefit analysis before
making any major investment pur-
chase. It is also necessary to obtain
at least three independent bids for
comparison. Remember, the old stra-
tegic adage applies to combat as well
as business: “No battle plan survives
contact with the enemy.” Indeed,
the best cost/benefit analysis is not
a match for the real life experience;
hence, the importance of both proac-
tive and retroactive loss prevention.
Tips on Web Design
for Your Practice
R. Mack Harrell, MD, FACP, FACE • Socioeconomic Committee Chair
Continued from page 21
The real heavy lifting occurs when
you create your content. This process
is usually quite involved. Remember
that the average Internet user’s atten-
tion span is about two minutes, so be
brief and to the point. When dealing
with text, I prefer using bullets to em-
phasize major talking points or issues.
Remember that a picture is worth a
thousand words.
Streaming picture sequences of your of-
fice space with action shots of the ultra-
sound suite or diabetes education area
may serve to differentiate your practice
and Web site from the competition next
door. My favorite content is high defi-
nition (HD) video. HD video allows the
patient to meet you at the push of a but-
ton. I use video on my site, www.ftles.
com, to discuss my philosophy of care
for thyroid nodules, adrenal nodules
and hyperparathyroidism. In addition,
if you are asked to perform public ser-
vice announcements or TV spots for lo-
In summary, the simple and effi-
cient approach to vendor manage-
ment may be summarized as follows:
• Loss Prevention. Create a Loss
Prevention Department even if this
is only a one-person unit. Make
sure your vendors know that you
have such a department. Give your
Loss Prevention Officer (LPO) in-
centives to discover current losses
and prevent future ones. Most
practices have already successfully
developed incentive systems that
financially motivate employees
working with accounts receivable.
Remember that the LPO is your fi-
nancial extender (just like the LPN
is your clinical extender). There-
fore, he/she has to be mentored
and supervised while relying on
simple protocols. These protocols
should incorporate periodic com-
parison shopping for supplies al-
ready provided by current vendors.
• Understand Creditworthiness.
Educate yourself and your of-
fice manager on how creditwor-
thiness is being assessed. Learn
how any accidental damage to
your credit history may be re-
cal media outlets, be sure to request the
right to Internet-post your clips. Media
clips with introductions by local news
“In my opinion, your
personal office Web site
may be one of the most
important tools you can
create to market your
medical skills in the
Internet age.”
personalities generate immediate cred-
ibility and copious phone calls. Please
be aware that creating all this content
with a professional Web designer is not
cheap. I personally spent $2,000 on the
development of www.ftles.com, but this
included the expense of creating and
editing 60 minutes of HD video plus
many hours of translation of my written
content into HTML and FLASH. Also,
remember that there may be ongoing
costs as you pay to maintain domain
PAGE 25
paired. It is a good idea to invest
in a consultation with a reputable
financial advisor about the issue.
• Understand the Vendor Mental-
ity. The interesting history of the
rise of medical vendors special-
izing in serving private practice is
presented by A. Bhide (The Origin
and Evolution of New Businesses.
OP 2000). According to this paper,
certain large medical vendors fa-
vor enthusiasm for making sales
by their representatives over meri-
torious experience. The strategy
works well for them. In the same
paper, founders of this company
brag about having “nice homes,
boats, and a couple of cars apiece”
as a result of their financial suc-
cess. The question is: did this be-
havior work as well for patients of
physicians whose practices were
serviced by those under-qualified
sales enthusiasts? Many corporate
vendors refuse to acknowledge the
basic realities of today’s healthcare
industry. They simply do not care.
A representative of a large compa-
ny stated verbatim to a physician:
“We cannot work this way and wait
three months for payment for our
products.” Unfortunately, all phy-
sicians and hospitals in this coun-
try have worked “this way” for the
last 30 years. Physicians should
be very sensitive in recognizing
this type of corporate mentality.
names (your Internet addresses), add
new content and pay for server space to
house your site.
The best Web sites are dynamic. Not
only do the graphics move as clients in-
teract with your content, but the content
changes constantly as new information
becomes available. Many physicians
choose to create new content via Web
logs (blogs), where they post commen-
tary on newsworthy events and recent
developments in diagnosis or treatment.
Such Web forums facilitate rapid fire
communication and arm’s length writ-
ten interaction with your patient base.
Blogs also bring in more Internet traffic
via extra search engine exposure.
With a healthy pocketbook, the right
databasing software, and a Web utili-
zation consultant, you can add the fi-
nal layer of Web sophistication. This
involves optimizing your Web site’s
visibility to the search engines (like
Google™ and Yahoo®) and develop-
ing a database to keep track of exactly
who is using your site and what parts
of the site are most heavily trafficked.
Search engine optimization has actu-
ally become a cottage industry within
the Internet marketing field, and many
consultants are available to assist you
for a price. I recently had a Web uti-
lization consultant offer to set up a
database to serve my site for ~$1,500,
with additional subsequent quarterly
Ultimately, doctors are fiducia-
ries of their patients - not vendors.
There are numerous vendors to
choose from. While change may
be painful, there are circumstanc-
es where change is unavoidable.
• Efficient Bill Verification. De-
liberate or accidental billing er-
rors do occur. Resist two extreme
approaches to accounts payable.
First, many office managers tend
to introduce numerous, redundant
forms to verify the validity of
bills. Second, other managers de-
velop a total reliance on vendors’
billing statements. Invest time in
developing the most efficient way
to verify your bills and track your
payments. Never pay a bill from
a vendor statement alone. Instruct
staff to always cross-reference
bills with packing slips, and make
sure that delivered items were us-
able on arrival (not damaged or
with short expiration dates). If
inaccuracies are found, inform
vendors that you will dispute their
bill and keep records of such dis-
putes. Insist that vendors provide
you with detailed and easy to un-
derstand statements. Delivering a
confusing bill is the oldest trick
in the book - don’t be a victim of
business as usual. Take charge of
your expenses - your patients will
thank you. FM
fees for a reporting function. After a
brief financial evaluation with associ-
ated wallet biopsy, I elected to remain
“…by posting appropriate
content, you afford
established patients the
opportunity to revisit
clinical issues and
questions without having
to occupy your office
staff on the phone.”
blissfully ignorant of my Internet cli-
ents’ shoe sizes until further notice. If
your office has enough of a revenue
stream, the information you gain from
databasing your client traffic can be
quite useful, but I’m not there yet.
In summary, I am a firm believer in
having an endocrinologic Internet
presence. I believe that such a pres-
ence serves to show potential patients
what you do, and what to expect from
your office in terms of service and sup-
port. In addition, by posting appropri-
ate content, you afford established pa-
tients the opportunity to revisit clinical
issues and questions without having to
occupy your office staff on the phone.
Dr. Harrell’s practice Web site can be
accessed at www.ftles.com. FM
 PAGE 10
Comments to the Author Re: Reproductive Medicine
Corner Paper “The Need for Objective Approach” From
The First Messenger, Sept/Oct 2006 issue Walter Borg, MD
Dear Dr. Borg:
My name is Dr. Alan Terlinsky and I
practice in the Washington, DC, area. I
am a member of The Endocrine Society,
The American Association of Clinical
Endocrinologists, and The North American
Menopause Society. I treat a substantial
number of women for menopausal and
perimenopausal symptoms. Many of these
women come to me requesting “bioidenti-
cal” hormone treatment.
I read your piece in The First
Messenger regarding a need for an objec-
tive approach to bioidentical hormones
and I applaud the spirit of your message.
But I would like to take issue with the
statement you make in the article in the
section commenting on the use of salivary
hormone assays. The paragraph begins,
“First, there is no evidence that levels of
steroid hormones and saliva can be used
as reliable ancillary tests for clinical pur-
poses with the exception for cortisol mea-
surements.” This is simply not true. For
the purposes of full disclosure I rely on
serum hormone assays and I do not order
salivary reproductive hormone tests. I do
prescribe “bioidentical” hormones that
are FDA approved and come from various
pharmaceutical drug makers. However, so
many of my patients have had the salivary
hormone tests that I decided to look into
the issue myself.
The references that you use to sup-
port the notion that there is “no evidence”
are either on the dated side or they come
from American College of Obstetricians
and Gynecologists. On the other hand,
at the recent annual meeting of the North
American Menopause Society, Robert
T. Chatterton,, PhD, from Northwestern
University, presented a session on the
validation of hormone salivary testing for
estradiol and progesterone. He came to the
following conclusions:
1. salivary assays are useful for assessing
individual hormone status only if greater
than or equal to five daily samples were
collected
2. salivary hormone patterns correlate
with serum only within individuals; ratio
of saliva to serum concentration is vari-
able between individuals.
3. salivary hormones may be useful for dis-
cerning treatment effects between groups
of subjects, but differences between popu-
lations may not reflect certain levels.
Here are several references that you
may find important to review:
• Chatterton RT Jr. et al.
Characteristics of salivary profiles of
estradiol and progesterone in premeno-
pausal women. Journal of Endocrinology
2005: 185: 77 – 84
• Gann PH, et al. Saliva as a medium
for investigating intra-and interindividual
differences in sex hormone levels in pre-
menopausal women Cancer Epidemiology
Biomarkers Prev 2001; 10:59 – 64
• Ishikawa M, et al. The clinical
usefulness of salivary progesterone mea-
surement for the evaluation of the corpus
luteum function Gynecol Obstet Invest
2002; 53 (1): 32 – 7
• O’Leary P, et al. Salivary, but not
serum or urinary levels of progesterone
are elevated after topical application of
progesterone cream to pre-and post meno-
pausal women. Clin Endocrinol (Oxf)
2000 November; 53 (5): 615-20
While there may be a long way to go
to further elucidate how salivary hormone
testing could benefit the prescription of
hormone therapy to perimenopausal and
postmenopausal women, it is not the case
that “no evidence” exists of the usefulness
of salivary estradiol and progesterone
measurement. I would appreciate your
reply to my comments, and, if you feel
this would be worthwhile to publish it in
The First Messenger, please forward it to
the editor.
Thank you for your time,
Sincerely.
Alan S. Terlinsky M.D. FACP
Arlington, Virginia 703 -379- 7110
AUTHOR’S RESPONSE:
I greatly appreciate Dr. Terlinsky’s
feedback about my paper, “Need for
objective approach.”[1] However, I have
to respectfully disagree with his comment
that the statement related to salivary sex
hormone testing is untrue. Specifically,
Dr. Terlinsky takes an issue with the
notion that “(…) there is no evidence that
levels of steroid hormones in saliva can be
used as reliable ancillary tests for clini-
cal purposes with the exception for cor-
tisol measurements” (emphasis added). I
have reviewed the references kindly pro-
vided by Dr. Terlinsky; however, I remain
unconvinced about the presence of the per-
suasive evidences in these specific regards.
The plural of anecdote is not evidence2.
As it was elegantly formulated in AACE
Protocol for Standardized Production of
Clinical Practice Guidelines, philosophi-
cally, physicians uniformly act, and must
act on the basis of an incomplete set of
information3. In order to help physicians
to sort through such a set of information,
several strength-of-evidence scales have
been proposed3, 4, 5. Some authors have
argued against the use of generic scales
for all medical disciplines because of
subspecialty differences in patient popu-
The First Messenger • March/April 2007
lations, clinical contexts, and health care
settings6. Nevertheless, those systems
appear to balance the need for simplicity
with the need for careful consideration
of available data in the process of mak-
ing clinical decisions4. Unfortunately, the
evidences quoted by Dr. Terlinsky simply
do not pass the muster of the level 1 or
even 2 of the Level of Evidences (LOE) as
endorsed by AACE.
Namely:
• C h a t t e r t o n RT J r. e t a l .
Characteristics of salivary profiles of
estradiol and progesterone in premeno-
pausal women. Journal of Endocrinology
2005: 185: 77 – 84.
The objective of this study was to
characterize salivary sex steroid levels in
56 women undergoing annual mammog-
raphy who were participating in a breast
density study, and to determine the pre-
dictability of the patterns within women.
In their conclusion, the authors them-
selves emphasized the natural variation
among and within women in the absence
of any intervention. In fact, authors called
“for properly controlled studies before
attributing changes in hormonal levels to
therapy.” In addition, they emphasized the
importance of sampling at multiple time
points when examining the relationship
between hormones and risk.
• Ishikawa M, et al. The clinical
usefulness of salivary progesterone mea-
surement for the evaluation of the corpus
luteum function Gynecol Obstet Invest
2002; 53 (1): 32 – 7.
It is indeed an interestingly designed
study, but it is limited to showing that sali-
vary progesterone 0 useful for the diag-
nosis of luteal phase defects rather as a
replacement for the classic progesterone
serum assay.
• O’Leary P, et al. Salivary, but not
serum or urinary levels of progesterone
are elevated after topical application of
progesterone cream to pre-and post-meno-
pausal women. Clin Endocrinol (Oxf)
2000 November; 53 (5): 615-20.
This is a quite limited study involv-
ing six (6) subjects. In addition, its design
may be flawed. Please judge for your-
self: OBJECTIVE: The use of topically
applied micronised (‘natural’) proges-
terone as a substitute for synthetic oes-
trogens and progestogen preparations is
controversial. The aim of this study was
to examine the changes in blood and sali-
vary concentrations of progesterone fol-
lowing a single topical application of a
progesterone cream. PATIENTS AND
MEASUREMENTS: We investigated six
premenopausal women in the luteal phase
and six postmenopausal women to deter-
mine the short-term changes in serum,
urinary and salivary progesterone concen-
trations following a single 64 mg topical
application of micronised progesterone.
RESULTS: Serum progesterone concen-
trations did not increase during the first
three hours after application of progester-
one cream; however, salivary values rose
significantly in both premenopausal and
postmenopausal women, consistent with
the view that progesterone is absorbed
and transported through the body. Salivary
progesterone concentrations were sig-
nificantly elevated above basal levels by
30-60 minutes and reached peak levels
at 1-4 h, with mean levels approximately
fivefold higher in premenopausal, than in
menopausal women. CONCLUSIONS:
Salivary progesterone measurements con-
firm that topically applied progesterone
is absorbed, despite the lack of change
in serum progesterone concentrations.
However, at the dose administered, serum
progesterone levels do not reach those
observed after oral or vaginally delivered
progesterone preparations. Higher doses
may be required to induce biological
responses within the endometrium.
• Gann PH, et al. Saliva as a medium for
investigating intra-and interindividual
differences in sex hormone levels in pre-
menopausal women Cancer Epidemiology
Biomarkers Prev 2001; 10:59 – 64.
Again this is quite a limited study (12
subjects). Authors acknowledge them-
selves that: “More methodological
research regarding the application of
salivary methods is needed.”
In their editorial published in February
2006, MacLennan and Sturdee expressed
the following opinion about the saliva
testing, “It should be clearly stated that
there are no published peer-reviewed data
to show that a single or multiple salivary
hormone assays can accurately reflect the
hormonal status or needs of a woman, and,
in particular, there has been no validation
that they can be used to titrate hormone
regimens to give an appropriate hormonal
response. 7”
Interestingly, Dr. Terlinsky himself
states that: “While there may be a long
way to go to further elucidate how sali-
vary hormone testing could benefit the
prescription of hormone therapy to peri-
menopausal and postmenopausal women,
it is not the case that there exists “no evi-
dence” of the usefulness of salivary estra-
diol and progesterone measurement.” In
addition, he discloses that he relies on
serum hormone assays and does not order
salivary reproductive hormone tests.
Clearly, there are data indicating
some possible utility of saliva testing, and
this issue shall be followed with interest.
However, at this time the serum hormone
assay remains the only reliable method
suitable for clinical purposes. This may
obviously change as new data becomes
available. As I stated in my paper: “Science
is not a static collection of unquestionable
dogmas. To the contrary, science proceeds
when earlier hypotheses are refuted by
new data. (…) Science is uncertain, ten-
tative, probabilistic and universal. Every
scientific statement remains tentative for-
ever.”
References
1. Borg, W. Need for objective approach. The
First Messenger. American Association of Clinical
Endocrinologists. 2006;15(5): 1,7.
2. Ratzan, S.C. The plural of anecdote is not
evidence. Journal of Health Communication.
2002;7:169-170.
Continue on next page
 Vol. 16, No. 2 • www.aace.com PAGE 11

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Continued from page 10 Editorial History of The First Messenger

The premiere edition of The First new role as editor.
3. AACE Ad Hoc Task Force for Standardized
Messenger newsletter was published in AACE extends its sincere apprecia-
Production of Clinical Practice Guidelines. AACE
Protocol For Standardized Production Of Clinical December 1991, as a four page newslet- tion to Drs. Dickey, Rodbard and Petak
Practice Guidelines. Endocr Pract. 2004;10(4):353- ter, and subsequent issues grew in size for their individual and collective time
61. and scope until the publication was and dedication that has allowed the
4. Guyatt G. and GRADE Working Group.
published on a bimonthly basis in 1994. newsletter to continue to grow, and serve
Grading quality of evidence and strength of recom-
mendations. BMJ;2004: 328(7454):1490. One year later, Richard A. Dickey, MD, as an important news source for AACE
5. AACE Nutrition Guidelines Task Force. FACE and Helena W. Rodbard, MD, members on the latest information on
American Association of Clinical Endocrinologists FACE, were appointed coeditors of the legislative, socioeconomic, and other
medical guidelines for the clinical use of dietary
newsletter, and continued to serve for the issues that impact endocrinologists’
supplements and nutraceuticals. Endocr Pract.
2003;9:418-470. next five years. After Dr. Dickey ended practices. We look forward to continu-
6. Liberati A, B.R., Grilli R, Magrini N, Minozzi his term, Dr. Steven Petak assumed the ous enhancements to the newsletter in
S, Which guidelines can we trust? Assessing role of coeditor with Dr. Rodbard from the years ahead under the editorship of
strength of evidence behind recommendations for
2000 – 2005. After he was elected presi- Dr. Philip Levy.
clinical practice. West J Med 2001;174:262-265.
7. MacLennan, A.H. and D.W. Sturdee, The dent of AACE, Dr. Petak relinquished his
‘bioidentical/bioequivalent’ hormone scam. position and Dr. Rodbard has served as
Climacteric;2006;9(1):1-3.  sole editor since 2006. The March/April
2007 issue of The First Messenger will Clockwise starting with top left: Photos
mark the beginning of Dr. Philip Levy’s of Drs. Rodbard, Dickey, Levy and Petak
 Vol. 16, No. 6 • November/December 2007 • www.aace.com
Reproductive Endocrinopathies
and Psychopathology
Common Misconceptions
Walter P. Borg, MD • Reproductive Medicine Committee Member
Sex hormones affect numerous organ sys-
tems in addition to regulating reproduc-
tive functions. Consequently, the symp-
toms and signs of excess or deficiency
of sex hormones are extremely diverse.
Such symptoms vary from generalized
as fatigue, to localized as hirsutism, acne
or baldness1. This variable nature of the
clinical presentations of many reproduc-
tive endocronopathies may result in their
going unrecognized for prolonged periods
of time2. Typically PCOS is being over-
looked since its clinical features are being
attributed to lifestyle-related obesity. Male
and female sexual dysfunction, related to
underlying primary or secondary hypogo-
nadism, are being sometimes explained
as “psychogenic” or caused by external
stress. By contrast, there is an unfortunate
tendency - both in the general public and
in the medical community to believe that
“sex hormone imbalance” is a culprit for
various psychological symptoms. Such
claims are made with a disturbing degree
of certainty even when the evidence is
lacking. For example, hormonal changes
occurring during puberty or menopause
are automatically evoked to explain mood
swings, irritability or attention deficit.
Some of these psychological symptoms
may be, in fact, caused or aggravated by
endocrinopathies3. However, diagnosis
in endocrinology should rest not on the
nature of the symptoms, but on the rigor-
ous clinical and laboratory evaluation4.
Moreover, even if presence of endo-
crinopathy is confirmed in individuals
manifesting psychological symptoms, it
does not mean that such symptoms are
caused exclusively by hormonal disor-
der. In a contrast to popular misconcep-
tion the most common cause of depressed
mood is depression (i.e., psychiatric dis-
order), and not “hormonal imbalance.”
Individuals suffering from major depres-
sion may be affected by endocrine disor-
der in addition to their primary psychiatric
condition. The aforementioned coexisting
endocrinopathy may aggravate preexist-
ing mood disorder. However, depression
will not be permanently cured by correct-
ing concomitant hormonal abnormality.
Unfortunately, a large segment of the
general public and even some referring
physicians are unaware of those objec-
tive facts. This situation puts substantial
strain on clinical endocrinologists.
It is not uncommon to encounter a patient
who believes very strongly that “sex hor-
mone imbalance” is responsible for the
wide array of the psychological problems
and associates them with life difficulties.
Such patients come to see an endocrinol-
ogy consultant with certain preconceived
notions. They believe that a properly
chosen “hormonal pill” is all they need
to solve their existential problems. They
expect that unhappiness, anxiety, uncon-
trollable anger, or mysterious “brain fog”
will be lifted with the properly “fine-
tuned” hormonal treatment. Many of
those patients do not even verbalize those
unrealistic expectations, since they con-
sider them to be obvious and true. They
were told to anticipate this treatment out-
come by their friends, and read about it
on the Internet. On occasions, their hopes
were raised high by well intentioned but
misinformed primary care physicians.
Astute endocrinology consultants should
not miss an opportunity to correct those
misconceptions early on in the evaluation
process. Otherwise numerous problems
will inevitably follow.
The number of patients who expect that
treatment of real or imaginary reproduc-
tive endocronopathies will result in alle-
viation of psychological problems varies
between communities. There are several
reasons for this situation. First, in certain
areas, any treatment by a psychiatrist or
psychotherapist still has a bad stigma.
Some patients feel deeply offended and
protest when their primary care physician
suggests any kind of a referral to a mental
health specialist. It is therefore easier and
safer for some PCPs to recommend endo-
crinology consultation instead. Second,
certain regions are underserved in terms
of psychiatric coverage. Finally, many
insurance policies do not cover mental
heath treatment. Yet, patients demand
that their PCP refer them to “someone
who can help.” Unfortunately, some
well intentioned primary care physicians
erroneously believe that “sex hormone
imbalance” can cause virtually any con-
dition, including psychosis or personality
disorder.
There is no question that it is beneficial
to diligently correct any existing hor-
monal abnormality in patients affected
by psychiatric problems3. However,
PAGE 
many reproductive endocrinologists face
the following dilemma: How to handle
patients who present for endocrine con-
sultation with both endocrine and Axis I
(Clinical Psychiatric Disorders) or Axis II
(Personality Disorders) diagnoses5? Is it
appropriate for a clinical endocrinologist
to serve as a surrogate psychiatrist– even
temporarily? The answer to this question
should be based upon the most funda-
mental principle of medical practice. In
the treatment of their patients, physicians
should first and foremost do no harm6.
Therefore, decision about involvement
in management of purely psychologi-
cal issues should be made by the clinical
endocrinologists based upon objective
assessment of their training and expertise
in the realm of psychiatry. Psychiatry is an
extremely complex clinical science that
relies on diagnostic and therapeutic para-
digms that are distinctly different from
those of somatic medicine. Graduates
of American medical schools receive a
superb training in modern psychiatry as
medical students. However, certain for-
eign medical graduates may not receive
mental health education consistent with
American standards. General psychiatry
has only limited presence in the curri-
cula of the medical, pediatric, OB/GYN
residencies and endocrine fellowships. In
addition, only a limited number of endo-
crinologists actively pursue continuous
medical educations related to psychiatric
diagnosis and treatment. Endocrinologists
who do not feel that they are qualified to
serve as “surrogate psychiatrists” should
resist the demands of their patients to
serve in this capacity. Instead they should
use a two-step approach:
• Correct misconceptions.
Endocrinologists should educate their
patients that endocrine treatment, while
very helpful, does not replace psychiat-
ric therapy. The emphasis should be put
on realistic expectations. Patients should
be made aware about what they should
not expect from their endocrinologists,
and why additional specialized consul-
tation by a mental health professional is
beneficial.
• Secure qualified psychiatric consul-
tation. Endocrinologists should do their
best to help their patients in securing
prompt consultation by a qualified mental
health specialist. Subsequently, clinical
endocrinologists should fully cooperate
with those mental health professionals in
the treatment process. Teamwork is a key
to therapeutic success.
In conclusion, it is true that certain very
severe and rare in 21st century endocri-
nopathies such as thyroid storm, severe
hyperadrenalism, and hypoglycemia
can cause acute mental status changes7.
However, there is no scientific data to
support the popular belief that a mild to
moderate sex hormone abnormality can
result in a profound psychopathology.
Only extremely severe anabolic steroid
abuse has been clearly implicated as a
causative (or contributing) factor in vari-
ous mental status changes8. The public
should be educated that the most com-
mon cause of depressed mood is a mood
disorder, not a mysterious endocrine
disease. Unfortunately, psychiatry refer-
rals still have a bad stigma, and some
patients insist on being referred to an
endocrinologist instead. It is beneficial
to correct the existing hormonal prob-
lems in a patient affected by psychiatric
problems. However, hormonal treatment
alone will not replace psychotherapy and
psycho-pharmacotherapy administered
by competent mental health profession-
als. More well-designed research studies
are needed to understand the relations, or
lack thereof, between excess or deficiency
of sex hormones and alterations of mood,
cognition, and perception. It is important
for clinicians to carefully screen for psy-
chiatric morbidity in patients who pres-
ent with endocrine disorders. Conversely,
patients who appear to present with pri-
mary psychiatric syndromes should be
carefully evaluated by physical examina-
tion and biochemical screening to exclude
the presence of a coexisting endocrine
disorder3.
References:
1. Speroff L. Clinical Gynecologic
Endocrinology and Infertility. 7th ed.
2005: Lippincott Williams & Wilkins.
2. Federman DD, The Endocrine Patient
in Williams Textbook of Endocrinology.
10th Ed. 2000.
3. Joffe RT, Brasch JS, MacQueen GM.
Psychiatric aspects of endocrine disor-
ders. Psychiatr Clin N Am 2003. 26: p.
683–691.
4. Felig P. The clinical manifestation of
Endocrine disease in Endocrinology and
Metabolism, P. Felig, Editor.
5. APA, DSM-IV R. 2005.
6. AMA Council on Ethics and Judicial
Affairs, Code of Medical Ethics. 2006:
AMA Press.
7. Bazakis AM. Altered Mental
Status Due to Metabolic or Endocrine
Disorders. Emerg Med Clin N Am, 2005.
23: p. 901–908.
8. Lukas SE. The Pharmacology of
Steroids in ASAM Textbook of Addiction
Medicine. 2003. FM
American Physicians and
Meiji-era Samurais:
Is History Repeating Itself?
Walter Borg, M.D.
In The Death of the Guilds, which concerns the decline in
power of a number of professions in Western countries, Elliott
Krause points out a peculiar paradox: Even while doctors were
increasing their power to control disease, the medical profession
as a whole was losing autonomy and its powers of self-
determination and self-regulation.
For many years physicians enjoyed very high social status,
and understandably so. The training required to become a
physician was always very intensive, difficult, and costly. The
oldest and most famous aphorism about medical education says it
all: Ο βιος βραχυς, η δε τεχνη µακρη: Ho bios brachys, he de
techne makre. This translates as, “Life is short (to live), (medical)
art is long (to learn).”
Formal education in medicine is not only extremely
competitive; it also lasts longer than education for any other
profession. To become an independent medical subspecialist with
full earning potential, one has to spend many years as a meagerly
paid trainee. Most physicians do not work from 9 to 5 as the
majority of “white collar” professionals do. Physicians have to be
on call, and they have to attend emergencies around the clock.
Most importantly, physicians provide services that are not just
valuable, but indispensable for society. From birth to death,
everybody is at risk of needing a physician.
Because of their sophisticated education, grueling duties, and
valuable services, one might expect that society’s high
appreciation of physicians would remain forever unchallenged.
This is obviously not the case.
For hundreds of years, patient-physician interactions were
based upon mutual interest. Physicians offered to patients
something of value, and in exchange, patients compensated
doctors for their services. Those who were poor or affected by
sudden or grave medical problems could not always receive the
best medical care. However, the charity care offered by many
physicians assisted those in need. The system, though not ideal,
worked reasonably well.
Certain mistakes in political thought caused numerous
social, political, and cultural changes. Today, the mutual interest
between patient and physician has largely disappeared. Despite
all the wishful thinking, there is now an adversarial character to
patient-physician interaction. Although there may be more than
one culprit in this grim reality, one reason appears to be
distinctly important. The introduction of third parties into the
Journal of American Physicians and Surgeons Volume 12 Number 2 Summer 2007
patient-physician relationship has grotesquely deformed the
practice of medicine.
Reliance on government or an employer for payment for
medical services appeared to some to be a logical solution. It was
reasoned that governmental entitlement programs would provide
a quick fix for expensive medical services. However, the resulting
reliance on third-party payment violates one of the fundamental
laws of human interaction, and makes conflict unavoidable.
Those who deliver care and those who profit from withholding
care (insurers and government) have contrary interests. When
paid by a third party, physicians no longer work for the sole benefit
of their patients; they actually work for the third party. They serve
at the pleasure of the insurer or the government.
Sadly, most patients are unwilling or unable to understand
this reality, and third-party payers have amply profited by
capitalizing on this public ignorance. Patients become irritated
by exponentially rising costs of medical services. They see their
insurance premiums steadily rise, while more and more
payments for services ordered are being denied as “not
medically necessary.”
Patients are also outraged by what appears to them to be a
disproportionate increase in fees their doctors are now charging.
Many of them are oblivious to the true reasons behind those
increases in charges. The bureaucratic burden imposed on
physician practices by third-party payers inflates costs, while
squeezing profits to a fraction of their previous amount.
Americans are accustomed to high-quality medical care and
take it for granted. Our immediate-gratification society, which is
accustomed to “factory outlet stores,” cheap but acceptable food,
and discount-priced electronic devices, imagines that we can also
obtain “bargain-basement prices” for high quality medical care.
Wal-Mart stores have replaced many independently operated
private shops. Many wonder whether it still makes sense to rely
on the cottage industry of private medical doctors. If such a
mindset were to prevail, it is very likely that Wal-Mart-based
walk-in clinics, and emergency rooms staffed by physician
assistants will soon replace the current diverse and sophisticated
medical marketplace.
Highly trained subspecialists such as endocrinologists would
become as obsolete as Samurais in 19th century Japan. There are
some people who believe that this would be a good thing. They
think that no one would even notice a difference—except for
“greedy” physicians who would rightfully lose their “exorbitant”
income and social status. They are gravely mistaken—and in time
society will learn just how mistaken.
43
 The current “health care crisis” is not about “falling physician
incomes” as some would like to represent it. It is about unfair
payment schemes and decreasing physician control over medical
decision-making—which will inevitably lead to decreased access
to good medical care. Patients will ultimately suffer much more
than physicians.
Sadly, physicians have failed to govern themselves, and have
lost control over both their own and their patients’ destinies. It is
simply shocking that highly educated and hard-working medical
professionals have allowed themselves to be controlled and
manipulated by bureaucrats.
We live in times when a poorly educated “utilization review
nurse” can override medical decisions made by an extensively
trained and experienced university professor of medicine. I have
not seen a law practice in which a paralegal or secretary would
override a decision made by the firm’s senior partner.
Undoubtedly, the litigation record of such a “cost-effectively
managed” law practice would be dismal. Yet, society allows such
absurd schemes in medicine. Grim consequences of this situation
are inevitable, although the enthusiastic and “cost-effective”
44 Journal of American Physicians and Surgeons Volume 12
nurse practitioners and physician assistants may create an illusion
of good medical care for some time.
The comparison of the declining position of physicians to the
fall of the Samurai caste is educational. Indeed, during the
beginning of the so-called Meiji Era in Japan—which marked the
beginning of the end of the Samurais—no one initially missed this
snobbish group of scholar-warriors. Those well-educated
swordsmen indeed appeared to be obsolete in the era of modern
firearms. However, after some time, it became clear to the
Japanese Empire that even the best-equipped army of uneducated
peasants, led by equally uneducated petty officers, is ineffective.
Eventually, a class with the Samurai’s characteristics was restored
in the form of high-ranking officers and administrators.
There is still some time for organized medicine to wake up,
and to at least try to prevent our own version of the Meiji Era.
Time, however, is running out. Those who have not learned the
lessons of history are bound to repeat them.
Walter Borg, M.D., is a Yale-trained endocrinologist practicing in
Lafayette, La. He serves on the Reproductive Medicine and
Socioeconomics Committee of the American Association of Clinical
Endocrinologists. Contact: drwborg@aol.com.
Number 2 Summer 2007
 Vol. 16, No. 1 • www.aace.com
Walter Borg, MD
AMA Calls for Reality Check on
Bioidentical Hormones
In November 2006, the American
Medical Association (AMA) passed the
resolution urging FDA to increase regu-
lation and oversight of so-called “Bio-
identical Hormones” (BH)1. This resolu-
tion has been introduced by AACE, The
Endocrine Society, and American Society
for Reproductive Medicine. AMA asks
FDA to:
• Conduct surveys for purity and
dosage accuracy of all compounded
“bioidentical hormone”
formulations
• Require mandatory reporting by
drug manufacturers, including
compounding pharmacies, of
adverse events related to the use of
“bioidentical hormones”
• Create a registry of adverse events
related to the use of “bioidentical
hormones”
• Require the inclusion of uniform
patient information (warnings
and precautions), in packaging of
compounded bioidentical
hormones
The AMA Reference Committee has
recommended that FDA should prohibit
the use of the term “bioidentical hor-
mones” unless the preparation has been
approved by the FDA2. The Committee
pointed out that there was substantial
confusion regarding the meaning of the
term “bioidentical”. Many consumers,
nonmedical professionals, and some
physicians believe this term refers to a
custom-compounded recipe containing
various “natural” hormones in “indi-
vidualized” amounts for every patient.
However, there are commercially manu-
factured hormones, such as levothyroxine
and estrogen, which are “bioidentical”
and under the purview of the FDA. AMA
expressed concern about unfounded
but highly publicized claims about “the
higher safety and efficacy” of com-
pounded “bioidentical hormones.” AMA
stated that such unsubstantiated claims
provide misleading and flawed informa-
tion to patients.
The recent action of AMA and other
concerned medical societies is very
important and should not be misun-
derstood3. These initiatives are neither
about tenuous criticism of the “novel”
approach, nor an attempt to preserve the
medical “status quo.” Nor are they about
limiting the freedom or access of health
care consumers to “alternative” health
care services. They are simply a call for
a reality check. This call by now is long
overdue. It is also a call for open dialog
with those proponents of BH whose judg-
ment has not been clouded by emotions,
and who are open to constructive criticism.
The scientific aspects of the BH con-
troversy have been previously discussed.4
The purpose of this paper is to outline the
socioeconomic aspects of the BH debate
in the context of the recent AMA reso-
lution. Actions of certain compounding
pharmacies that promote BH are very
worrisome for any objective observer5,6.
Even if the existing legal rules are not vio-
lated, there is a clear disregard for basic
scientific principles, common sense, and
even professional ethics. There are many
compounding pharmacists that strive to
achieve a high level of professionalism.
At the same time, however, there are
pharmacists whose behavior ceases to
be acceptable, and who are clearly moti-
vated by other factors than a desire to
serve their patients7,8,9,10. Such nefarious
acts can go undetected for years, espe-
cially if they take place in small commu-
nities where perpetrators have achieved
prominent social status11. In such a
context, it is in the public interest to be
proactive and closely examine the activi-
ties of those who clearly transgress well
defined boundaries of their profession.
The ethical pharmacists should welcome
such a call for scrutiny, transparency and
accountability - the same way in which
most physicians have embraced similar
calls related to the policing of the medi-
cal profession.
There is a growing chasm between
desires and expectations of the general
public and the reality of what the current,
even most advanced medical science can
actually deliver. It is unfortunate that
there are those who try to unscrupulously
profit from such a reality gap. Patients
should be educated more, not only about
what they can expect from medicine, but
also about what they should not. This task
is not an easy one. Due to socioeconomic
changes, the medical profession has been
losing its traditional powers - including
the power of persuasion. Sociologists
have demonstrated that even while physi-
cians were increasing their power to con-
trol treatable diseases, the medical profes-
sion as a whole has been losing both its
autonomy and its time-honored clout 12,13.
In addition, much of the public has
little understanding of science, and does
not accept our evidence based medi-
cal model14. Health care consumers are
increasingly seeking non-scientific or
pseudo-scientific models of care. This
phenomenon comes not necessarily from
lack of intelligence, but mainly due to
PAGE 3
scientific knowledge deficits. Patients
demand safe and effective drugs, free
from any side effects, for all imaginable
ailments. At the same time, however,
they often fail to take proven drugs when
prescribed, and substitute dubious alter-
native remedies instead15.
There was always a tendency in
both the general population and in some
part of medical community to attribute
an endocrine basis to common com-
plaints, even when evidence was lack-
ing16. Hypothyroidism and hypogonad-
ism are still automatically evoked to
explain non-specific complaints such
as fatigue, depressed mood, and weight
gain. Although each of those symptoms
may, in fact, be due to endocrine disor-
Targeting Non-LDL
Cholesterol:
What are the Options?
Washington State Convention and Trade Center
Satelliet Symposium
Luncheon 12:00 – 1:00pm
AACE Sixteenth Annual Meeting and Clinical Congress
der, a proper diagnosis should rest not
on the nature of symptoms, but on rigor-
ous clinical and laboratory evaluation16.
Yet, many still wrongly believe that any
patient who presents with a set of non-
specific somatic complaints has to have
some type of organic (likely “glandu-
lar”) disorder. However, as reported
by Greenberg, in about 50% of clinical
encounters in out-patient settings, physi-
cians are unable to identify any obvious
organic disease basis for patient’s non-
specific complaints17,18,19,20. In reality,
there are numerous reasons for subjective
symptoms perceived by a patient21. There
may be a distinct organic, endocrine or
non-endocrine pathology which is severe
enough to influence patient’s health.
Such process can usually be validated
by objective testing methods. Obviously,
there are likely disorders that have not yet
been discovered or classified. Therefore,
they cannot be detected by available test-
ing, nor treated by existing medications.
Still, this possibility does not justify use
of unproven therapies. In the long term,
such “cures” may be worse than the “dis-
eases” they treat. Patients’ complaints
may also be secondary to somatization,
factitious disorders or malingering. Such
patients are usually reluctant to accept
the possibility that there is no severe
organic disorder - even in the face of
multiple negative tests17,22. Finally, many
symptoms present in endocrine disorders
simply overlap with features of normal
Continue on page 10
What is the Science?
Wednesday, April 11, 2007
Educationsal Session 1:00 – 2:30pm
®
Sponsorship by the American Association
of Cinical Endocrinologists
This activity is supported by an educational
grant from Abbott Laboratories.
 PAGE 10 The First Messenger • January/February 2007

AMA Calls for Reality Check 2. Vassall J. AMA House of Delegates

Continued from page 3
physiological processes such as aging,
menopause or puberty.23 How aggressive
physicians have to be in their attempts to
alleviate such complaints is a subject of
debate.
Unfortunately, the above scientific
diagnostic paradigm is perceived as too
complex and not empathic enough by
the public. We are living in a sound-bite
driven society dominated by cable news,
aggressive infomercials and Internet mis-
information highways.24 It was inevitable
that such an audience is easily lured by
“too good to be true” promises of eter-
nal youth, boundless energy and disease-
free living. Surprisingly, many honest
and well meaning physicians have been
swept up in this misinformation process
as well.
In the above context, “bioidenti-
cal hormones” are the tip of the ice-
berg. Desiccated animal thyroid, growth
hormone, or adrenal gland extracts are
being touted as all-purpose tonics. There
are also important economic aspects of
an unrestrained propagation of those
unproven aggressively marketed treat-
ment fads. While the cost of compounded
drugs is usually greater than one of
traditional preparations, compounded
medications are not reimbursed by insur-
ance.5 Therefore, a patient has to pay
out of pocket for clinically useless “sali-
vary tests”.5,25 The budget of an average
American family is already tight. Many
women are influenced by the mixture of
unsubstantiated promises and reckless
scare tactics employed by BH promot-
ers. Such patients are making choices
they would never make if presented with
objective facts. Those women will pay
for a bottle of an unproven nostrum and
receive “free consultation” by a com-
pounding pharmacist acting as a self-pro-
claimed “hormone expert.” Also, those
women will waste their money rather
than pay their deductible and co-pay-
ment for the OB/GYN and/or reproduc-
tive endocrinology evaluation. In the free
market society, everybody may spend his
or her money as he/she pleases. However,
by definition – the free market requires
that traders do not coerce or defraud each
other, so all trades are morally voluntary.26
The actual value and quality of a product
cannot be deliberately misrepresented by
the seller.
The unchallenged proliferation of
medical misconceptions is already put-
ting a serious strain on an overburdened
health care system, and impinges upon
the Patient-Physician relationship.15 All
physicians practicing scientific evidence-
based medicine are frustrated with the
time required to correct pseudo-scientific
misinformation their patients are being
fed on a daily basis. Patients are grow-
ing increasingly distrustful towards their
qualified, well trained medical doctors.
The source of this distrust is related to
the discrepancy between over-hyped popu-
lar information disseminated by the mass
media and sobering but simple truths given
by ethical physicians. Let us hope that the
AMA resolution will mark the beginning
of the end of the reign of pseudo-science
fueled by pecuniary interest.
References:
1. American Medical Association, FDA
Oversight of Bioidentical Hormone (BH)
Preparations. Resolution 706 (I-06) in
AMA House of Delegates Meeting. 2006:
Las Vegas, NV.
(I-06). Report of Reference Committee J.
2006.
3. American College of Obstetricians
and Gynecologists, ACOG Committee
Opinion #322: Compounded bioidentical
hormones. Obstet Gynecol, 2005. 106(5
Pt 1): p. 1139-40.
4. Borg W. Need for Objective
Approach. The First Messenger. American
Association of Clinical Endocrinologists,
2006. 15(5): p. 1,7.
5. MacLennan AH, Sturdee DW. The
‘bioidentical/bioequivalent’ hormone
scam. Climacteric, 2006. 9(1): p. 1-3.
6. Citizens, Citizen’s Petition Seeking
to Counter Flagrant Violation of the
Law by Pharmacies Compounding Bio-
Identical Hormones” October 6, 2005.
http://www.fda.gov/ohrms/DOCKETS/
dockets/05p0411/05p-0411-cp00001-01-
vol1.pdf.
7. Ukens C. Compounding pharmacists
cash in on bioidentical hormones. Drug
Topics February 21, 2005. www.pharma-
cycompoundingfacts.org, 2005.
8. Appleby J. Safety Concerns Grow
over Pharmacy Mixed Drugs. USA
TODAY, 2005.
9. Bouts BA. The misuse of com-
pounding by pharmacists. Quackwatch,
November 26, 2005.
10. Perrin JH. Comments on Drugs
Difficult to Compound and the Quality of
Chemicals to be used in Compounding.
FDA Docket 98D-0272. http://www.fda.
gov/ohrms/dockets/dockets/98d0272/
c000005.pdf. 1998.
11. Hallissy E, and R. S. Who’s Mixing
Your Drugs? Bad medicine: Pharmacy
mix-ups a recipe for misery. Some drug-
stores operate with very little oversight
San Francisco Chronicle June 23, 2002.
12. Krause EA. Death of the Guilds. Yale
University Press. 1999.
13. Gray M. The resourceful patient.
2002, Oxford: eRosetta Press.
14. Baron JH. If I were Dean: a challenge
to new medical students. Mt Sinai J Med,
2004. 71(2): p. 134-8.
15. Groopman J. No ‘Alternative’. Wall
Street Journal - August 7, 2006.
16. Felig P. The clinical manifestation of
Endocrine disease, in Endocrinology and
Metabolism, P. Felig, Editor.
17. Greenberg D. Somatization, in Up To
Date, B. Rose, Editor. 2006: Wellesley,
MA.
18. Kroenke K, Mangelsdorff A.
Common symptoms in ambulatory care:
incidence, evaluation, therapy, and out-
come. Am J Med, 1989. 86: p. 262.
19. Katon W and Ries R, The prevalence
of somatization in primary care. Compr
Psychiatry, 1984. 25: p. 208.
20. Katon W, Walker E. Medically
unexplained symptoms in primary care.
J Clin Psychiatry, 1998. 59(Suppl 20:):
p. 15.
21. Feldman M. Playing sick. Untangling
the web of Munchhausen Syndrome,
Munchhausen by Proxy, Malingering and
Factitious Disorder. 2004, New York:
Brunner-Routledge.
22. Smith R. Primary Care Management
of Medically Unexplained Symptoms, in
Up to Date, B. Rose, Editor. 2006.
23. Federman DD. The Endocrine
Patient, in Wiliams Textbook of
Endocrinology. 10th Ed. 2000.
24. Alpert JS. Online Buyers Beware: A
Warning for Physicians and Patients. The
American Journal of Medicine, 2006.
119: p. 623.
25. Chatterton Jr RT, et al. Characteristics
of salivary profiles of estradiol and pro-
gesterone in premenopausal women.
Journal of Endocrinology 2005. 185: p.
77 – 84.
26. Rothbard MN. Free Market, in The
Concise Encyclopedia of Economics.
2006, Liberty Fund, Inc. 

in discussions pertaining to endocrinol- cation; insulin pump and sensor hands-on

Cyprian A. Gardine III, MD, PhD, Fellow-in-Training Representative
Salutations. I by the ivory towers of our institutions
pray everyone of higher learning from the vagaries of
had a wonderful clinical practice in a world of rising costs
holiday season and limited resources. We are all aware
with family and that the practice of medicine is changing.
friends. Those of Our mentors often opine with a radiant
us in the Midwest glow of the good old days, to which we
now begin the nod dutifully in agreement, our ignorance
annual process the sole buoy preventing our submersion
of physical and emotional preparation for into cynicism. Fortunately, our fate is
the long cold winter ahead. Many of you not predetermined. One of the functions
can empathize with this ritual. For those of AACE, that we as fellows may not
of you still wearing shorts, short sleeves, fully appreciate, is the preservation of the
skirts, or open-toed shoes, empathy may autonomy, integrity, and patient-centered
require a little more soul searching. At any focus of the practice of endocrinology.
rate, a new year has begun and as such it Members of AACE are actively engaged
is the season of resolutions. Millions of in discourse and debate with legislators
us are in the process of resolving to give and regulators on the federal, state, and
up a bad habit or commence one that is local levels. Our membership in AACE
good. I encourage you to resolve to con- serves to further our awareness of these
tinue to participate in AACE and to par- issues even before we begin to experience
take of its many benefits. their ramifications in our daily clinical
For most endocrinology fellows, our practice. Furthermore, as a united body
existence is fairly insular. We are shielded of clinical endocrinologists, our position
ogy is strengthened.
In addition to working to improve
our future practice environment, AACE
is dedicated to the current enrichment
of our education as endocrinology fel-
lows. Every two months I write this
column and find myself detailing all the
benefits of membership in AACE. Since
fellow enrichment is such a fundamental
tenet of AACE, I will once again high-
light the benefits in the following list:
free membership; discounted rates to
all AACE meetings; free subscription
to all AACE publications (Endocrine
Practice, and the AACE member news-
letter, The First Messenger); access to
AACE Online at www.aace.com (consist-
ing of an online membership directory; a
calendar of AACE endocrine meetings,
and other meetings around the world;
AACE Clinical Practice Guidelines;
the Fellow’s Corner; AACE Endocrine
Careers® for employment opportunities;
AACE practice enhancement materials
and educational programs; AACE Online
News; and participation in Endocrine
University® (an opportunity for senior
fellows to participate in a week of train-
ing, education, and hands-on learning
that provides thyroid ultrasound accredi-
tation; bone density measurement certifi-
cation; metabolic laboratory CLIA certifi-
instruction; endocrine surgery sessions;
practice management issues; and “Meet
the Expert” sessions).
Once again, I encourage all endocrine
fellows to avail themselves of the numer-
ous conferences offered throughout the
year, many of which are funded. AACE,
the Endocrine Fellows Foundation, and
The Endocrine Society are a few of the
organizations that organize conferences
for fellows. Most conferences send
notices to program directors asking them
to nominate fellows. I encourage you to
continue to query your program directors
regarding all of the conference opportu-
nities that pass across their desks.
For all the online junkies out there,
here are some useful endocrinology-
related websites. These include www.
aace.com (American Association of
Clinical Endocrinologists); www.endo-
text.org (EndoText – good for refer-
ence); www.diabetes.org (American
Diabetes Association); www.thyroid.org
(American Thyroid Association); www.
asbmr.org (American Society for Bone
and Mineral Research); and www.endo-
society.org (The Endocrine Society). If
you know of any other good sites please
let me know via e-mail.
As a final note, registration with
Continue on page 3
 Vol. 15, No. 5 • www.aace.com PAGE 1
A M E R I C A N A S S O C I AT I O N O F C L I N I C A L E N D O C R I N O L O G I S T S

T HE F IRST M ESSENGER
www.aace.com

Vol. 1 5 , N o . 5 • S e p t e m b e r / O c tober 2006 Jacksonville, Florida

INSIDE
REPRODUCTIVE
MEDICINE CORNER

The Need for Objective Approach

Cover

POP METHODOLOGY
3 Walter P. Borg, MD examples of “compounded” hormonal
prescriptions. All the physician needs to
In the practice therapy” has been objectively discussed do is copy the script into his/her prescrip-
AACEPAC of medicine, any [7], [8], [9], [10]. Even the non-medi- tion pad and hand it to the patient. The
4 physician has cal press started to present much more most disturbing fact about these situa-
to strictly fol- objective views on the subject [11]. tions is that many of the patient’s requests
low scientific It is clear for any practicing endo- for “natural” hormonal therapy are made
SOCIOECONOMICS principles, legal crinologist who deals with the issues before the most essential question is
rules and ethical of reproductive endocrinology that asked and answered: “Does this specific
6
guidelines. This most women are seeking the so called patient truly require any (conventional or
is the most essen- “natural/bioidentical” hormone therapy otherwise) HRT;” “Are there any indica-
ACE APPLICATION tial cannon of mainly due to their worries about safety tions specific for this patient, and are there
clinical practice. of “conventional” hormonal prepara- any contraindications to HRT?” In brief,
16 Those guiding directives are not static, but tions. (Patients direct their requests (or each potential patient should be provided
evolve with time. This evolution recently sometimes even demands) for the treat- by her physician with an individualized
became more rapid than ever. U.S. health ment with the “bioidentical” hormones evaluation regarding the benefits and
care law has evolved over the last 20 not only to endocrinologists.) Many pri- risks of HRT – before the decision about
years into one of the most regulated and mary care physicians, OB/GYNs, and the introduction of any kind of HRT is
complicated areas of the legal system[1]. urologists receive requests as well. Some made. The “one size fits all” approach
ALSO... Today, each patient encounter involves patients requesting treatment with “bioi- to education, counseling, and treatment
a myriad of compliance issues. Medical dentical” hormones were never carefully is inappropriate [7]. Endocrinologists
President’s Perspective 2 ethics has undergone many unprece- evaluated by any physician regarding the should play an active role in explaining
Genomics 8 dented changes as well [2], [3]. The pace necessity of HRT. They simply learned those issues to both their patients and
The Second Messenger 10 of scientific advancement is astonishing. about “bioidentical” hormones from the their colleagues who are not endocrine
Chapter News 11 The theories that were considered to be Internet, mass media, popular books, specialists.
“conclusively valid” just a few years ago or were advised by local pharmacists When the evaluation is completed,
International Corner 12
are being proven false today. Hormonal or friends. On occasions, such patients and the patient meets the current crite-
Member Spotlight 14
replacement therapy (HRT) in females is bring to their physicians printouts from ria for the initiation or continuation of
Classifieds 18 a good example of such a scenario. HRT the Internet or booklets from the local the HRT, the issue of “bioidentical hor-
Upcoming Meetings 19 was initially considered to be universally compounding pharmacy with preprinted monal” replacement therapy should be
beneficial and of great preventive value.
Continue on page 7
However, it has been shown to be det-
rimental in many aspects [4]. Recently,
terms “bioidentical,” “natural,” and
“compounded” sex hormones started to
gain visibility in the media. Those terms
appear to be quite “scientific” (at least
to the lay audience), in reality, however,
there is a lot of confusion and misconcep-
tions about what they really mean. There
is a wide spectrum of opinions about the
subject ranging from very harsh criticism
by some medical experts to enthusiastic Web-Cast Now Available

W
endorsements by well intentioned celebri- Visit www.aace.com
ties [5], [6]. However, until recently there
were very few fair and balanced reviews
of the subject. Fortunately, the issue of the
so called “natural hormonal replacement Web-Cast

®
 Vol. 15, No. 5 • www.aace.com
has found someone to see the patients at a
lower fee than you will accept. Suddenly
20% of your practice disappears, and you
have to struggle to fill those slots.
If you are very busy, like many endo-
crinologists in practice, have a waiting list
for new patients of several weeks or more,
and do participate in some managed care
plans, one way to increase your practice
revenue is to look closely at those plans.
Need for Objective Approach
discussed with her - if she continues to
request this form of treatment. Due to the
nature of this article, it would be impos-
sible to provide a comprehensive review
of the subject. Interested readers should
refer to the quoted references [7], [8], [9],
[10]. Presented are opinions of the critics
and the proponents, and some suggestions
on how to address those issues in the clini-
cal settings.
The term “bioidentical hormones,”
despite its outwardly “scientific” appear-
ance, is quite vague and is used in vari-
ous contexts. Most commonly, it denotes
plant-derived hormones that are com-
pounded by pharmacists - as pills, gels,
suppositories, etc. [8], [9] “Compounding
process” refers to the creation of a drug by
mixing various components by a qualified
pharmacist. It is done according to “cus-
tomized” specifications for every patient.
In the past, this was the only method of
producing medications. The need for com-
pounding has dramatically decreased after
mass pharmaceutical manufacturing pro-
cess has been developed. The large chain
pharmacies started to replace stand alone
private “pharmacy shops.” However, in
certain communities the concept of com-
pounding pharmacies not only survived,
but it appears to have experienced a
revival.
The list of compounded hormones
includes, but is not limited to, estradiol,
estrone, estriol, progesterone, testos-
terone, and DHEA. The compounded
medications are usually not reimbursed
by insurance companies. In general, the
compounding is done at a physician’s
request and according to his written com-
pounding prescription. Quite disturb-
ingly, in some communities the treatment
is initiated and directed by a pharmacist,
with a minimal (if any) involvement of a
physician. Women typically are asked to
submit saliva samples to measure baseline
hormone concentrations for initiation and
monitoring of the therapy. This way of
sampling does not require venipuncture;
therefore, it may be done at the pharmacy.
Sometimes women are asked by phar-
macists to fill a “Bioidentical Hormone
Replacement Confidential Evaluation
Form” [12] or similar document. The
form includes a section in which women
are instructed to grade various symptoms
they experience on a scale from one to
ten. This data is sometimes used to cre-
ate elaborate graphs of patient’s “symp-
toms severity” which are printed along
the “saliva tests” results. Based upon the
data, the prescriber selects the individual
hormones and doses to be compounded.
In such a setting, the instructions on how
to compound a product comes from a
pharmacist rather than from a physician.
See what the average payment per claim is
compared to other patients without man-
aged care insurance. Remember that just
because you are paid the same or maybe a
little more for an office visit or consulta-
tion, if you are not allowed to perform any
ancillary services on these patients, you
are not receiving the maximum you could
be collecting. Add the potential grief asso-
ciated with collecting your proper amount
Treatment with “bioidentical” hor-
mones is usually desired by patients since
they believe that by its very nature of
being “natural” - those preparations have
to be “safer,” “more effective,” and “free
of side effects.” Those are also the main
claims of the proponents of the “bioiden-
tical” approach to HRT. Unfortunately, a
systematic review of the current literature
does not appear to support those notions
[9], [10]. Caution has to be advised
before drawing any conclusions related
to the lack of supporting literature. This
simply means that, to date, there are only
a few observational studies and clini-
cal trials comparing conventional hor-
mone therapy with bioidentical hormone
therapy (BHT). Moreover, the available
studies generally lack adequate design
to unequivocally prove (or disprove) the
unique safety and efficacy purported by
BHT proponents [10]. To be fair - there
are no well designed studies demonstrat-
ing any seriously detrimental effects
unique to the properly compounded BHT.
However, there are understandable con-
cerns related to purity, potency, and pos-
sible contaminations of the compounded
BHT preparations. Those are intrinsic
risks to any compounding process [9].
More well designed studies in this area
are needed. Until this will take place,
the existence of meaningful differences
between “bioidentical” and conventional
hormones remains to be established.
Salivary hormone level testing rec-
ommended by BHT proponents as a way
of providing patients with “individual-
ized” therapy requires separate comment.
There are many troubling aspects of such
an approach [9].
First, there is no evidence that lev-
els of steroid hormones in saliva can be
used as reliable ancillary tests for clinical
purposes with the exception for cortisol
measurements [13]. Theoretically saliva
is an ultrafiltrate of blood, therefore the
assumption was made that saliva can be
used to determine free (i.e. unbound)
concentrations of all steroid hormones.
Unfortunately, the expected meaning-
ful relationship between salivary sex
steroid hormone levels and free serum
sex steroids concentrations could not be
demonstrated [14], [15]. Moreover, in a
contrast to the cortisol salivary level, the
large intra-subject variability has been
shown in salivary sex hormone concen-
trations [13], [9]. Salivary sex hormone
levels varied depending upon numerous
variables such as diet, hydration status,
circadian rhythm, etc., which are difficult
to standardize [9].
Second, independently of the issue
of bioidentical hormones and need for
strict laboratory monitoring of HRT (or
PAGE 7
due, and the value of not having use of
your money until your claim is finally
paid, and it may not make financial sense
to continue with the plan, especially if you
have a waiting list of new patients who
want to see you. You might be better off
in dropping the “poorer paying” plans and
replacing those patients with other patients
who have better insurance.
I realize that this whole scheme is very
Continued from page 1
lack thereof) the standard blood tests for
the sex steroids are well established with
the exception of free testosterone mea-
surement - reliability of which is con-
stantly questioned [16]. Venipuncture is
a straightforward and minimally invasive
procedure. Hence, there is little need to
resort to salivary sex hormone testing in
the setting of medical practice.
Third, the argument against salivary
tests cited by the critics of BHT is of
pharmacological nature. Even if saliva
levels of sex hormones would be clini-
cally significant, it has been pointed out
that sex hormones do not belong to a
pharmacological class of drugs with clear
indications for individualized dosing [9].
From the perspective of clinical pharma-
cology, individualized dosing is indicated
for drugs characterized by a narrow ther-
apeutic window. Drugs with nonlinear
pharmacokinetics (those that are renally
eliminated as the active ones) are good
examples. Drugs that are not metabolized
during the first pass through the liver, and
those with clearly defined (in large popu-
lation pharmacokinetic studies) thera-
peutic and toxic concentrations meet the
requirements for individualized dosing
as well. In contrast, sex hormones do not
meet this criteria [9]. Those are the argu-
ments from the pharmacological stand-
point, and should not be misconstrued as
the endorsement for a “one size fits all”
approach [7]. Theoretically, unusual cir-
cumstances may arise in certain patients
who may require individualized dosing
of sex steroids. Critics of BHT argue that
such cases will be rare exceptions.
All the facts should be carefully
explained to the patient who requests
BHT, and any misconceptions have to be
tactfully, but firmly corrected. The deci-
sion about instituting any type of HRT
has to be based upon careful clinical eval-
uation of the benefits and risks of such
therapy in a specific patient. Physicians
should remain objective in the middle of
any controversy. There are situations in
medicine when there are many differ-
ent right answers to the same question,
or where there is no single right answer.
Physicians should not deny beneficial
treatment to patients. Physicians should
not enthusiastically promote the therapies
which are scientifically unproven, either.
Having said that, physicians should
remember that science is not a static col-
lection of unquestionable dogmas. To
the contrary, science proceeds when ear-
lier hypotheses are refuted by new data.
This was elegantly summarized by Dr.
Baron: “Science involves the conception
and construction of refutable hypotheses,
and their testing by repeatable experi-
ments, followed by publication of the
complicated and may sound discouraging
to younger doctors, but it is another exam-
ple of how business skills can be used to
improve the profitability of your practice.
If and when managed care companies find
no endocrinologists to accept their low fee
schedules and lack of allowance of perfor-
mance of ancillary services, then perhaps
they will begin to increase what they pay
for the services that you provide. 
results. Thus, science is uncertain, tenta-
tive, probabilistic and universal. Every
scientific statement remains tentative
forever” [17]. The classic statement of
Drs. Glymour and Stalker is still valid
today: the practice of Scientific Medicine
is similar to consultant engineering. The
subjects are people rather than a con-
struction; but, similarly to engineers,
physicians must apply in their work both
explicit scientific principles and a great
deal of tacit knowledge [18].
References:
1. Babitsky S. The Biggest Legal Mistake Physicians
Make. 2005: SEAK.
2. AMA Council on Ethics and Judicial Affairs, Code
of Medical Ethics. 2004: AMA Press.
3. Baker R. The American Medical Ethics Revolution.
1999: The Johns Hopkins University Press.
4. Rossouw JE, AG, Prentice RL, et al. Risks and ben-
efits of estrogen plus progestin in healthy postmeno-
pausal women: principal results from the Women’s
Health Initiative randomized controlled trial. JAMA,
2002. 288: p. 321-333.
5. MacLennan AH, Sturdee, DW The ‘bioidentical/
bioequivalent’ hormone scam. Climacteric, 2006. 9(1):
p. 1-3.
6. Sommers S. The Sexy Years. Discover the Hormone
Connection: The Secret to Fabulous Sex, Great Health
and Vitality, for Women and Men. 2004, New York:
Crown Publishers.
7. American Association of Clinical Endocrinologists
Medical Guidelines for Clinical Practice for the
Diagnosis and Treatment of Menopause. Endocr Pract,
2006. 12(3): p. 315-37.
8. Martin KA, Rosen HN, Barbieri, RL. Preparations
for Postmenopausal Hormone Therapy, in Up to Date,
B. Rose, Editor. 2006., Up to Date: Waltham, MA.
9. ACOG Committee Opinion #322: Compounded
bioidentical hormones. Obstet Gynecol, 2005. 106(5 Pt
1): p. 1139-40.
10. Boothby LA, Doering PL, Kipersztok S.
Bioidentical hormone therapy: a review. Menopause,
2004. 11(3): p. 356-67.
11. Parker-Pope T. New Controversy Over Menopause
Hormones. Wall Street Journal, 2006: p. D1.
12. Bioidentical Hormone Replacement Confidential
Evaluation Form. 2000, International Academy of
Compounding Pharmacists.
13. Nieman LK. Measurement of cortisol in serum
and saliva., in Up to Date, B. Rose, Editor. 2006, Up to
Date: Waltham, MA.
14. Marder MZ, Joshi U, Mandel ID. Estrogen con-
centration in human parotid and submaxillary saliva. J
Dent Res, 1979. 58(12): p. 2370.
15. Lewis JG, et al. Caution on the use of saliva
measurements to monitor absorption of progesterone
from transdermal creams in postmenopausal women.
Maturitas, 2002. 41(1): p. 1-6.
16. Snyder PJ. Clinical features and diagnosis of male
hypogonadism in adults., in Up to Date, B. Rose,
Editor. 2006, Up to Date: Waltham, MA.
17. Baron JH. If I were Dean: a challenge to new medi-
cal students. Mt Sinai J Med, 2004. 71(2): p. 134-8.
18. Glymour C, Stalker D. Sounding board. Engineers,
cranks, physicians, magicians. N Engl J Med, 1983.
308(16): p. 960-4. 
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 PAGE 14 The First Messenger • September/October 2007

American Association of Clinical Endocrinologists

AACE Reproductive Medicine Committee

Position Statement on Bioidentical Hormones
Updated on 07/15/07
This statement was developed by
the AACE Reproductive Medicine
Committee comprised of:
Rhoda H. Cobin, MD, MACE; Chair
Steven M. Petak, MD, JD, FACE,
FCLM; Board Liaison
Maya B. Bledsoe, MD, FACE
Walter P. Borg, MD
Steven A. Brody, MD, FACE
Elena A. Christofides, MD, FACE
Rebecca Fenichel, MD
Walter Futterweit, MD, FACP, FACE
Samara Beth Ginzburg, MD
Neil F. Goodman, MD, FACE
Ira Andrew Katz, MD, FACE
Alfred Wayne Meikle, MD, FACE
John Edwin Nestler, MD
Geoffrey P. Redmond, MD, FACE
Arthur G. Shapiro, MD, FACOG, FACE
Keith D. Smith, MD, FACE
Richard F. Spark, MD, FACE
M. Antonia Verso, MD, FACE
Kathleen Louise Wyne, MD, PhD,
FACE
Disclaimer:
This statement is not intended to be con-
strued or to serve as a standard of medi-
cal care. Standards of medical care are
determined on the basis of all the facts
and circumstances involved in an indi-
vidual case, and are subject to change
as scientific knowledge and technology
advance and practice patterns evolve.
This statement reflects the views of the
Reproductive Medicine Committee of
the American Association of Clinical
Endocrinologists (AACE) and review of
scientific literature as of July 2007.
INTRODUCTION
Several major medical societies have
recently published statements reflect-
ing their concern regarding so called
“Natural” or “Bioidentical Hormones”
(BH)1,2,3,4. The terms “bioidentical,”
“natural,” and “compounded” sex hor-
mones started to gain visibility in the
media a few years ago - mainly due to
the enthusiastic endorsements by some
celebrities. Despite its outwardly “scien-
tific” appearance, the term “bioidentical
hormones” is quite vague, and is used in
various contexts. Most commonly, this
term denotes plant-derived hormones
which are claimed to be “identical in
structure” to those produced by the
human body. The plant estrogens are not
detected by assays for estrone, estradiol
and estriol. Estriol has weak biological
action and a very short half life. These
preparations are compounded by phar-
macists - as pills, gels, suppositories, or
even injectable solutions1,5. The “com-
pounding process” refers to the creation
of a drug by mixing various components
by a qualified pharmacist. It is usually
done according to a physician’s prescrip-
tion said to be “customized” for every
patient. The need for compounding dra-
matically decreased after the mass phar-
maceutical manufacturing process was
developed. However, in certain com-
munities, the concept of compounding
appears to be experiencing a revival.
Moreover, in some instances, treat-
ment with compounded preparations is
initiated and directed by a compound-
ing pharmacist, with minimal (if any)
involvement of a physician.
The list of compounded hormones
includes, but is not limited to: estradiol,
estrone, estriol, progesterone, testoster-
one, and DHEA. In contrast to commer-
cially produced pharmaceuticals, com-
pounded medications are not subjected
to stringent FDA oversight. Currently
there are commercially manufactured
hormones, including estrogen and pro-
gesterone, which are, indeed, molecu-
larly identical to hormones produced
in human bodies. Those commercial
preparations are under the purview of
the FDA. In contrast to bioidentical hor-
mones, FDA-approved preparations are
reimbursed by most third party payors.
CONCERNS ABOUT
“BIOIDENTICAL HORMONES”
AACE expresses concerns about
unproven but highly publicized claims
about the alleged higher safety and effi-
cacy of compounded bioidentical hor-
mones. In addition, from a clinician’s
perspective, AACE believes that poten-
tially serious dangers of BH use have not
been sufficiently exposed. The primary
concern about bioidentical hormone
use is patient safety. These substances
have not been shown within the medi-
cal community to be clinically effective.
In addition, utilization of these formu-
lations may be associated with various
risks inherent to the compounding pro-
cess.
The exaggerated claims about efficacy
and safety of BH are made despite clear
evidences of variability in potency, high
potential for contamination and impu-
rity of those preparations. Also, some
unorthodox clinical practices utilized
by BH promoters are quite worrisome.
Those practices include individualized
dosing frequently based upon unproven
testing methods such as salivary assays,
which has not been validated. Finally,
the cost effectiveness of this modality
requires careful consideration.
Exaggerated Claims about
Efficacy and Safety
The public has been persuaded that
treatment with bioidentical hormones
has to be safer, more effective, and free
of side effects since those preparations
are “natural.” Those are the main claims
of the proponents of the “bioidentical”
approach to menopausal hormone ther-
apy. Those assertions have been made
in popular publications or disseminated
via the Internet. They have not been
properly peer-reviewed or subjected to
formal scientific scrutiny. A systematic
review of the current scientific literature
does not appear to support these notions.
Well designed studies in this area are
needed. Until evidence-based, scientific
studies are available, the existence of
meaningful differences between “bioi-
dentical” and conventional hormones
remains to be established.
Compounded drugs known as Biest and
Triest raise the following concerns. The
name Biest, or biestrogen, is commonly
used to describe a preparation consisting
of 20% estradiol and 80% estriol on a
milligram per milligram basis. Similarly,
Triest, or triestrogen, contains a ratio of
10% estradiol, 10% estrone, and 80%
estriol. Some compounding pharmacies
claim that these mixtures are designed to
mimic natural estrogenic activity occur-
ring in young females with intact ovaries.
However, the hormonal ratios found in
Biest and Triest are not based on each
agent’s estrogenic potency or individual
bioavailablity when given orally, but
simply on the milligram quantity of the
different agents added together6.
Estriol is the peripheral metabolite of
estrone and estradiol - not a secretory
product of the ovary7. Estriol is pro-
duced in significant amounts during
pregnancy by the placenta. It can be also
produced by some tumors. Therefore,
concentrations of this hormone are very
low in healthy non-pregnant females. In
non-pregnant females, the formation of
estriol is considered to be an example
of metabolic detoxification, i.e., con-
version of biologically active mate-
rial to less active form 7. Each woman
uniquely produces estriol based on indi-
vidual tissue estrogen metabolism. The
enthusiasm about the potential role of
estriol in menopausal hormonal replace-
ment therapy may be traced back to past
reports that this estrogen limited the
growth of breast tumors in the rat model
8
. However, subsequent research did not
confirm those initial observations6,9.
Estrone is minimally produced by ovar-
ian secretion. Most of it is produced
by peripheral conversion from adrenal
and ovarian androstenedione, mainly in
adipose tissue10. However, estrone, as
estrone sulfate, a commercially avail-
able product, can provide adequate hor-
monal therapy.
In summary, there is no scientific evi-
dence that specific combinations of oral
estrogens provide improved safety or
efficacy compared to FDA-approved
pharmaceutical products in the treat-
ment of menopausal females. Additional
clinical and basic research of this sub-
ject is needed.
Variable Potency
There have been instances when patients
received compounded preparations con-
taining much larger or much smaller
amounts of the active ingredient than
was indicated on the label [11]. In addi-
tion to clinical reports, limited FDA sur-
veys revealed disturbing inconsistencies
in the strength and purity of compounded
preparations [12]. Inappropriately high
levels of hormonal components in a
compounded formulation can cause
serious patient injury [11], [13]. This is
especially true for compounded inject-
able depot-testosterone preparations. On
the other hand, inappropriately low hor-
monal content in compounded formula-
tions can result in a situation in which the
patient, unbeknownst to the physician,
receives suboptimal doses of prescribed
medication. In addition, the stability of
compounded medication is not known,
as each drug is individually formulated.
Expiration dates given by compounding
pharmacists are often based upon edu-
cated guesses.
Impurity and Contamination
The possibility of cross-contamination
of compounded preparations with vari-
ous medications is a valid concern. Such
a scenario is particularly likely to occur
in smaller pharmacies, where the same
compounding equipment is used for
preparation of various types of drugs11,13,
14
. In addition, assuring the sterility of
compounded formulations may be diffi-
cult. Most compounded medications are
not clinically tested to determine their
sterility. Professional Compounding
Centers of America and similar organi-
zations have protocols advising stringent
sterilization procedures for injectable
preparations. However, it is unknown
how strictly these voluntary protocols
are followed and with what success.
There are certain compounding pharma-
cies that prepare purportedly “aseptic”
preparations without the use of the auto-
clave11.
Individualized Dosing and Salivary
Hormone Testing
Salivary hormone level testing is recom-
mended by many BH proponents as a
way of providing patients with “individ-
ualized” therapy. Such tests are available
to consumers over the Internet. Some of
the websites include elaborate question-
naires supposedly designed to establish
the type of saliva testing needed15. The
results of these tests are subsequently
used to determine the type and dosage
of compounded formulations. Only a
few types of salivary hormone testing
 Vol. 16, No. 5 • www.aace.com
methods are FDA/CLIA approved16. In
fact, the vast majority of the salivary
hormone tests results contain the dis-
claimer that those tests are not FDA/
CLIA approved and should be used only
for research purposes. Yet such tests are
still utilized to support clinical decisions
by some supporters of BH.
Endorsers of salivary assays quote their
positive empiric experience as well as
some recent research studies in support
of this methodolog17,18,19. There are many
troubling aspects of such an approach.
First, when talking about the empiric
experience, those practitioners simply
report anecdotal information such as
positive testimonies of their patients,
or their own subjective impressions.
Therefore, they base their conclusions
on non-scientific information, which
is not randomized, placebo-controlled
data and not peer reviewed20. Second,
the limited research, although interest-
ing, does not prove that salivary testing
can be used as reliable ancillary tests
for clinical purposes. AACE Protocol
for Standardized Production of Clinical
Practice Guidelines points out that the
physician must frequently act on the
basis of incomplete information21. In
order to help the physician sort through
such information, several strength-of-
evidence scales have been proposed22,23.
Unfortunately, the evidence often
quoted by Salivary Test promoters sim-
ply do not pass the muster of the level
1 or even 2 of the Level of Evidences
(LOE) as endorsed by AACE21. The
only exception here is cortisol mea-
surement24,17. In contrast to cortisol
salivary level, large intra-subject vari-
ability has been shown in salivary sex
hormone concentrations24,1. Salivary
sex hormone levels fluctuate depending
upon numerous variables such as diet,
hydration status, and circadian rhythm.
These conditions are difficult to stan-
dardize1. Finally, standard blood tests
for sex steroids are well established,
with the exception of free testosterone
measurement25. Free testosterone direct
analog methods are unreliable for free
testosterone. Dialysis methods and cal-
culation methods that have accurate
and sensitive assays for blood testos-
terone such as mass spectroscopy are
reliable26,27,28. Also, venipuncture is a
straightforward and minimally invasive
procedure. Hence, there is little need to
resort to salivary sex hormone testing
in the setting of medical practice.
Sex hormones do not belong to a phar-
macological class of drugs with clear
indications for individualized dosing.
From the perspective of clinical phar-
macology, individualized dosing is
indicated for drugs characterized by a
narrow therapeutic window. Drugs with
nonlinear pharmacokinetics (those with
renal elimination) are good examples.
Drugs that are not metabolized during
the first pass through the liver, and those
with clearly defined (in large population
pharmacokinetic studies) therapeutic and
toxic concentrations meet the require-
ments for individualized dosing as well.
In contrast, sex hormones do not meet
these criteria and dosage is evaluated by
clinical response parameters1.
Cost Effectiveness
The cost of compounded drugs is usu-
ally greater than that of traditional prep-
arations and compounded medications
are not reimbursed by insurance2. In
addition, patients pay out of pocket for
salivary hormone tests2,17. The budget of
an average American family is already
tight. Many women are being influenced
by the mixture of unsubstantiated prom-
ises and scare tactics employed by some
BH promoters. Such patients are making
choices they probably would not make
if presented with scientifically-based
information.
CONCLUSIONS
All the information presented here
should be carefully explained to patients
who request BH Therapy (BHT). Their
misconceptions about BHT should be
tactfully and thoroughly discussed.
The decision to prescribe any type of
menopausal hormone therapy should be
based upon careful clinical evaluation
of risks and benefits of such therapy in
a specific patient29. Based upon avail-
able evidence-based medicine, the saf-
est and most effective hormonal therapy
for menopausal women is to utilize
FDA-approved commercially avail-
able hormonal preparations, following
the guidelines published by the various
medical societies.
AACE, along with The Endocrine
Society, and American Society for
Reproductive Medicine, has introduced
AMA’s recent resolution urging the FDA
to increase regulation and oversight of
BH [4]. Specifically, AMA asked the
FDA to:
• conduct surveys for purity and dosage
accuracy of all compounded “bioidenti-
cal hormone” formulations;
• require mandatory reporting by drug
manufacturers, including compounding
pharmacies, of adverse events related to
the use of “bioidentical hormones”;
• create a registry of adverse events
related to the use of “bioidentical hor-
mones;” and
• require inclusion of uniform patient
information (warnings and precautions),
in packaging of compounded bioidenti-
cal hormones.
REFERENCES:
1. American College of Obstetricians
and Gynecologists, ACOG Committee
Opinion #322: Compounded
bioidentical hormones. Obstet Gynecol,
2005. 106(5 Pt 1): p. 1139-40.
2. MacLennan AH, Sturdee DW. The
‘bioidentical/bioequivalent’ hormone
scam. Climacteric, 2006. 9(1):
p.1-3.
3. The Endocrine Society, Bioidentical
Hormones. Position Statement. October
2006.
4. American Medical Association, FDA
Oversight of Bioidentical Hormone
(BH) Preparations. Resolution 706
(I06). in AMA House of Delegates
Meeting. 2006: Las Vegas, NV.
PAGE 15
5. Martin, KA, Rosen HN, and Barbieri
RL, Preparations for postmenopausal
hormone therapy, in Up to Date,
B. Rose, Editor. 2006., Up to Date:
Waltham, MA.
6. Boothby LA, Doering PL, and
Kipersztok S, Bioidentical hormone
therapy: a review. Menopause, 2004.
11(3): p. 356-67.
7. Speroff, L., Clinical Gynecologic
Endocrinology and Infertility. 7th ed.
2005: Lippincott Williams & Wilkins.
8. Lemon HM, Estriol prevention of
mammary carcinoma induced by 7,12-
dimethylbenzanthracene and procar-
bazine. Cancer Res, 1975. 35(5): p.
1341-53.
9. Weiderpass E., et al. Low-potency
oestrogen and risk of endometrial can-
cer: a case-control study. Lancet,1999.
353(9167): p. 1824-8.
10. Grodin, JM, Siiteri PK,
MacDonald PC Source of estrogen
production in postmenopausal women.
J Clin Endocrinol Metab, 1973. 36:
p. 207.
11. Hallissy E and RS Who’s Mixing
Your Drugs? Bad medicine: Pharmacy
mix-ups a recipe for misery. Some
drugstores operate with very little
oversight San Francisco Chronicle June
23, 2002
12. FDA Center for Drug Evaluation
and Research, Report: Limited FDA
Survey of Compounded Drug Products.
Available at http://www.fda.gov/cder/
pharmcomp/survey.htm., 2003.
13. Appleby J. Safety Concerns Grow
over Pharmacy Mixed Drugs. USA
TODAY, 2005.
14. Hileman B Counterfeit Drugs.
Chemical & Engineering News.
American Chemical Society., 2003. 81:
p. 36.
15. Aetna, Salivary Hormone Tests.
Clinical Policy Bulletin:, 2006.
16. Food and Drug Administration,
CLIA Electronic Database.
http://www.accessdata.fda.gov/scripts/
cdrh/cfdocs/cfCLIA/search.cfm. 2007.
17. Chatterton RT Jr et al.
Characteristics of salivary profiles of
estradiol and progesterone in premeno-
pausal
women. Journal of Endocrinology
2005. 185: p. 77 – 84.
18. Ishikawa M, et al. The clinical
usefulness of salivary progesterone
measurement for the evaluation of the
corpus luteum function. Gynecol Obstet
Invest, 2002. 53(1): p. 32-7.
19. Gann PH, et al. Saliva as a medium
for investigating intra- and interindi-
vidual differences in sex hormone
levels in premenopausal women.
Cancer Epidemiol Biomarkers Prev,
2001. 10(1): p. 59-64.
20. Ratzan SC The Plural of Anecdote
is not Evidence. Journal of Health
Communication, 2002. 7: p. 169-170.
21. AACE Ad Hoc Task Force for
Standardized Production of Clinical
Practice Guidelines, AACE Protocol
For
Standardized Production Of Clinical
Practice Guidelines. Endocr Pract.,
2004. 10(4): p. 353-61.
22. Guyatt G and GRADE Working
Group Grading quality of evidence and
strength of recommendations. BMJ,
2004. 328(7454): p. 1490-.
23. Liberati A, BR., Grilli R, Magrini
N, Minozzi S Which guidelines can we
trust? Assessing strength of
evidence behind recommendations for
clinical practice. West J Med. , 2001.
174: p. 262-265.
24. Nieman LK Measurement of corti-
sol in serum and saliva., in Up to Date,
B. Rose, Editor. 2006, Up to Date:
Waltham, MA.
25. Snyder PJ Clinical features and
diagnosis of male hypogonadism in
adults., Up to Date, B. Rose, Editor.
2006, Up to Date: Waltham, MA.
26. Steinberger, E et al. Utilization of
commercial laboratory results in man-
agement of hyperandrogenism in
women. Endocr Pract, 1998. 4(1): p.
1-10.
27. Ayala C et al., Serum testosterone
levels and reference ranges in reproduc-
tive-age women. Endocr Pract,
1999. 5(6): p. 322-9.
28. Goodman NF Hyperandrogenism:
Defining the reference ranges for “nor-
mal” androgens. Endocr Pract,
1999. 5(6).
29. AACE, American Association of
Clinical Endocrinologists Medical
Guidelines for Clinical Practice for the
Diagnosis and Treatment of
Menopause. Endocr Pract, 2006. 12(3):
p. 315-37.
J
CHAPTER 9

1 Classification of Diabetes
i
Mellitus
-. ~ ., _.
1 . I ~;'
Walter P. Borg, M.D.
Clinical Postdoctoral Fellow. Yale University School of Medicine. New
Haven. Connecticut

Robert S. Sherwin, M.D.

j C.N.H. Long Professor of Internal Medicine. Yale University School of
Medicine. Director. Diabetes Endocrinology Research Center. New
Haven. Connecticut

iabetes mellitus is not a single clinical entity, but rather a

D group of distinct syndromes characterized by relative or
absolute insulin deficiency. Regardless of its mechanism, insulin
deficiency results in the impaired homeostasis of glucose and
other metabolic abnormalities, which lead to development of late
vascular and neuropathic complications. Although hyperglycemia
is the common feature of all diabetic syndromes, its etiology and
pathogenesis vary significantly, depending on the particular syn­
drome. This diversity represents a substantial challenge for devel­
. I ~;.
opment of a comprehensive and clinically useful classification of
diabetes mellitus. Classification of diabetes is an ongoing process.
Diabetes terminology will continue to change as our understand­
ing of this disease grows. This constant revision has several impor­
tant goals. It should provide the medical community with an easy­
to-use, straightforward classification and terminology. It should
reflect current knowledge about the etiology and pathogenesis of
different diabetic syndromes. Ideally, the terminology used should
J be easily understandable, creating a common language between
patients and the medical community.
Before 1979, there was no universally accepted classification of
diabetes mellitus. Early attempts were limited by the lack of
knowledge regarding the etiology of most diabetic syndromes, and
as a result, hyperglycemic states were generally classified accord-

f Advances in Internal Medicine ®. vol. 45

(0 2000. Mosby. Inc.
279

I ~l •

,
.

 280 w.P. Borg and R.S. SheIWin

ing to the time of disease onset or the treatment used to control
hyperglycemia. This caused several misnomers and led to miscon·
ceptions about diabetes in both the medical community and the gen­
eral public. To solve these problems. an expert panel, the National
Diabetes Data Group (NDDG) was commissioned two decades ago;
after considerable debate, a more comprehensive classification sys­
1 tem was proposed. 1 The new classification was adopted by the
American piabetes Association and subsequently endorsed by the
World Health Organization (WHO).2 The most important aspect of
1 this classification scheme was the recognition that diabetes mellitus
;
is a heterogeneous group of disorders that have different etiologies
but share the common feature of hyperglycemia. This NDDG/WHO
classification divides all these hyperglycemic conditions into five
major categories: (1) insulin-dependent diabetes mellitus, (2)
.• ;i­
non-insulin-dependent diabetes mellitus. (3) gestational diabetes
mellitus (GDM), (4) malnutrition-related diabetes, and (5) other
1 types of diabetes. In addition to these clinical categories, the new
category of impaired glucose tolerance OGT) was created to include
the subgroup of patients whose plasma glucose levels during oral
glucose tolerance testing (OGTT) were below those consistent with
J overt diabetes but above those defined as normal.
The new classification, although superior to earlier, less sys­

1 tematic attempts, was far from ideal. In 1979, understanding of the

etiologies and pathogenesis of major diabetic syndromes had just
begun. Consequently, the NDDGIWHO classification represented
the consensus among various viewpoints rather than a categoriza­
tion of diabetic syndromes made from defined etiologies. It was
obvious that revisions of this classification would be necessary as
new knowledge about diabetes emerged.
The major weakness of the NDDGIWHO classification was the uSe
1 of the terms "insulin-dependent diabetes mellitus" and "non­
insulin-dependent diabetes mellitus" to denote the two most common
forms of diabetes. These terms replace the even more misleading
1 "juvenile onset" and "adult onset" diabetes. The designation "insulin­
dependent diabetes" was intended to reflect the patient's dependency
on exogenous insulin to prevent diabetic ketoacidosis and not the way
patients were treated. Indeed. many patients with "non-insulin­
dependent diabetes" do require treatment with insulin. and although
much less common, diabetic ketoacidosis can also occur in this group.
As might be expected, this equivocal-sounding term was the cause of
1 many mistakes in classification of patients with diabetes.

OVERVIEW OF THE NEW CLASSIFICATION

The problems with the NDDGIWHO classification of diabetes and
J the accumulation of new knowledge related to its etiology provid­

1 . ',­

T :­
I
 Diabetes Mellitus 281

ed the impetus for revision of the 1979 classification system. To

accomplish this goal. an international expert committee was con­
vened in 1995 under sponsorship of the American Diabetes
Association. After extensive debate, the panel published its report
on the diagnosis and classification of diabetes. 3 Several substantial
changes in the classification and diagnosis of diabetes were recom­

1
mended to reflect progress in medical knowledge and to improve
comprehensibility of the nomenclature dealing with diabetes. The
ExpE}rt Committee specifically emphasized the necessity to aban­
.do~ "Classification of diabetic syndromes based on their treatment.
1
Etiology of the disease was stressed as tha primary guideline. for
classification whenever possible. Consequently. the terms "insulin­
dependent" and "non-insulin-dependent" diabetes mellitus. as
well as their abbreviations. lOOM and NIDOM. have been eliminat­
ed. In their place the terms type 1 and type 2 diabetes should be
used. The Arabic numerals (Le.• 1 and 2) instead of the previously
used Roman numerals (Le.• I. ll) were recommended. because the
1
Roman numeral "U" was frequently interpreted by general public "'i'"
as the number 11. The new classification system does not include
the former category of "malnutrition-related diabetes" because cur­
j rent evidence does not support the view that protein deficiency can
be directly responsible for development of diabetes. 4 "Fibrocalcu­
lous pancreatopathy" B. which was formerly designated as a sub­
I
type of the malnutrition-related diabetes. is now classified as a sub­
category of "diseases of the exocrine pancreas."
Classification of the conditions in which glucose levels are
higher than normal, but lower than those consistent with the diag­
nosis of diabetes mellitus. has also changed. The Expert
Committee recommended retaining the old category of IGT. but to
introduce the term "impaired fasting glucose" (IFG) to denote an
1
analogous intermediate level of fasting glucose elevation.
The old WHO/NDOG definition of "gestational diabetes melli­
tus" has not been changed. However. the Expert Committee rec­
ommended more selective screening instead of the previously rec-.
1
ommended universal testing for glucose intolerance in pregnancy.
Finally. the report emphasized that an understanding of the ." ,i'
pathogenesis of hyperglycemia in a particular patient with dia­
1
betes is most crucial, because it allows the clinician to choose the
most effective treatment. This process is more relevant for the
patient than rigid classification attempts aimed at "the proper
i
lab~ling" of any clinical case of diabetes. a
Table 1 summarizes the newly revised classification system of
diabetes mellitus. Clinical diabetes has been divided into four
general subclasses, including (1) type 1 (characterized by
1
absolute insulin deficiency caused by f)-cell destruction); (2) type

I ' J ~I"
"i

I
 282 w.P. Borg and R.S. Sherwin

TABLE 1.

Classification of Diabetes , ~;.

Clinical Diabetes
I. Type 1 diabetes (formerly insulin-dependent diabetes or juvenile
onset diabetes)

1 A) Immune mediated
B) Idiopathic
II. Type 2 diabet~s (formerly non-insulin-dependent diabetes or adult
onset diabetes}
III. Other speCifidypes:
A) Genetic defects of ~cell function
Maturity onset diabetes of the young (MODY types 1-3)
Point mutations in mitochondrial DNA
Others
B) Genetic defects in insulin action
Type A insulin resistance
Leprechaunism
C) Diseases of the exocrine pancreas
Pancreatitis, trauma, pancreatectomy, neoplasia, cystic fibrosis,
hemochromatosis, fibrocalculous pancreatopathy .' *;­
D) Endocrinopathies
Acromegaly, Cushing's syndrome, hyperthyroidism, pheochro­
mocytoma, glucagonoina, somatostatinoma, aldosteronoma
EJ Drug induced or chemical induced
Glucocorticosteroids, thiazides, diazoxide, pentamidine, Vacor,
thyroid hormone, dilantin, ~agonists, oral contraceptives
F) Infections
Congenital rubella, cytomegalovirus
G) Uncommon forms of immune-mediated diabetes
"Stiff-man" syndrome, anti-insulin receptor antibodies
H) Other genetic syndromes
Down, Klinefelter's, Turner's syndromes; Huntington's disease,
myotonic dystrophy, lipodystrophy, ataxia-telangiectasia
IV. Gestational diabetes mellitus

Risk Categories
I I. Impaired fasting glucose
II. Impaired glucose tolerance
. ' ~;.

1 2 (characterized primarily by relative insulin deficiency in con­

junction with insulin resistance); (3) other specific types of dia­
betes (caused by various clinical conditions); and (4) GDM. In I

addition to these clinical categories, two risk categories- name­

1 , '~i·
 Diabetes Mellitus 283

I ly. IFG and IGT-have been incorporated into the classification

system.
r~ The diabetes classification process can take place only after
diagnosis has been established based on measurements of plasma
glucose levels in the fasting or postprandial state. The diagnostic
•f;·
criteria should not be arbitrary but should be set at the level of
1 glycemia that will cause adverse effects. Ideally, the diagnostic cri­
teria based on either fasting or postprandial glucose values should
reflecLthe same level of metabolic disorder, thereby minimizing
1 any.,potential discrepancies that result from differences in the
diagnostic method used.
In the light of all those considerations, the Expert Committee of
the American Diabetes Association has revised the old WHO diag­
nostic criteria for diabetes. Table 2 presents a summary of these
new criteria. According to the old WHO criteria, diabetes was pre­
sent if fasting plasma glucose was higher or equal to 140 mg/dL or
the 2-hour plasma glucose level during the OGTT was higher or
equal to 200 mg/dL. Unfortunately. these fasting and 2-hour diag­
nostic values are not equivalent. It is now known that virtually all
patients with fasting plasma glucose levels higher than or equal to
j 140 mg/dL have 2-hour OGTT values higher than or equal to 200
mg/dL. Only about 25% of those with diagnostic 2-hour OGTT
results (and without a history of diabetes) have fasting plasma glu­
1 cose higher than or equal to 140 mg/dL. Clearly, the diagnosis of
diabetes was a function of which test was chosen. The Expert
• f ~/.

Committee found that this diagnostic disparity is unacceptable

I and that the 2-hour OGTT value of 200 mg/dL was sufficient to ~
h induce diabetic complications. Consequently, diagnostic values
-<
~!<-

have been adjusted to reflect a similar degree of hyperglycemia

and risk of adverse outcomes.
There are two major advantages of the new diagnostic criteria.
First, the diagnostic methodology has been simplified, making the

TABLE 2­
Criteria for the Diagnosis of Diabetes Mellitus
One of the following should be present:
1. Typical symptoms'" of diabetes and casual plasma glucose>
200 mg/dL, or
2. 8-hr fasting glucose> 126 mg/dL. or ,
t 3. 2-lll- plasma glucose level during an OGTTT > 200 mg/dL "t .i­
·Polyuria, polydipsia. weight loss,

t
tOral glucose tolerance test with 75 g of anhydrous glucose.

Abbreviation: OGTT. oral glucose tolerance test.

r i

I
 284 w.P. Borg and R.S. Sherwin

diagnosis of diabetes more cost-effective. Second, the revised cri­

teria will increase the number of patients recognized as affected by
this disease. allowing faster therapeutic intervention. It is note­
worthy that HbAlc is not recommended as a screening method
because of its lack of sensitivity as well as the variability caused
by the lack of universal standards for the assay.
t CUNICAL DIABETES
TYPE 1 D~ETES MEWTUS
Type :~q.iabetes accQunts for about 10% of cases in the United
States. This disorder is characterized by totally absent or rudimen­
tary insulin secretory capacity. Consequently, patients with type 1
diabetes depend on exogenous insulin to prevent metabolic decom­
pensation (i.e.• ketoacidosis). The majority of patients in this group
are nonobese, previously healthy children or adolescents. It is now
known that the disease develops in as many as one third of these
patients after they reach 20 years of age. Usually the clinical onset
of the disease is rapid. This is particularly true for younger patients,
whereas in older patients this form of diabetes may begin more grad­
ually and in some cases may be confused with type 2 diabetes. A
1 typical patient is initially seen with the characteristic constellation
of symptoms. including polyuria. polydipsia, polyphagia. and
weight loss. Sometimes immediate hospitalization of a patient with
new onset of type 1 diabetes may be required because of Diabetic
ketoacidosis. This category of diabetic conditions includes two sub­
categories: immune-mediated and idiopathic diabetes.
• ' ~t"..

IMMUNE-MEDIATED DIABETES
Immune-mediated diabetes usually affects younger patients (chil­
dren and young adults), but it can occur at any age. The develop­
ment of the overt diabetic syndrome in this subcategory of type 1
diabetes is most likely preceded by a prolonged latent phase. dur­
ing which the ~cells of the pancreas are progressively destroyed
by an autoimmune process. On occasion. an episode of acute stress
(such as· infection). by producing insulin resistance. may hasten
progression from the latent to the overt clinical phase of the dis­
ease. This type of diabetes has a strong association. with genes
encoding human leukocyte antigen (HLA) DR3 and 4 and DQ2 and
B. Several other genes have been associated with type 1 diabetes,
including one in the insulin promoter region. Genetic factors alone
t cannot account for the disease; only 30% to 50% of identical twins
are concordant for type 1 diabetes. The importance of autoimmune
factors is supported by evidence for the presence of several mark­
ers of an active autoimmune process directed against pancreatic (3­
cell antigens. These markers include islet cell autoantibodies . , ~;.
 Diabetes Mellitus 285

(ICAS),5 autoantibodies to insulin (IAAs),6 autoantibodies to glu­

tamic acid decarboxylase (GAD).1 and the tyrosine
phosphatase-like molecule designated lCA 512.. 5-8 Most patients
express at least one of these autoantibodies before and at onset of
the overt diabetic syndrome. The prevalence of other conditions
associated with the autoimmune process (e.g., Graves' or
Hashimoto's disease. Addison's disease. pernicious anemia. and
vitiligo) is higher among patients with this type of diabetes.
The/presence of islet-directed autoimmunity and overt hyper­
glycemia does not necessarily imply that the total destruction of
thEtpancreatic ~-cells has already occurred. Some patients (espe­ .' ~'.
cially adults) retain enough ~-cells to prevent development of
ketoacidosis. However, as the disease progresses, this residual
insulin secretion is usually lost, as reflected by the absence of cir­
culating levels of C-peptide.
In certain patients, initiation of insulin therapy may be accom­
panied by a transient improvement in ~-cell function. During this
1 "honeymoon period," lesser amounts of exogenous insulin, as
compared with the initial period of the disease, are sufficient to
maintain normoglycemia. The honeymoon period may last a few
I months or even years, but ultimately ~-cell function will be lost.
Although in recent years our knowledge of the etiology of type
1 diabetes has expanded substantially, there are still many unan­
swered questions, particularly with respect to the factors involved
in the initiation and progression of the pathologic process.
Nevertheless. it is likely that the disease results from the interplay
of genetic. environmental. and autoimmune factors.

IDIOPATHIC DIABETES
. , ~;.,
A small segment of patients with a clinical picture consistent with
type 1 diabetes belongs to the idiopathic category.9 They are
patients who. despite being prone to ketoacidosis because of the
absolute lack of insulin. show no evidence of I>-cell autoimmuni­
ty. The majority of those patients are of African or Asian descent.
In contrast to "immune-related diabetes," idiopathic diabetes is
not HLA associated. and the insulin deficiency tends to vary peri­
odically in those patients. tO Certainly this clinical subcategory
labeled "idiopathic" is a clear deviation from the etiology-based
classification system. Hopefully. future research will help clarify
the true etiology of this rare subtype of diabetes, allowing for its
proper. reclassification.

lYPE 2 DIABETES MEWTUS

Type 2 diabetes, the most common form of all diabetic syndromes,
I affects about 90% of the diabetic population. It is frequently asso-

286 w.P. Borg and R.S. Sherwin

1 dated with obesity; it usually, but not invariably. occurs later in

r-- life; and it has a high rate of genetic penetrance, which is unrelat­
1­ ed to HLA genes. In contrast to type 1 diabetes. concordance rates
in identical twins are nearly 100%. Overall. the genetics of this
form of diabetes are complicated and poorly understood thus far.
The disease is more prevalent and may appear at an earlier age in
I
specific minority groups in the United States, such as Native
Americans, Mexican-Americans. Latinos, and African-Americans.
It'is aEpearing with higher frequency among Asians and Pacific

1
Is1an.ders who adopt the diet and lifestyle of Western countries.
'In' contrast to type 1, type 2 diabetes is characterized by relative
insulin deficiency in association with insulin resistance. l l The
pathogenesis of hyperglycemia in type 2 diabetes is complex. and
1
the sequence of pathologic processes leading to development of
this disease is still controversial. Hyperglycemia itself impairs i'
,I

insulin secretion and action (so-called glucose toxicity), and by the

time overt hyperglycemic syndrome appears, practically every
J
patient has both insulin resistance and inappropriately low
insulin secretion. Because these two key abnormalities are interre­
lated, the question of which is the primary event that leads to type
)
2 diabetes cannot be answered easily. To address this issue, sever­
al studies have been performed in populations characterized by
high prevalence rates of diabetes, such as the Pima Indians. These
I
studies support the view that insulin resistance is the initial
defect. A similar picture is seen in healthy relatives of type 2 dia­
betic patients (including prediabetic offspring of diabetic parents).

r-­ In keeping with these data, hyperinsulinemia is seen in prediabet­

ic subjects for up to two decades before the onset of overt diabetes.
However, insulin resistance per se is not sufficient to produce the
clinical picture of diabetes in these subjects.
;,t,.)

) The presence of an insulin secretory defect is crucial as well.

The mechanisms for this secretory defect are unclear. They could
include I3-cell exhaustion. I3-cell dysfunction caused by hyper­ ,,;;.
J
glycemia or fatty acid elevation. excessive secretion and precipita­
tion of amy lin within the islet. or a minor genetic defect in IJ-cell
signal transduction that can be tolerated by the healthy organism
but can become a problem with prolonged overstimulation of ~­
J
cells. It is likely that in some patients the sequence is reversed,
that is, the insulin secretory defect is the initial event and insulin
resistance develops as a secondary phenomenon. Regardless of the
I
sequence of events, more than one pathogenic mechanism is
responsible for the syndrome of type 2 diabetes.
Typically, the onset of type 2 diabetes is much more insidious

I
than that seen in type 1 diabetes. Commonly. nonspecific com­
plaints, such as general fatigue, weakness, dizziness. and blurred

J
-I

-~.--~ .. ~-~, .. ~­ .
 Diabetes MelJitus 287 , .j_

vision dominate the clinical picture. The classic symptoms of dia­

betes may be mild. or even absent. For these reasons. the diagno­

sis of type 2 of diabetes is usually delayed for many years.

Unfortunately. such undiagnosed and untreated patients are still at

increased risk for macrovascular and microvascular compIica­

tions. 12 For this reason, early detection and treatment of type 2 of

1
diabetes is of paramount importance.

OTHER SPECIFIC
.- TYPES OF DIABETES
Xhelarge class of other specific types of diabetes includes various
diabetic syndromes that could be attributed to a specific disease.
drug. or condition. Despite the substantial number of subtypes
included in this class. these conditions affect only a small portion
of the diabetic population. The Expert Committee suggested divid­
ing this broad category into eight subcategories, discussed below.

GENETIC DEFECTS OF CEll FUNCTION

Maturity Onset Diabetes of the Young
The term "maturity onset diabetes of the young" (MODY) has been
used to describe a peculiar familial form of diabetes characterized
by autosomal dominant inheritance and the onset of mild hyper­
glycemia at an early age. typically before age 25. Initially. MODY
was thought to be a specific variation of type 2 diabetes. This view
1 is not supported by data showing that the development of diabetes
in these patients is associated with defective insulin secretion.

with only slight or even absent abnormalities in insulin action. 13

Subsequently. the results of genetic studies have revolutionized

our concept of this unique form of diabetes. MODY is a heteroge­

neous disorder linked to several distinct genetic defects that lead

to impaired ~-cell function. Currently, five genetic mutations

located on different chromosomes have been identified in MODY

families. 14 The most prevalent genetic variant in the United States,

known as "MODY type 3," is caused by a mutation of the gene on

chromosome 12 encoding hepatic transcription factor HNF-la.

(hepatocyte nuclear factor la.}.12.13.15.16 The identification of HNF­

10. as a cause of MODY was unexpected, and its role in the .' ,i'
impairment of ~-cell function remains to be established. Type 2
MODY is linked to mutations of the glucokinase gene located on
chromosome 7p. which encodes the enzyme that catalyzes the first
step in glucose metabolism within the pancreatic p-cell (and
liver)y,18 In healthy individuals, glucokinase is believed to act as
a "glucosensor" for the pancreatic I)-cells. Production of a defec­
tive glucokinase alters the capacity of the /3-cell to sense and, in
turn. respond to elevations in circulating glucose concentration;
hence. the development of diabetes. Another form of MODY that

-' ~'.
 288 w.P. Borg and R.S. Sherwin

1 has been characterized, known as "type 1," is caused by a muta­

tion in the HNF-4ex gene on chromosome 20q.19.20 This transcrip­
tion factor is involved in the regulation of the expression ofHNF­
lex and presumably is linked to diabetes by this mechanism.
Recently. two new forms of MODY have been described.14
MODY 4 is caused by the dysfunction gene encoding insulin pro­
1
moter factor-l (IFF1, also known as PDX-l: pancreatic and duode­
nu~ 'ho:g:tebox), which is located on chromosome 13q. Type 5 of
MODY is linked to a mutation of HNF-l~ gene on chromosome
17cen~q."Finally, the existence of additional forms of MODY is
1
likely. because there are patients who have a similar clinical syn­
drome. but the genetic basis of their metabolic dysfunction is still
uncertain. 14
1
Point Mutations in Mitochondrial DNA
A rare syndrome characterized by the coexistence of diabetes mel­
litus with deafness has been attributed to point mutations in mito­
J chondrial DNA.21 Several families with this syndrome have been
identified. In the vast majority of cases, the mutation resulted in

I
the substitution of guanine for adenine (A-to-G transition) at posi­
tion 3243 in the tRNA leucine gene. Interestingly, although an
indistinguishable lesion is present in patients with mitochondrial
myopathy, encephalopathy, lactic acidosis, and strokelike
I
(MELAS) syndrome, these kindreds are not affected by diabetes.
Although the reason for this puzzling discrepancy is unclear. this
paradox may be caused by different phenotypic expressions of the
same genetic abnormality. 22
Numerous other genetic abnormalities, which are even less
common than MODY or mitochondrial mutations. associated with
~-cell dysfunction leading to diabetes. have been reported. Among
them, genetic defects causing the inability to convert pro insulin to
insulin and production of defective "mutant" insulin molecules
are noteworthy.2J.24
1
j
GENETIC DEFECTS IN INSUUN ACTION
Genetic abnormalities may cause disturbances of glucose home­
ostasis by affecting the function of the pancreatic ~-cells and by
interfering with the action of insulin. These genetic defects may
interfere with insulin receptors, as well as postreceptor signal
transduction pathways.
i
Mutations of the genes encoding insulin receptors are associat­
ed with a broad spectrum of metabolic problems, ranging from
mild asymptomatic hyperglycemia to ~vert diabetes. 25 It has been
t
established that the syndrome known' as "type A insulin resis­
tance," characterized by the coexistence of virilization acanthosis

1
t .'.;­
 Diabetes Mellitus 289

nigricans and the presence of ovarian cysts in hyperinsulinemic

females. is caused by mutation of the insulin receptor. Insulin
receptor genetic mutations also are responsible for two well­
described pediatric syndromes: leprechaunism and the Rabson- .
Mendenhall syndrome. . . ~.
Abnormalities in postreceptor signal transduction pathways

1
may produce reactions similar to those seen with the dysfunction
of insulin receptor. This is the case in insulin-resistant lip oat­
rophlc diabetes. in which a postreceptor defect is inferred. given
that the function and structure of the insulin receptor appears to
1,

1 be normal in these patients. 26

DISEASE Of THE EXOCRINE PANCREAS

The massive destruction of pancreatic tissue by any pathologic
process will result in diabetes caused by the decreased produc­
tion of insulin. The most common examples of such processes
include pancreatitis. pancreatectomy. trauma, infections. pancre­
1
atic carcinoma. hemochromatosis. and advanced cystic fibro­
sis. 24 ,27 Even very small pancreatic adenocarcinomas may be
accompanied by the appearance of diabetes. The mechanism
1
responsible for this exemption to the rule is uncertain. As men­
tioned above. fibroca1culous pancreatopathy is included in this
category of diabetes.

ENDOCRINOPATHIES ASSOCIATED WITH HYPERGLYCEMIA

Any condition associated with the excess of hormones, which are
insulin antagonists, can result in frank diabetes or can unmask
I
preexisting latent diabetes. Classic examples of such
endocrinopathies include Cushing's syndrome, glucagonoma
acromegaly. and pheochromocytoma. 28 Less commonly,' rare
1
endocrine tumors such as somatostatinoma and aldosteronoma
can cause diabetes. most likely by interfering with insulin secre­
tion. 28 In all of the above conditions, hyperglycemia usually

I
resolves after successful treatment of the primary endocrinopathy.

DRUG- OR CHEMICAL-INDUCED HYPERGLYCEMIA

Numerous drugs can have a negative impact on carbohydrate
I
metabolism. These drugs can exert diabetogenic effects on insulin
secretion or interfere with the action of insulin. A detailed discus­
sion of this topic is beyond the scope of this review and has been
) presented elsewhere. 29 The most common culprits include gluco­
corticoids. thiazides. nicotinic acid. beta agonists or blockers, .' ;,..
dilantin, and pentamidine. In addition to drugs, many substances

I used in industry and toxins, such as the rat pOison, Vacor. can
induce diabetes in humans.

I
1
I
I
290 WP. Borg and R.S. Sherwin

INFEcrtONS
A number of viral infections have been linked with the destruction
of ~-cells and development of diabetic syndromes. These would
include rubella, coxsaclcievirus B, cytomegalovirus, adenovirus,
and mumps infections. 3o

UNCOMMON FORMS OF IMMUNE-MEDIATED DIABETES

Anti-insulin Receptor Antibodies
Two type~ of antibodies that act as anti-insulin receptors have
been .d.escribed: blocking and stimulating. Anti-insulin receptor­
blocking antibodies· cause diabetes by binding to the insulin
receptor, thereby interfering with the proper insulin-receptor
interaction. 25 In contrast, anti-insulin receptor-stimulating anti­
bodies may intermittently mimic the action of insulin and cause
h ypogl ycemia.

The Stiff-Man Syndrome

The stiff-man syndrome is a rare autoimmune disorder that
mainly affects the central nervous system. The syndrome is char­
acterized by high titers of the GAD autoantibodies and clinical
features characterized by the stiffness of the axial muscles and
painful spasms. Diabetes will develop in about 30% of patients
with this condition, and the majority express islet cell autoanti­
bodies. 31

OTHER GENETIC SYNDROMES ASSOCIATED WITH DIABETES

Several well-known genetic syndromes are characterized by an . I 0:;"
increased incidence of diabetes mellitus. 32 The most common
include Down, Turner's, Klinefelter'S, and Wolfram syndromes.

GESTATIONALDIA8ETES
The term "gestational diabetes" is used to describe any degree of
impaired glucose tolerance that appears or is diagnosed during preg­
nancy. According to this definition, women who were diagnosed
with diabetes before conception should be considered to have "dia­
betes in pregnancy" and not GDM. Onset of GDM typically occurs in
the second and third trimesters of pregnancy, at which time there
are significant elevations of pregnancy-associated insulin antagonis­
tic hormones. Usually, but not always, this gestation-associated glu­
cose intolerance disappears after delivery. However, it is well
known that all patients with GDM are at increased risk for having
type 2 diabetes develop later in life. Diabetes will develop in about
30% to 40% of such patients within 5 to 10 years.
Much less frequently, pregnancy can also precipitate the onset
of type 1 diabetes. At least 6 weeks after the end of pregnancy, .,~I"

·1
 Diabetes Mellitus 291

patients in whom diabetes has developed during pregnancy

should be reclassified into one of the following categories: (1) nor­
moglycemia. (2) IFG, (3) IGT, (4) diabetes.
In the United States GDM complicates about 2% to 4% of all
pregnancies. 3o Depending on the population studied. prevalence
rates vary from 1% up to 14%-with the lower rate for white and
1
I
the higher for Asian and African populations. 33 GDM is the most
colDfIlon form of abnormal glucose homeostasis in pregnancy,
acconnting for about 90% of all cases of diabetic disorders that
occur during pregnancy.33
The clinical picture of GDM is frequently characterized by only
asymptomatic hyperglycemia. but this outwardly mild course is
still associated with serious fetal morbidity and mortality.34 These
perinatal problems can be substantially reduced by early institu­
tion of appropriate treatment, such as diet or insulin therapy if .' ;;.
necessary. Therefore, the screening, early diagnosis. and intensive
management of diabetes in pregnancy should be considered
important elements of comprehensive prenatal care.
The Expert Committee of the American Diabetes Association
has modified previous recommendations regarding screening for­
GDM. Previously, screening was recommended for every pregnant
patient. This approach is .not cost-effective and has been aban..;
doned. Specific factors place women at lower risk for the develop­
ment of GMD. This low-risk group includes women who:
• Are younger than age 25 and of normal body weight
• Have no family history (i.e., first-degree relative) of diabetes
• Are not members of an ethniclracial group with a high preva­
lence of diabetes (e.g., Hispanic, Native American, Asian,
African American)
According to the new recommendations, this low-risk group of
pregnant patients may not be'screened for GDM.

RISK CATEGORIES
IMPAJRED GLUCOSE TOLERANCE AND IMPAJRED FASTING GLUCOSE
The terms "impaired glucose tolerance" and "impaired fasting glu­
cose" are used to denote abnormal metabolic states in which plas­
ma glucose levels (during oral glucose tolerance tests and fasting
values, respectively) are higher than in normal individuals, but
lower than those consistent with diagnosis of diabetes mellitus.
These patients do not have diabetes, yet they should not be con­
sidered as "normoglycemic." These intermediate disturbances of
glucose homeostasis are not associated with the symptoms or with
the microvascular and neuropathic complications typical for dia­
betes mellitus. However, such patients have a twofold higher rate of

'.

 292 IN.?. Borg and R.S. Sherwin

] macrovascular complications. particularly cardiovascular disease.

1 ~;..

Moreover. both IGT and IFG significantly increase the risk of devel­
f~" oping diabetes mellitus. Indeed. in some instances, IFGIIGT reflects
the "preclinical stage" of a slowly developing diabetic condition.
It is noteworthy that any kind of severe illness or physical stress
may induce a transient impairment of glucose homeostasis. which
in some cases may induce a state consistent with the diagnosis of
diabetes. Although in some patients serious illness may uncover a
, •.J.

latent'diabetic state. this stress-related metabolic disequilibrium

frequently resolves spontaneously after the patient's recovery. For
this reason. any rush to judgment about the presence of the true
diabetic state in such patients should be avoided.
SYNDROME X
Although not a part of the classification of diabetes. the term "syn­
drome X" (also known as the "metabolic syndrome") has been
used to denote the frequent coexistence of hyperinsulinemia. mild
glucose intolerance. lipid abnormalities. and elevated blood pres­ ~ I ria
sure. 35 As a result, syndrome X has been associated with acceler­
1i ated atherosclerosis. The proposed underlying abnormality in syn­
1 drome X is insulin resistance, which may occur in outwardly
healthy individuals. particularly in industrialized western coun­
tries. Frank diabetes does not develop in these individuals.
because insulin resistance is compensated by increased insulin
secretion. Chronic hyperinsulinemia, however. may have adverse
effects on arterial smooth muscle proliferation. sympathetic ner­
vous system activity. renal sodium reabsorption. and triglycerides ~::
!
synthesis. which could promote atherosclerotic disease. ~,

Another nondiabetic syndrome in which hyperinsulinemia

plays an important role is polycystic ovary syndrome.36•37 In this
syndrome. insulin excess stimulates ovarian androgen secretion,
producing a whole spectrum of abnormalities ranging from infer­
I tility to hirsutism. Therapy to reduce insulin resistance reverses
! abnormalities associated with androgen excess. Whether reversal
1 of insulin resistance has 8 similar beneficial effect on the develop­
ment of atherosclerosis in type 2 diabetes or syndrome X remains t ~;.

to be determined. 38

CONCLUSIONS
Differentiation among the various types of diabetes mellitus can be
performed easily on clinical grounds. However. at times a specific
clinical case of diabetes may be encountered that does not fit into
any classification paradigm. In such cases, the physician's attention
I should be directed at understanding the specific pathologic process
to optimize treatment. Fitting the patients into the right classifica­

I
 Diabetes Mellitus 293

tion scheme should be less important. The current classification of

diabetes is not by any means the final one. It will continue to
improve along with expansion of our knowledge about the specific
molecular causes of this heterogeneous illness. This effort will ulti­
mately lead to improvements in the care of diabetic patients.

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i 2. Wor!d'>Health Organization: Diabetes Mellitus: Report of a WHO

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1 fication of diabetes mellitus. Diabetes Care 21:85-S19, 1998.
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1 5. Baekkeskov S. Neilsen JH. Marner B. et al: Autoantibodies in newly

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1 10. Banerji M. Lebovitz H: Insulin sensitive and insulin resistant variants

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11. Thrner RC. Holman RR. Matthews D. et al: Insulin defiCiency and
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) contribution by feedback analysis from basal plasma insulin and glu­

cose concentrations. Metabolism 28:1086-1096,1979.

12. Moss SE. Klein R. Klein BEK. et al: The association of glycemia and

I cause specific mortality in a diabetic population. Arch Intern Med

154:2473-2479,1984.
13. Herman WH, Fajuns SS. Oritz Fl. at 1;11: Abnormal insulin secretion.
not insulin resistance, is the genetic or primary defect of MODY in the

I RW p~digree. Diabetes 43:40-46,1994.

14. Chevre JC, Hani EH, Boutin P, et al: Mutation screening in 18
Caucasian families suggests the existence of other MODY genes.
Diabetologia 41:1017-1023, 1998.
I 15. Vaxillaire M, Boccio V, Philippi A. et al: A gene for maturity onset

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diabetes of the young (MODY) maps to chromosome 12q. Nature

Genet 9:418-423. 1995.
16. Yamagata K. ada N. Kaisaki PI. et al: Mutations in the hepatocyte
nuclear factor-1 alpha gene in maturity-onset diabetes of the young
(MODY 3). Nature 384:455-458. 1996.
17. Froguel P. Vaxillaire M. Sun F. et a1: Close linkage of glucokinase
locus on chromosome 7p to early-onset non-insulin-dependent dia­
1 betes mellitus. Nature 356:162-164. 1992.
18. Vicmnet N. Stoffel M.Takeda J. et al: Nonsense mutation in the gIu­
cokinas~... gene causes early-onset non-insulin-dependent diabetes
meJ.Htus.Nature 356:721-722. 1992.
1 19. BellCt, Xiang K. Newman MV. et a1: Gene for non-insulin-dependent
diabetes mellitus (maturity-onset diabetes of the young subtype) is
linked to DNA polymorphism on human chromosome 20q. Proc Natl
Acad Sci USA 88:1484-1488, 1991. .
20. Yamagata K. Furuta H. ada N. et al: Mutations in the hepatocyte fac­
tor-4 alpha gene in maturity-onset diabetes of the young (MODY 1).
Nature 384:458-460,1996.
) 21. Kadowaki T. Kadowaki H, Mori y, et al: A subtype of diabetes melli­
tus associated with a mutation of mitochondrial DNA. N EngJ J Med
330;962-968,1994.

I 22. Vionnet N. Stoffel M, Takeda 1. et al: Nonsense mutation in the glu­

cokinase gene causes early-onset non-insulin-dependent diabetes
mellitus. Nature 356:721-722, 1992.
23. Gruppuso PA. Gorden P. Kahn CR. et al: Familial hyperproinsuline­

1 mia due to a proposed defect in conversion of proinsulin to insulin.

N Engl JMed 311:629-634, 1984.
24. Haneda M, Chan S1. Kwok SCM. et al: Studies on mutant human
insulin genes: Identification and sequence analysis of a gene encoding
[Ser sup B24] insulin. Proc NatJ Acad Sci USA 80:6366-6370. 1983.
25. Taylor SI: Lilly lecture: Molecular mechanisms of insulin resistance:
Lessons from patients with mutations in the insulin-receptor gene.
Diabetes 41:1473-1490,1992.
26. Hubler A. Abendroth K. Keiner T. et al: Dysregulation of insulin-like
growth factors in a case of generalized acquired lipoatrophic diabetes
mellitus (Lawrence syndrome) connected with autoantibodies against
adipocyte membranes. Exp Clin EndocrinoJ Diabetes 106:79-84, 1998.
27. Handwerger S, Roth J. Gorden P. et al: Glucose intolerance in cystic
fibrosis. N EngJ J Med 281:451-461. 1969.
28. Berelowitz M. Eugene HG: Non-insulin-dependent diabetes mellitus
1 secondary to other endocrine disorders. in LeRoith D. Taylor SIt
Olefsky 1M (eds): Diabetes Mellitus. New York. Lippincott-Raven.
1996. pp 496-502.
29. Pandit MK, Burke J. Gustafson AB. et al: Drug-induced disorders of
t glucose.tolerance. Ann Intern Med 118:529-540. 1993.
30. Karjalainen J. Knip M, Hyoty H. et al: Relationship between serum
insulin antibodies, islet cell antibodies and Coxsackie-B4 and mumps

1 virus-specific antibodies at the clinical manifestation of type I

(insulin dependent) diabetes. Diabetologia 31:146-152, 1988.

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J 31. Solimena M. Folli F. Aparisi R. et a1: Autoantibodies to GABA-nergic

neurons and pancreatic beta cells in stiff-man syndrome. N Eng} J

r-­ Med 41:347-353.1992.

32. Rimoin DL: Genetic syndromes associated with glucose intolerance.
in Creutzfeldt w. Kobberling J. Neel J (eds):The Genetics of Diabetes
Mellitus. Berlin. Springer-Verlag. 1976.
33. Engelgau MM. Herman WH. Smith PJ. et al: The epidemiology of dia­
betes and pregnancy in the U.S.• 1988. Diabetes Care 18:1029-1033.
).995.
34: Lan~er O. Rodriq"uez DA. Xenakis EMJ. et al: Intensified versus coo­
ventional management of gestational diabetes. Am J Obstet Gynecoi
1 '"170;1036-1047; 1994.
35. Baillie GM. Sherer JT. Weart CW: Insulin and coronary artery disease:
Is syndrome X the unifying hypothesis? Ann Pharmacother

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l
32(2):233-247, 1998.

.1 36. Ciaraldi TP. El-Roeiy A. Madar Z. et al: Cellular mechanisms of

insulin resistance in polycystic ovarian syndrome. I Clin Endocrino!

Metab 75:577-583.1992.
37. (New) Dunaif A, Segal KR. Shelley DR. et al: Evidence for distinctive
and intrinsic defects in insulin action in polycystic ovary syndrome.
Diabetes 41:1257-1266, 1992.
38. Ehrmann DA. Schneider DJ. Sobel BJ. et al: Trogiitazone improves
j defects in insulin action. insulin secretion, ovarian sterOidogenesis.
and fibrinolysis in women with polycystic ovary syndrome. I Clin
Endocrinol Metab 82: 2108-2116. 1997.

. • ri~

--
I

 In Brief
] The stepped hypoglycemic clamp technique has provided a powerful tool to
examine factors that influence how individuals recognize and respond to hypo­
glycemia. The method has bee.n use~ to define the defects i~ coumerreg~latory
hormone response induced by intenSive treatment of type I dIabetes. The Impor­
tance of the brain in coordinating such counterregulatof)i responses and the
impact of intensive treatmem on brain metabolism and function art:: discussed.

I
ifhe Brain and Hypogfycemic Counterregu,lation:
insights From Hypoglycemic Clamp Studies

The results of the Diabetes Comrol and
Complication Trial (DCCT) put to rest
the longstanding debate over whether
l\yaltt::r P. Borg, MD, Monica A. Borg. intensive insulin therapy :' ..tn delay the
1\10, and William V. Tamborlane, MD development of late microvascular and
~
neuropathic complications of diabetes.!
! The benefits of intensive insulin thera­
py aimed at near-normalization of glu­
cose le\'els in type I dia beres have been
esta blished, and, as a result, this thera­
peutic approach has been recommend­
ed as the treatment of choice for most
patients with type I diabetes. l Unfor­
tunately, the frequency and severity of
hypoglycemia is markedly increased by
intensive treatment regimens, in spire
of close medical supervision. The
DCCT reported a threefold higher inci­
dence of severe hypoglycemia and
coma in those patients assigned to
intensified therapy as compared to con­
ventionally-treated controls. U
In the past, iatrogenic hypoglycemia
in patients with diabetes was attributed
to the so-called "conventional risk fac­
rors," such as excessive or inappropri­
ately timed insulin doses, skipped meals
or snacks, and excessive exercise.
However, analysis of the epidemiology
of hypoglycemic episode", has demon­
strated that these conventional risk fac­
tors are responsible for only a minority
of cases. l It is now appreciated that dia­
betes mellitus is a disease characterized
not only by absolute or relative insulin
deficiency, but also by the impairment
of hormonal responses that counteract
insulin-induced hypoglycemia. This dis­
covery has renewed interest in the phys­
iology of counterregulation in general
and in rhe role of central nervous sys­
tem (eNS) glucose sensors in particular.
It has been hoped that in-depth charac­
terization of the effects of diabetes and
its treatment on counterregulatory
mechanisms will eventually lead to
f
strategies or interventions that would
eliminate this major obswde to the ben­
efits of imensive insulin therapy.
Defective Glucose Counterregulation
in Type I Diabetes
In subjects without diabetes, the earli­
est and most important response ro a
fall in blood glucose level is the sup­
pression of endogenous insulin secre­
tion. In individuals with diabetes who
are treated with exogenous insulin,
there is no feedback suppression of
plasma insulin levels, and in the pres­
ence of insulin autoantibodies, the
hypoglycemic effect of insulin maf-'be
prolonged and may impair reco~'err
from hypoglycemia: In rhose without
dia betes, if suppression of insu'lin secn~­
tion is insufficient to stabilize glucose
levels, glucagon and epin~phrjnt art:
the key counterreguluwry hormol1t:S
that counteract the fall in blood glu­
cose. s However, JUSt as diabetes
destroys the ability of the pancreatic G­
cell to secrete insulin in response to
hyperglycemia, the ability of the a-cell
to seCrete glucagon in response to
hypoglycemia is lost in many patient;;
with established type I diabetes.' By
contrast, glucagon responses to other
secretagogues, such as amino acids, are
unaffected or even increased in patients
with diabetes.
In the absence of a glucagon re­
sponse, epinephrine becomes the most
important hormone for promoting glu­
cose recovery. Activation of the auto­
nomic nervous system, including s:imu­
lation of epinephrine secretion, serves
.to alert patients to falling blood glu­
cose levels by inducing the classical
warning symptoms and signs: pound· .
ing heart, tremors, hunger, and swear­
ing. In individuals without diaberes,
epinephrine responses alone a.re suffi­
cient to promote recovery from hypo­
glycemia, even when glucagon seere­
 tlon is blocked by agents such as
] somatostatin. Unfortunately, diabetes
also adversely affects this line of
fense against hypoglycemia. Al­
1 though deficient epinephrine responses
are commonly observed in long-stand­
Ing diabetes, this impairme~t is not
simply a consequence of aging. T~e
1 epinephrine response to hypoglyc~mla
is similar in healthy elderly subjects
and in young adults without diaoete.~.7
It has long been recognized that the
degree of diabetes control srtdngly
influences how patients recognize and
respond ro reductions in pl3sma glu­
cose levels. Indeed, in his Nobel Lecture
delivered in Stockholm on September
IS, 1925, Frederick G. Banting noted
that:
I "The onset of hypoglycemic symp­
toms depends not only on the extent,
but also on the rapidity, of fall in blood
sugar. The level at which symptoms
1 occur is slightly higher in the diabetic
with marked hyperglycemia than in a
patient whose blood sugar is normal.
When the blood sugar is suddenly
reduced from a high level, premonitory
sympcoms may occur with a blood
sugar between the normal levels of
1 hormone responses to hrpoglycemia in
0.100% and 0.080%, while the more
I marked symptoms of prostration, per­
spiration, and incoordination develop
between 0.080% and 0.042 %. As a
p:J.tient becomes accustomed to a nor­
mal blood sugar, the threshold of these
reactions becomes lower. One patient
who formerly had premonitory symp­
toms of hypoglycemia at 0.096% now
has no reaction at 0.076%, but symp­
toms commence between this level and
I 0.062%."
With the advent of the insulin pump
and multiple injection therapy in the
late 1970s and early '80s, it became
J apparent that even lower plasma glu­
cose levels were required to induce
hypoglycemic symptoms in well-con­
I trolled, intensively-treated patients with
type I diabetes, suggesting that the
threshold for release of epinephrine had
been lowered to subnormal values.
I Hypoglycemic Clamp Technique
One of the major obstacles in studying
counterregulatory hormone responses
to hypoglycemia was the lack of meth­
ods that would allow investigators to
produce a controlled and reproducible
hypoglycemic stimulus in vivo. Inter­
J pretation of the studies in which hypo­
glycemia was induced by large bolus
injections or continuous infusions of
I insulin was difficult because of the
variations in the rate and the magni­
34 I
tude of the glucose decline between
subjects and in the same subjects stud­
ied under different conditions. To over­
come these obstacles, the glucose clamp
was modified to provide a standardized
hypoglycemic stimulus in which the
rate and magnitude of glucose fall were
under the control of the investigator.
With this technique, subjects are stud­
ied in the fasting state, and separate
Intravenous catheters are inserred for
infusion of exogenous glucose and
insulin and for obtaining sequential
blood samples. Generally, a fixed rate
of insulin is administered in a dose suf­
ficient ro obtain the desired degree of
hypoglycemia, anG' exogenous glucose
is infused at a variable rate to control
the rate and degree of fall of plasma
glucose. The rate of glucose infusion is
adjusted every 5 minutes based on plas­
ma glucose measurements made at the
bedside, and the plasma glucose level is
allowed to fall in one or more steps
over several minutes or several hours.
The hypoglycemic clamp technique
was initially used in our laboratory to
test the hypothesis, proposed by
Banting above, that the rate of glucose
decline influences counter regulatory
normal subjects and conventionally
treated subjects with diabetes." In one
gtoup of experiments, plasma glucose
was reduced gradually from approxi­
mately 90 to 50 mg/dl (4.4 to 2.8 mM)
in 10 mg/dl (0.5 mM) steps over 2
hours. In the other experiment, eug­
lycemia was maintained for 2 hours
and then plasma glucose was acutely
lowered in one step from 90 to 50
mgldl over 10-15 .~inutes. Despite the
marked differences m the rate at which
plasma glucose declined, no significant
differences were detected in the magni­
tude of the elevations of any of the
counterregularory hormones in either
healthy volunteers or conventionally­
treated subjects with diabetes.'
However, the plasma gl ucose level that
triggered the release of epinephrine
(determined from the study when plas­
ma glucose was reduced slowly) varied
widely between subjects (range: 48-74
mgldl, or 3.0-4.1 mM). These observa­
tions suggested that individual varia­
tions in the glucose thresholds for epi­
nephrine release might contribute to
differences in the plasma glucose levels
associated with hypoglycemic symp­
roms, as Banting had also indicated.
In two subsequenr separate studies,
single-step and multiple-step hypo­
glycemic clamps were used to examine
prospectively the effects of strict
glrcemic control on epinephrine
responses to hypoglycemia.>·'o In these
studies, the magnitude of the epineph­
rine response to identical reductions in
plasma glucose was reduced by
.
50-60% in the patients with type I dia­
betes after achieving near-normal gly­
i
cosylated hemoglobin values with con­
tinuous subcutaneous insulin infusion,
reaching levels th:lt were significantly
below those in healrh\' conrrols
Epinephrine release was i~paired afte~
intensive therapy irrespective of
whether glucose was lowered rapidly in
one step from 90 to 50 mgldl' or grad­
ually in several steps over 4 hours.'o
Indeed, in the latcer study, imp3ired
epinephrine release was shown to be
due to a downward shift in the glucose
level, which triggered the release of epi­
nephrine. lo Dda \'ed release of other
counterregularory hormones (cortisol,
growth hormone, and norepinephrine)
was a 150 observed with intensive
insulin treatment, and defective glu­
cagon responses were not restored. As
might be expected from these results, a
greater hypoglycemic stimulus was
required to elicit signs and srmprvms !
•
of hypoglycemia when parient$ wae I
j
stricr! y controlled. t·;
Because defects in epipephrine
I
i!
release developed after .onlr 2-6 i
I
months of intensi\'e therapy in healthy
young patients with diabetes who did
not have clinical autonomic neuropa­
thy, it was likely that the impairment
was due to acclimatization to lower
ambient glucose concentrations during
intensive management rather than being
I
caused by some ocher confounding vari­
able_ A similar defect in counterreguIa­
tory hormone release was subsequently
observed in chronically h::poglrcemic
insulinoma patients and in women with
diabetes who were aggressively treated
during pregnane;, .".11
Further clamp studies have demon­
strated that a number of other factors
besides the degree of metabolic control
of diabetes influence the glucose
threshold for counrerregulatory hor­
mone responses (Table 1).13 It is partic­
ularly noteworthy that adolescents
with and without diabetes have early
and exaggerated epinephrine responses
compared to those in adults. I< Never­
theless, in the DCCT/ being an adoles­
cem was the onlr other independent
risk factor for the development of
severe hypoglycemia besides low HbNe
level. The large doses of insulin that are
typically required in adhlescent patients
and irregularities in diet and exercise
undoubtedly contributed to the greater
 '" '.. ... ".'.- ',; -,',- ·'-'··""'i:.:·
··:rtt~_I~ttF.!'lct.ors~l_nf!!J~n~I!J,g:;~-;
.-:~~.6n~eta'ndJjia·nltiirl@Ji1?~~~;
(. ··'..··~>"!r'··.;~ ..·Ji.,.... ~.' ~".-'~f':'-:.; ....~I·~~
.. ,I.n.e. p., h.r.tne.:. He... . 9.".P~._.L
-.' ", E.,p
f . :!~·:'<HYe·~9.!~~~'· !~~~~c~:ij ~:~:~.
1 L1 rly or exaggerated
Poor diabetes control
cholinergic blockade WIth phento­
Children and adolescents.
lamine, propranolol, and atropine.
Male sex
Caffeine
Dd<lved or reduced
Strict diabetes control with
ing hypoglycemi~l. Symptom scores
recurrent hypoglycemia
Prolonged disease duration
Female sex
High-do:re insulin infusion
~o effect
Insulin species (human or pork)
Rate of glucose fall
.·fC,!tlClkY of s.;v<.:re !n'poglyct:l1lla 111
rh!, .~r()lIp in tht: DCCT, <.:vell though
: I \ lu Ih.'l'd COU n tc:rrt:l;ul,l ror" res ponscs
h'lUki h:1\l' protl'Ctl..'J aLlol~;;cl·t1tS irom
n\ p\l~ I\"CI: flU,),
\ \\ arcn..:s~ of Symptoms
(<.:'--i to Hypoglyccmi;l
Tc, fi f[e<.:l1 rears ago, hypoglycemic
<'\l11proms were bru;ldly divided inw
.\fl:. ··adn::nt:rgi..:" warning srmp[Urn~
~fld I.Her ne:uroglycopenic symptoms, It
pl:brn~1 glucose le\'e!s conrinl1~d to iall.
'5\ combining the stepp~d h\'po­
;h-ct:lIli,: c/amp with mon: careful scor­
lilt: ot hypoglycemia-related symproms,
nnr insights have been obtained
eg.lrd ing the hormonal ,111d physiolog­
(,I! changes responsible ior symptom
.lW~lrel1t:ss in subjects witn and witnout
·J~~!bt:tcs, In subj..:cts without diabetes,
>"':h \,:;1 rtz and <.'ulleagues" showt:d tha t
.he gly<.'<::mic threshold for an increase
In :;YI111'wm scores was 53 :!: 2 mgldl
:2.'1 =: 0.1 mM}, significandr lower
h,111 the dl1cme rhresholJ for increJses
1[1 pLhl!1',1 epillephnm: I~\'el, (68 :!: 2
,mg/dl, LB' 3.8 =: 0.1 1ll~1). In contr~lSt,
n adults with poorly-controlled type I
Jlabetes, the glycemic threshold for
~ymptoms of hypoglycemia (77 :!: 6
'TIg/dl, or 4.3 :!: 0.3 mM) was higher
:hJll th;lt for release of epinephrine, t.
.>ugg<:sting thar ,ldulrs with poorly-con­
troUL'".1 diabetes are able co perceive low
')1 5lu..:ose levels before the adrener­
~I<.' II:SpOIlSe is triggered.
Tuwler and associates" quantified
hypoglycemia-rdated symprom scores
:[1 yUl1llg ;ldult vulufltt'crs witholH
i.kd)etes under four t.:ondirions: I}
clamped euglycemia, 2} cbmped hypo­ by combming the stepped hq)(l
glycemia, 3) clamped hypoglycemia glycemic clamp with microdiaf...;!)
techniques to estimate changes in c~te­
with combined a- and p-adrenergic
..JI'!.fl.
...:.....,'.•'.:._> blockade, i.e., simultaneous adminis­ cholamine levels in adipose and mu~..:!e
tration of phenrolamine and propra­ extracellular fluid Jl:~lag baselr:'c',
nolol, and 4) damped hypoglycemia h y per ins u j in e miL' e u ~!:- c~e m Ia. ,1:1,:
with panautonomic adrenc-rgic and hypoglycemic conditlu::" . :\:; exr,'~:
ed, pbSIll<1 c,ltc..:hohm.:lc·s \u£h:h,ln;':e,!
during euglycemia) rose Juring hvp,)'
Subjects' response to the question of glycemia, \-dth plasm'l t:riilephrine b·­
o ver:!1 I awareness of hvnoglycemia ds increaSIng abou[ fivdc!d more th,l:l
. (l~., blood gl~cose low) did not change plasma norepinephrine ["I·ds. In ":Uil­
',during euglycemia but did In..:re3se dur­ trast, ar the local tissue the hIT\)'
glycemia-induced incremerl[5 in m~i~..:iC'
thar declined significantly during dialysate norepinephrine Jnd epineph·
adrenergic blockade included rine wete nearly idenrl-:.d, suggcSt~[:g
shaky/tremulous, heart poullLiing, and local generation of no;;:pinephr;:·...:,
nervolls/anxious, whl:re~ls sVll1proms oi Thus, cenrr,lI symp;Hhc[;-: J.:ti\;ul\w, .h
being sweary, hungry, and tingling did ma n i fested by I oca I 11L' ~<:' P Inep nr .,:,.
not change. This indicated that they release from the sympathe'i.: nerve <:'r:,I·
were cholinergic. Neurog!~'copenic lngs, may playa more important r,)/;::
symproms, i.e" those produced by in hypogl:'cemic councerregulat;L)!1
hypoglycemia but nor reduced by than previously thought
pcwauronomic blo..:bde. included feel­
I ng w ~1 r III 0 r WI:;1 k , d I ff i c ul t y The Brain :lnd Defecti ~'t:
thinkingkonfused. and riredlJrowsy. Counterregu!ation
The authors concluded th,H cholinergic The hypoglycemic dan;~ Cc\:hniqut.: ;~.b
ml'chanisms mediate an impurt,lfH and ~lls() been used to shu,,'. th,l[ deL:. ~',l
pn:viously uncharacterizt:d component ;wd redu..:ed counterre~,darory I-:x­
of the sj'mproms of hypoglycemia and m 0 n ere s p 0 n sest 0 h\ po g lye e t:: ; .1
awareness of hypogl~·cemia. induced by intensive tre.l:rnenr m:l. :'<:
Kerr and associates used the: damp due to iatrogenic hypugh.:emia Pt:~A~"
technique in a different war to examine In heahhy subjects and ,n type 1'2;:1­
individual components of tne hypo­ betes patients, a brief period of moc~r­
gly..:emia-re1ated symptom cumplex." Jte antecedent hypogk"emia ·f't'd;~':t:s
They compared symptom scores in 10 hormonal responses and symptoms \It
healthy volunteers dur~.,g a hypo hypoglycemia durin~ eXDerimenrJ:l\
gl,-cemic cbmp witn symptom scort:s in induced hypoglycl'I11I~; Uf: ~hl' totlo·!. ,:ll-;
volunteers during n euglycemic clamp d;]y.~" This sequence of events has t::C'il
combined with exogenous infusion of called iatrogenic hypogl:. .:emia-as5;J':I·
epinephrine, norepinephrine, cortisol, ated auronomic failure,:' Jnd rr.·)rt'
glucagon, and growth hormone to recent evidence impllc,Hes adap::,!:
mimic the plasma hormone profile alterations in brain glucuse trans;::CJrt
observed during the hl'poglycemic or metabolism as it~ p,uh','Dhysio[o,,:.li
cl;lmp. Although the hormone infusion basis. ".
caused adrenergic symptoms to Since the brain is J!r.:'Jsr exclt.!~:."
increase, as they did dming the hypo­ dependent on circulatln~ ducose fu: ::'
glycemic clamp, hunger, swcJting, and energy needs,'! profound hypogl:·ct::·!.l
"feeling low" did not increase. This may cause coma, permanent bra;n
suggested that these symptoms .1re spe­ damage,!]!' or even dtJrh.)'·)' It i, :".;.l[
cific to hypoglyo,:mia per Sl' ,ll1d an: nor surprising, tht:rcfor<.:, t::.1t the b: .L!;
the hormonal action of epinephrine, would play an impOfCJnt role in h'.:v·
Studies examining changes in circl!­ glycemia detection and counterr{;g~:,l'
l;Iting hormone concentrarions during tion in order to protl:ct itself.!> J: rut
hypoglycemia have emphasized the example, animal studies have shv!.ll
imporrance of adrenomedullary rather rhat maintenance of no:mal certf.::JI
than cermal symparhetic stimulation, glucose levels by infusion of gluv,:>t'
since increments in plasma epinephrine into the carotid and v!;[[t'bral arte~;:',
during hypoglycemia greatly exceed during systemic hypoglycemia mark~".
those of norepinephrine. A very differ­ Iy reduces the countt'rregulntorv r,')~,
ent picmre emerges, however, when mone responses observed when' c..>~S,
changes in local concentrarions of epi­ as well as systemic, glucose concen::,l'
nephrine and norepinephr;.q: in periph­ tions were reduced. ll Hence, ir hes b':en
eml tissues are measured. Maggs and hypothesized that tht: lower glul">~'
colleagues recendy <lcl:omplished rhis rhreshold for counrcrregubrory Lr.
 mone release caused by recurreOl hypo­
glycemia in type I diabetes is due co a
reciprocal increase in glucose transporr
-"KroSS the blood-brain barrier. In non­
1 IIJbetic rars, cecurrent hypoglycemia
Incceases the efticiellc\' of glu\.:ose
c:xtcJcrion bv the brJin";' Jnd also is
,lhle to indu~e defects in countaregula­
tuCv hormone responses to hypo­
gly~emia rh:H are comparable to those
heres. J'
. .
III intensivelv-neated patients wirh,d,j,a­
~"'
. nuclei have been implicated, data from ences the ability of the brain to fun..:­
Bovle .HlJ associatcs llsc:d thd"h~'pO­
~1:cer;lic glucose clamp in combination
with measurements of cerebra! blood
f!ow ,lnd brain arreriovetlou$ dl
CIKeS to examine these issues 1!l human
~lIblect~. In volunteers without dia
betes they del110nstr,lted rh,l( recurrenr
Illsul/n-inJuL-ed hypoglycell1t.l tor more
than 56 hours leads to ;lJJpt;1tlOnS that
.dlow mainren,lnce of normJl brain
glu.:ose uptake and induces ddect~ in
counterregubrory responses during
mild hypoglycemia.}' Using the same
tc:chniques. rhey subsequently showed
th;H patients with type I diabetes who
h;1\'(: nearly normal glycosybted hemo­
glohtn values maintain normal glucose
uptake tn the brain dUrIng hrpo~
__,glycemia. In turn, such preserv;:uion at
wrlllal cerebral metab()lism may
ro.:dllct;: cOl1nterl'eguLltory hormone
I'\"S pOl1ses and C<lllse Lilla W~l reness 0 f
hypoglycemia.'"
It should also be noted that trans­
pore and metabolism of glucose may
not be the only brain substrate affected
l)\· di'lberes. Srudies th.1£ han' com­
bined cbmps with microdialysis tech­
niques have reported srrikingly high
In a recent stud,' from our labor;.l'o­
L'oncenrrations of lact,He" in br;)in
extracellular fluid durIng hypo­
physiologic31ly bv measuring conical
glycemia.
auditory evoked potenri;:lis. The P300
Episodes of snere hyp\.lglyct'mia in
waveform, unlike the EEG, which I1\e;I'
children ,Jrt' often followed by re
"crsible unibteral neurological deficits.
of the brain, is generated by thL' active
It has been proposed that hypo­
cognitive processing of stimulus infor­
glyc.emia per se may result in the dis­
mation. It is referred to as the P300
tllroance of the cerebral blood flow
potential because the peak amplirudt:
sufficient to result in transient focal
ischemb. To address this issue, Jarjour
:Illd col k:agues investigated the dfect of
mild hypoglycemia on regionJI cerebral
subject and involves higher brain cen­
blood flow and cereoro,'ascular resis­
tanCe in right-handed children with
trpe I diaberes, using the intra venous
xenon· 133 clearance method:u These
'r<:slIlrs ~h()w~d rhar t:crchral gray mat­
rer blom.1 flow was signiticamly higher
tI1 the right hemisphere compared to
tht' left during hypoglycemia but not at
baseline euglyceOlia. Such a::;ymmetric,,!
cerebral blood flow ch'lnges may
explain the frequent latenllitr of neuro­
logical deficits afcer sC\"ere hypo­ glycemia can also be blocked bv Infu.
glycemia, sion of laerate Inco the V;\'-lH, the
Vl\tlH may act as a fuel sensor rarner
Role of the Ventromedial than being only a glucose sensor."
Hypothalamus
The importance of the Cl"S in hypo­
glycemic detection and .:ounterregula­
Brain Function and
Recurrent Hypoglycemia
tion has generated interest in determin­ The hypoglycemiC clamp has also
ing the precise location of such glucose permirred investigarors ro examine
sensors in the brain. \X'hile various wherher intensive insulrn therapF intlu
animal studies suggest th,.l[ counrerreg· tion in the LKe ot Ill! ld to moder..lte
ubtory responses during hvpoglycemi;l hypoglycemi'l. This b of pM.t01ounr
are activated, at least In PJrt, via the clinical import<lncc: since apch\..
hypothalamus: t " It has been frequent­ Increases in br,lin glucose transport
Ir suggested that the ventromedIal induced by recurrent mIld hypo
hypothalamus (VMH)," known as a glycemia could result tIl a favorable
regula cor of food inra ke ("sa [iety Cen­ down-shifring of the gluL'ose levL'1 :1£
wr"):··« contains glucosen~iti\'e tissues which brain fUl1ctlun hecomes IIlI
that could mediate the responses [0 paired.
hypoglycemia:-··­ This issue is controversial. sinc\: ir
This hypothesis was D.lsed prinurily has been reporteJ that Inrensivch­
on the observations that mjections oi treated type I diabete:> p:H!ents J.~e
2-deoxy-glucose into the third ventricle more, rather than less, vulnerable to
caused hyperglycemi.I." Initiall)" the neuroglycopenia than poorly Con­
Vl\lH was considered a sympathetic trolled counterpart:;, when convention­
ceorer, controlling mainly cate­ al electroencephalographic {EEGl
cholamine secretion in response to recordings are used as an endpoinr.'­
hypoglycemia.· t ... Gluc,lgon responses Other studies using neuropsychologl G 1!
were thought to be triggered by rests [0 assess cogn i ti \'e pertorm,lll-:e
intraislet rather rh'ln CNS mech· dming hypoglycemiJ in tn:t: I di:lh<:tes
anisllls.··· JU It has been demonstrnted, parients have found no chan~t<·'·" ,ur ~l
however, that electric stimulation of lowering of the pl~lsma gluL"'Osc t't-\:i.:\
the VMH caused an increase in plasma required to provoke cognitive drsfunc­
glucagon levels.'UU' :\Ithough these tion in patients tre~Hed irlrensi v ely.•oJ·.: It
studies did not directly address the role should be emphasized that the varioLl~
of the VMH during hypoglycemia they rests of cognitive function used in
suggested that the VMH could serve as these studies are likelv ro assess differ­
<l key cenrer for the activation of hypo­ em brain regions, whidl m~l\' havt: dIt,
glycemic counrerregulation. ferent glucose reqllireml:'l1[s ..
Our studies have further established
the VMH as a d:''1linant center for ry, brain function ~vas assessed de<.:tw­
sensing of glucopenia_ In rats, focal
iesioning of the VMH ~lbolishes hor­
monal response to systemic hrpo­
glycemia. I i j\'loreover, production of sures the SpOntaneollS eiectncd outpur
local neurog\ycopeni3 by perfusion of
2-deoxy-glucose directly inro the VMH
of awake rats triggers the release of
counterregulatory hormones in the
a bsence of srsremic hypoglycemia. I i normally occurs <1bour 300 millisec­
Conversely, hormonal responses to sys­ onds after the sensory Stimulus, Ir
temic hypoglycemia could be sup­ requires rhe acti';e p<lrticipation of tht:
pressed by mainraining normal glucose
concentrations in the V~IH by glucose ters, particularly the hipp(Kamptls ;llld
infusions via stereotaxically placed the parahippocampal gyrus.';
microdialysis probes_" Selective preven­ We have compared P300 responses
tion of hypoglycemia in the VMH, but to hypoglycemia III intensivelv-treated
not in the remainder of the eNS or vt:rsus convcntion;llly-rrc,ln:'J ty.p~· I
elsewhere. blocked catecholamine and dla~eres patlenb and healthy suhjC<':b
glucagon responses, thus providing dUrIng srepped hypogl,'cemi:1. :\~
strong evidence for these hypOthalamic expecred, glucose level~ ~riggering hoI"
glucorl:'!ceptors. Since preliminary monal responSes and pt:rcepriol1 of
results indicate that counterregulatory hypoglycemic sympWlllS were signifi­
hormone reSpOllSI:'!S to systemic hypo­ ca n tI y 10 W I:'! r in in tens i 'Ie Iy. t re;1tcd
 .,(I<.:ot, a~ -.:omp,l[ed to their poorly­ cose councerregulation, as well as in "DIJ.mond ,\\P, Reece EA, CJpno S, Jones T\\.
li~[rolled counrerpnrts, and hormonal investigating the impact of hypo­ ,.\.miel S, DeGennaro N, Gdt A, Addabo M
Sherwin RS: Impairment oi countcrreguhH~ry 1:.;:
l~pon~es were suppressed as com­ glycemia on brain function. It appears mone responses Co hypoglycemia In pregnane
'.lred to healrh\' controls, We also that intensive treatment of type I dia­ women with /OD,\1. Am] Oo,t!!: Gvnecol
"'c:p--'-rh~H a gre,;ter reduction in plas­ betes leads to adaptive changes that 166:70·:7.1992. .
f! .ose was required co alter PJOO enhance substrate availability for cog­ "Tamborlane \Xv, Amie! S..\.: H"rogfvCemlJ ,::
Lcnruls III the intensively-treated nirive function, but unforrunntely this ehe rre,Hed diabeeic panem: .1 mk o(l~eens[ve
~'J,ICl1t$ as compared to both the con­ lends ro delayed activation of brain Hlsulin eherapv. EnJocrmol M"ub Clm Norch.:. ..;
Ily-rreatt'd patierus with dia­ ceruers that initiate counterregulacory Z 1:313·27. 1992,
:;;~ ,lnd the nondiabetic group. Our hormone responses, While our under­ "Jones TW. Boufware SD. Kr,lemer DT. Caprio ).
"1 ar.: (ollsistenr with those of an standing of these issues has advanced Shcrv,')n RS. Tamborlane \X/Y: Independent efi~::,
din "t'port by Ziegler and associ cO,!)siderably, strategies to prevent the ot youth and poor di:lb"ees conccol on respon,e,
,-," tlLlt ;llso utilized the PJOO tode:velopmenr, of hypoglycemia in ro hypoglycem,a in children. DJ,:hc!res 40:358-6.;,
1'191.
'i\)["r -.:hJllg<.:s in (;()gnirin: function ,., iilstdm-tr<.:ated' patients rem.lin <.:Iusivt'.

,:t:1i-' h n'ogivcellll;1 III (V rt: I d ia bt:ro
,:i,'f!['. I)orh scudl<':s suggest rh;l(
··c:ohl\ .... h-·u<.:ated patients are less vul­
~Jbk Co cOf(J(at dysiuildion durmg
. ,i.J to nmdcr;.l(C hypoglycemiJ.
It \'.c:lI-conrrolled, inrensivelv-trear­
t1 Jcic:nrs an: less t'ILiner,1ble t~ corti­
,;1 'dysfunction during mild co moder­
:::: hypoglycemia than are poorly-con­
!.>lled, com'enrion:dly-treated patients,
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glucose metabo!ism in che ":cncra; :-oc:mllS ,vsee:.

"1\' becllllse they are unable to syn­ 'Amid SA, Simonson DC. TamboriJne \'flY, In HypoglycemJ.1.:tnd Diubeles. I'n~r BYI. FlShc:

'["cllllZe: insulin delivery normally with DeFronzo RA, Sherwin RS: The race of glucose B:-'I, Eds. London. Edward Arnok:. 1993, p. 56,

fall does nor affecr rhe counterregularor: hormone 71.

:,,<1 ingestion and acci\'iC);, but also
responst,,; co hypoglycemia in normal and diaberic
·,·,IUS<.: ch<.:y h;ln: defective LOllnrerreg­ l1I.m, DU/betes 36:511;-22. 191;7. "K:llimo H. Ol$;on Y: Efte..:es of S~';er" hypo­

,\ ron' re:spotlSt'S to protect rhern gly..:"nll:J orr the human brain: neurop'Hhologic;L

'JIll,; hypogl)'~t'mia, 'SII1\WbOn DC, TOlmhorbllt: \VY, Dd;ronl... RA, (,ISe repores. AClJ Nell"'! Smnd 1)':':345·56. I 'h

Sherwin R:i: hHt,,,,ivl' 1t\,,,lin rtl!:rOlpr r<'<!lIct'S

IZt"~·"lJtl;.· thl' role of CNS ill a~ri\'a­ '·:\g.,rdh CoD, K.llu1Io 11. UI,,,,;: '" '''t·.'IO 11K.

\.otlIHt-rr;.:gllbtory hOrll1ollc n.·~rOtht.·~ [l} hypo.

1:1 ,mel ~uordillacilln of the ~ollnter­
glyc"llll" fI\ parl<:nrs wHh rype I diahl't<:\. Afln Hypugly..:~nll~· br.lll] "'JIll')" I. .\!':u:'"h..: ,md II;::.'

ilu("rosc:op't: ftndmgs 111 rat . .·C'n:c::l: ,vr{t.,,"x Jurn.

~uLl(Ory re~p()nses CO hypoglycemia /nkm Med 1U3:1!!4-'JO. 191\5. p

profound insulm·induced hypoglf,'c:::t;\ and III :' ,

:' n:~t'ivt'd substanti.d .utention.
l.llly spe..:ific techniques have been
·,n.:'-'d to investigate rhe imricate
;.ll ;hips between the brain and
t.:ost: homeo$casis. Among them, the
:gl~'~emic-hypogl}'cemic clamp has
'Il, provcn to be an dfe~tive tool in
r ritying rhe role of [he eNS in glu­
'"Amid !;A. Sherwin ItS, Simonson DC,
Tamborlan WY: EHeer of int~nsivc insulin rherapy
on glycemic thresholds for coumt.'rr~gl\ratory hor­
mone release. Di"bett:s 37:901-907. 1987.
"Davis MR, Shamoon H: Ddi.iem counc~rregula.
wry hormone responses during hypoglycc.-mia in a
panenr wirh insulinoma.) Cli" F."dDa Met,lb
n:78!l·n.1991.
recover}' period iollowing glll<:mc Jj,mnistr.\[,,,,
Acta NellfopathO/ (Berlin) 50:31·41. 191;0.
!'Auer RN. Olsson Y. Siesjo BK: H"poglycemic
bram llllury III the rar: correia cion of densi!'\' of
brain damage: w,[h the EEG jsod~ctric eimi: a
quamitarive scudy. Diabetes 33:1090-98, 19J!'4.
"Agardh C·D, Rosen I, Ryding 1':: Per.im:llr vc;:':'
c
tanve stare with Illgh ~'''reor;ll b1u.... r1uw tollo" '
,>,

DIabetes Soeetrum Volume 10. Number 1 1997

 Hlg protour.J hypogi;;.;emla. Ann Neuroi 14:482·
)
S6,1983,
VJl·GuC\'.lrJ AT, Hsu T·H, White P: Juvenile
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I "Deckert T. Poulsen JE, brsen M: The prognosis
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,,'" 'pc" '.;1\• .I.hp.,,, ./11. \\',tI'.llllS PL. Cherrington
,.\ I). Fnnd RT Role ot br.lIn tn Lounccr[tgulaclOll
"I tnsu\",·tllJuLeJ hypof'h"emia tn dug,;. D:.!~:c';
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. \\'""ds::'e, Purrt: \) Jr.: """r,,lconrrof(,'f";he"
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ut· the- .n~[i tl1l)t11'1.; Innervaoon III the ..:untrol of
::iU,.I~(H1 (debe during hypuglp.:emiJ in rhe .;;tlf. j "Benzn CA, The hypochabmus lnd blood glUCOse
{,h·;",{ {l,()llJ· 236:611·23. 1974. rcgulJcioll. [.i/e Sci 32:2509·15. 1903.
1 Trtl.ld RT, J,lt1'" E!'.I. DJ\'I> SS, Biggers DW,
\1 \'a, SR. COllnoll" CC. ~c,ll DW, jasp:1I1 JB,
CI;"rrlll):r"It AD: C;,uIHcrrq,:ubrillJ1 dUring hypo­
c:.!YI.:t'flU.l t ... dtrCi.:ccd hv \VIJt..·spn:.JJ brJI11 (t...' gH)IlS. 2-!:J2~·Jo,
J ));.ltJctcs4.?:1253·61: 1993.
",,-kC-IIi :\1.. Frxm~1l LB, f-'k:llling 1', Tornh.:il11
K. Chid.. \X·. R"dC:rIlI.1n :-:B: Chronic: hypo·
).!.[I.I..:t:tiH.l m..:rL·~bt'", hr~lin ~lU1.':0.st· (r~lnspOn.
i'j'VSHI/2)I:EH2-47. 1':I~6,
Ant)
'1\·II,grtfl .. IH. "'<:~rll.l. :\lbn:..:llt Rf-': Krall\ glu.
_'''C l:rlltz.uhlll ,\tIcl cr.I;t>purr .1IId corei.:;!1 tUllcciOIl
.:hwnic '" CI':U(t' hYf}(l~k':Cflli;\. Am j I'h},;I,,1
,,1
f 2S"I:F 7 2')· ,). 19':111.
'.\h;C"n :\1.. :,\Iill!ll!;toll \Vlt. Wurfm.lII 1lJ:
\ 1.:1:11>,,1,,: fud alld amino ;Kid uallsporr infO chI.'
hr.l"l ". "xl't:rlllll'I\£,ll dubece, m.:ihws, /'m,' N.nf
,.\, .1(/ So ['SA -'!;,)' 40,,.10, 1'->1'2.
"i'uwdl :\\1. )11"r\\'il1 RS, Shullll.1I1 GI: Impaired
hllrnhH)~Jl rl':'lpOI1~I..·;" [p h~'pu~ly(erni~\ in :ipOnGl"
I
"cou,l\' dU[;<':(h: .Hld recurrendy hypoglyct'!lli.;
"1(,,, (:/In [m',·,1 ':12:2667·74, 1'.193.
'110\'1" PI, :\a!;y RJ, O'Conllor A.\l, Kempers SF,
)<:" RA. QU.llh C: Adclptation in brain glucose
uptak, t.. liowl!l~ rc';,;urrcnr hypogly,:clllia. Pr(K
J ,\',111 :\,.hi 'iLl C\A '.1[:':1352,56.1994,
'LI"yk l'j.l\empers SF. O'Connor AM, Nagy RJ:
Borg, MD, are post-doctoral fe/Iou,s in
f.)rain glu.:o,;e uptake and unawareness of hypo·
I glr';c't1lI.! i'l p.Hi,llCs with IOD.\!. N Eng/ J Med
n.,: I :lb·J!. 19'.1,1.
"\\'.111.,..:" E.-\. \ !,'ggS DC. Spl'Il.:er D. J;,,:ol> R,
Itlt.- F. Dun"t' .\IJ: Hil'h I,l.:t:m: C'oIH:<:mr:H;wls III
I
hulll.lll Eel': ;\11 ,1I,,:rn:HI\'C flld cllIrlllg hypo­
~[:';t·n".I? [klbetes4'! (Supp!. 11:562, [':I,)S,
''j,lqour IT, ity •• n Ci\I, Ilcd:cr Dj: Rcgjonalcae.
I bral blo,,,] now eluring hypoglyc<:mia in children
with IDD\1. V',lbel%gi.:; 311: I 090·95. 1995.
"HtlllSworth IU.: Hypochalami.; ':011([01 of adrcn·
•tlme se.:ret.on tI. response (0 insum.:i"nr glucos". j
1
I
PhySlOi (Lond) 206:4 11·17'. 1970. "Borg .\L-\, Sherwin R:i. Bor b WP. T JmborLI::"
':""iiilma A, Kannan H, Yamashica H: Keural
.:onerol of blood glucose homeostasis: effect of
Wv, Shulman GI: LacrJte perfused Io,;alk .nco rh~
ventromedial hypothlb~u> suppre;ses COUnt", .
regulation durmg SYS:em:c n"pugl'.:e:nl.l
mu.:roinjection of glucose into hypothalamic nucle,
D,,;beles45 (Suppl. 21'19:1.1':1':16.
on efferenr acn"ity of pancrcJ.nc branch of vagus
nerve in che rat, Br.zin Res B,,11 20:811·15.1988,
''Shmtzu N, Oomura Y, ~ovm D, Gri;a\'a CV.
Cooper PH: Functional correbtion between lateral
"Arnie! SA, POttHlger RC, C"IHIJh DC, :\c.:hlb.tiJ
HR. Prior PF. G:lle E.-\.\I: Eiie.:! or' ~m~.:",den! ..:!,:.
cose control on ccrebr.11 tun,Clun dU(lI1g h"?,,, "
glycemia. Diabetes eIre 14: 109·18,1991.
hypothalamic: gIUl.:ose·sensin\'e neurons and hepat·
h: porr~ll gllh:n5l"~5l"lhln\'t: unirs 1ft rae Rr~lin Res
265:4':1·54, I'IST
"H~chcringrOr1 A W. Ranson S\V: The 5pOnCJneou~
"\Vidol11 tI. Simollson D: Clv':<:IlIl': el)l\!",l ,II'.!
nturop:::,ydlolo~h.: t'un-':::!,l[~ ,junng ft.; rh).d.lo . . c:t;;.t
patl~n[s \vlrh 1I1suhn dependent JI.lhc:t.' tHeH.:",,,
:l
Am, Illr.:m .\!t-d 111:':104· l~. 1'I'l1)
.:; .\\.'riv,ry and food IIltak.: of r.us with hypmh.li:Jm;\.'
10'011>, Am j l'hyslO/ 136:60'1·\ "T, 1':142. ".\br.ln A. Cra'''CUIl I. \'".lI.l, I. .\\.k.t,,:!,,:,' :.
Amid SA: I'ror.:..:rrol1 lw Ltd.H<: ot ~er~hr.tl rUIt.,
non during hypogIF~Il;i;1. LllI,et 343: I 0·21).
1994,
nledlal and Iater:.1 hypochaL1mi~ artJS of C3(5.
Dough; F: Varbble dc:r~riorarron in 'orn..:~llllil'"
r'oll during insuhn inJu~<:d h"pogh·..:cm,,!
DI.lbefe, 34:6 7 7·S5. 1-:)::>5
··Sz.lbo 0, Szabo AJ: Studies on che n:Hure and
Illode of a":tion of ,h~ insulul-sensitive glu.:ore.:ep·
ror In rhe .:enrrJl nervous sYsrem. Dt,lb"res
"C!~rke WL. Gondcr-FreJcn~k LA. RI,h.lrJ, 11-"
Cr\'er PE: :<.llllcit.\c'wrtJI ofl)!:ill "f hypogi\'.:etnl.l ,
llnJW~lrt:ntts~ in lDD\\: ,1S':'l)..,:I:HHHl wt,h J\:!',,:\...-:-\Vt<
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glu..:ost: ~olul(C"rrct!.uIJ=HJD .11"11.1 ht:rrcr ...:.!v..:cnt, ...... , >1)
"lldrriSRW, Ingram WR: The effecc of experimen· rrol. DI.Jbeles 40:6S0·$5, 1991. ..
i
i
{~I hypotlt:lbmic lesions upon hlood sug.!r, Am j
['h),sio/I14:555·61.1930.
'-pJlmer J. Henry D, Benson J. JUhnSOll D.
J: GluC:lkiOIl r.:spon:;c co hypogIY":em", in
EIISII":I.;
·'F::tndli CG, EpltJ!1o L, Ibtl1buc(, :\.\1,
Pampandli S, Di VIfh:eIlZO A, ~1(ldJrdlt f-', L<:t'urc:
!'>1. Annibale B. Ciotccra :'\'1. Uorrint 1'. Por.:d.Hu r.
Scionri L, SalltcusiJno F. BrUlle[(i P. Bolh G:
I
sympathcLromizet! tn.lI1. J Clttl i)l!'t'sr 57:522·25. \kriculnll> pren'lInnn of h\'pogly(emi" Ilo",ul.
1':176. ilt") rhl' gl:~t'lnk- thrc:...ht>kb•. \lh.ln1J~:1I[ll:.k' '.'!
111USt of JH:llrot.·rk1t~l'i!k· rl',ptH~:'C~ {~-). ":loyfnp:I.!!ll"
·"l'.llll1cr J. \,(f erner P, Hol!,HlJer 1'. Ensmel.: J:
b':duarlOn of the .:umrul ot glucagon SeerC{lon by
the pJrJsympath"ti, nervous system in mall.
uf. :lnJ cognitive fun"::HHl Junng hy?ogl~'~c:!1!,t IU
imcnsiveiy u":Ired p.Hlcm, Wlch ,burr ccrm [[)\):<.I
[)I.lhet<!$ 42.: I b~:;-tl9. 1':IY.l, ?;.",
J
,\kt,lb"[",,, 211:549·52, 1':17'':1.
"'\X'ood CC, ;\kCJrrny G. :'quir~) :--;'r:, \',,;lgh,11l
"Fruhm.ln I.t\, IlcmarJi" 1.1.: Eftect oi hl'purhala. Co. WllO,!; DI., M.:C.lllliltl we An.ltollli".d .raJ
mll.: ~[lIl1ulattnn un pl.1snl,t ~Iu~l»)t·. Ifl~tlhn~ ~1nd physiol()~I\;';,.l1 :-.ulhrr.He"t or ,:v~·;;[.n:!.HCLl pott:n
glucagon kvds. Am) Ph),;1,,1121: 15%·161.)]. n.ti;. Attn Nr ,·k.ld Sci 415:6;) 1·721, 1 >':)-1,
1<)71.
··Zi<:gier I), Huhil\g~r .-\, ,\Iuhl<:n H, l;fll', i",.\:
"H;m:1 PJ, Veith RC, Dunntllg BE, TJborskv GE:
Role for Jutollol1li..: tlCrVOlb >1'5{(,"111 to IIKrelse
pan<.:rea{ie glucagon se>.:retlon during mJrker
Efi.:ct of previous gIY':~tlltc: control oil th~ (}I:,,:t
,HId masnirude of (oglltr."" dy,fun.:r,oll JlI' ;I.::
hypot:lycerni;1 in type I (illsulm·depCllJcllr: d,.lkt.
insulin induced hypoglyct:Olia in dogs. Diabetes ic patients. Di.1I1t!tulogl,l J5:112::;-J~. 1992.
40:1107·14.1991.
"Borg wr. Dunng "IJ. Sherwin itS. \)u,); :'\ IA. W.'alter p, Burg, ,\10, dt/d MOnlcd A.
I:$nnes ~ll., Shulman GI: Ventromedial hypothala·
nue lesions in rats suppre>s !.'ounrerregubrory
or
the Department Internal Medict11e.
responses to hypoglycemi:t.j Clin Int'est 93:1677.
gl, 1994.
"!lor,; \'('1'. Sherwin RS, Durilll,\ :....IJ. Borg :<'1..1.,
and William V. Tamborlcme. MD, IS (l
professor of pedi.1trics and dtrector u/
the Children's Clinical ReS(!<lrch CCllter
Shulman GI: \'0.;.11 VCI1((l}IlICUi;11 hyporh:1l.lInll~
()r
!;llI<.;op<:nia triggt:rs counrerrq;ulctwry hormone
rdcase. /)/.Ibett:s 44: U;Q·l)4. 1995,
Llt the )'ale Ulltn:Ti/ty Schuul
/V!edic:ine, in l\'ew f-Lwl:'n. Conn.
"I\org M.-\. Sherwin RS, During j\ Ij, Borg \'('1',
Shulm:!1l G1: LOCJI velluol11euial hyputhaiJmlls
glucose pnfusion blocks coun(errcguiJtioll during
systemic hypoglycemia. DIabetes 44 (Suppl. 1):2,
1995 .
nl"h..t .." !':l"lf'lclrum Volume 10, Numbet 1, 1997
 • FROM RESEARCH TO PRACTICE·

1
I

1-----------------------------
I Mechanism of of . Awarene~s
I,
II
I'
"f'

j Hypoglycemia: PerGeptlon of NeurogenIc

II
(Predominantly Ch~l.irergic) Rather
!
Than Neuroglycopenic Sympt0111S hunger,These·H ' " ' ' ' ' " " , , , ; : ' ' ' ' '
also mediate nypoglycemia. aware­
, I!.A TOWLER. c/:· flA \ -UN. 5. CRAFT. ond P. CR'r'ER ness: Adienergic inechaDisms midi­
[)htbL'It:~ -12: /7y/-yS. NY;' ,~tt..,9itR-.~r ,n.e1!J'ogep}c.symp t91llS .,such
.. ......................... .: ~ :§pakirig' and:,tremulousness, heart
p'oundirig; .ana . anXiety and nervous­
, Summary and Commentary by Walter P. Borg, MD, n·ess~ HyppglyceIllia"a:\viu:eries's"is
l-,u:¥.~iY; ,if'not..~:X.CIusive.lY ;:clue ~tP.
and \Villiam V Tamborlane, MD ,.paJ:t.eJ!~·:a~ili.~Y)o pe;rceive· .' .

l'
Objective. To study how to reproduce
hypoglycemi;J·rdatcd symptoms. objec­
tiv.:!: discern neurogenit: (autonomic)
t from neuroglycopenic symptoms. and
! ;Iddrl'~s whether hypoglycemia aware-
111.:.'.' I, the result oj per~·ei\'t.'J neurogenic
pr~t.neUrogenic ra~er than neurogly'­
glycemia with panautonomic adrenergic
,c~p:~nk.,sY!J1pto1llS ...
and chIorinergic blockade using phento­
lamine. propranolol. and atropine.
Cognitive function tests. which mea­
sured global cognitive function. aHen­ 0.00 I l. anJ anxiety and namusness (P <
lion. and memory. and hormone and 0002), Significant nellrogcni<: choliner­

or llL'uroglycopenic symptoms. melabolic measurements were also per­

gil' symptoms included ~vvC::ltin!! (P <
formed during each study. Blood pres­ 0.00 I). hunger (P < 0.00 I I. imu tin!.!ling
Q~si9n. R'lIldomiud controlleJ study.
sure and heart rale were monitored =
(p 0.(09). Significant n=u!'\}gIY~'9peni~

.ljects. Ten he.lithy young adults (7 throughout. symptoms, thOse prouu..:eu by h.~o­

men. :I women. ~~--~9 years of age). glycemia but not redU'::fJ by panalJto­

Results. Significant (analysi$ of vari­

Measurements. Hypoglycemia aware­
n"" (i.e .. il ,ubj..:ctivL' perception of low
blnoJ glUcose). 16 hypoglycemia-related
,ymptums. anJ J unrelated control symp­
ance P < 0.00 I) treatment effects on
hypoglycemia awareness were noted.
The mean ± SE score for this symptom
did not change during euglycemia but did
nomic blockade. incluue,! warmth (P <
0.001). weakness (P ::; 0.0 I I J. 'difficulty
=
thinking and confusion (P 0.00-+). and
tiredness and drowsine:--:; (P = 0.003),

tums were measured on four occasions in increase dming hypoglycemia (2.1 ± Conclusions. The author:-- concluded

r;lnd~)m sequence. The four occasions OA). This increase was not reduced sig­ that chOlinergic mechani$m~ mediate an

were as follows: 1) during clamped eug· nificantly by adrenergic blockade (1.6 ± important. previously uncharacterized

Iycemia (~S m:v! [90 mg/dJj); 2) during 0.5) but was reduced significantly and component of the neurogenic symptoms

clamped hypoglycemia (-2.5 mM [45 substantiall y (-70%) by panautonomic of hypoglycemia and hypoglycemia

mg/dl]J: J) during clamped hypo­ blockade (0.6 ± OJ). awareness. Hypoglycemia awareness is

glycemiil with combined 0:- and jj-adren­ Significant neurogenic adrenergic largeiy.. perhaps exclusi\ely. the result of

.... rgic blockade (phentolamine and symptoms included shaking and tremu· whether patients perceive neurogenic

propr:ulO!oIJ: and 4) clamped hypo- lousness (P < 0.001), heart pounding (P < rather than ncurogJycopenic symptoms.

...... .... ...... ......

·C 0 M MEN TAR Y·
In the' mid· J9~Os. the glucose damp. technique was adapted as a <:aused by mild-to·moderately reduced blood g!,:cose levels are
test 10 "sse;;;; the response to hypoglycemia.' This paved the way mediated by lH.:tivuting the autonumic 1ll:I'VOth ~: stell!. Crver's
!or numerous studies th'lt have greatly enh.mced our knowkdge group in St. Louis. frum which this papt.'r com" .... has re-tc;med

«huut factors thaI intllH:nce the n::sponse to and recognition of these "neurogenic" symptoms.

hypoglycemia. Towler and colleagues' sllluy is an cl\ccllent However, many warning symptoms (i.e .. s\\cating. hunger.

o.illnpir: of how the clamp technique can be combined with and tingling) appear to be mediated by choliner>:ti<:. rather than

_.Slttler complex infusion protocols to more precisely determine adrenergic, mechanisms because panaulonomic-blockade sup­

lich components of the autonomic nervous system contribute pressed these symptoms but adrenergic blockade alone did not.

~Ylllptomatic hypoglyl:emia awareness. Surprisingly, the same response pattern wa~ :--een for the more'

Tell or fifteen years ago. hypoglycemic symptoms would global· symptoms of low blood glucose. Adreneroic blockade

have been broadly divided into early adrenergic warning symp­ alone substantially decreased other symplom;,. such as shaldng

I hUllS nnd subsequent neuroglycopenic symptoms if blood glu­

....\}SC It:vels continued to fall. This study confirms that symptoms
and hean pounding. "

These findings nre Jifficult to interpret tx:cause the blocking

DIABETES SPECTRUM. VOLUME 7 NUMBER 4 JULY/AUGUST 1994 249

 • FROM RESEARCH TO PRACTICE •

agents directly affect the central nervous system. which could
~ake hypoglycemia harder to recognize. Towler's study illus­
trates this by the changes observed in cognitive function when
blocking agents were infused before blood glucose was
reduced. To overcome this obstacle. David Kerr, MD/ who was
a member of our group. used the glucose clamp procedure in a
different way. He directly ex-amim;d the effects of the rise in
i cou nterregulatory hormon:.~!=>rf·s ymptoms scores in the
absence of hypoglycemia. ... '.
Kerr compared hypoglycemic symptoms scores in 10 healthy
subjects during a hypoglycemic clamp (plasma glucose lowered
from 5.0 to 2.8 mM) with those during a euglycemic clamp com­
b i n..-:d wi th exogenous epi nephrine. norepi ne phri ne. cortisol.
glucagon, and growth hormone infusions to mimiC the plasma
hormone profile observed during the hypoglycemic clamp
study. Although the hormone infusions caused adrenergic symp­
toms to increase, as they did during the hypoglycemic clamp,
hunger, sweating, and "feeling low" did not increase.
These data are entirely consistent with Towler's. His data
also showed the importance of activating endogenous choliner­
gic mechanisms. The exogenous infusions of norepinephrine,
which functions as a neurotransmitter. probably had little physi­
ological effect.
A strength of this study is that the investigators addressed
clinically relevant questions using a scientifically rigorous study
design Nevertheless. no one study can cover all the bases. For
exa,;1ple. determining how cholinergic blockade alone affected
the responses to hypoglycemia would have been interesting.
Another caveat is that compared with how accurate many of the
measurements in this study are. the symptoms scores are subjec­
tive and Imprecise, and the scores during hypoglycemia
increased only modestly (1-2 POlnts on a '-POlO! scait').
The study results tend to downplay the imponancc of adren­
ergic symptoms in recognizing "feeling low" In nondlaoctH:
subjects. Would the same be true for patients v.nh IIhul:n­
dependent diabetes mellitus (IDOM). who ha,'c hau ample
opportunity to relate such adrenergic symptom~ to to\\ bluod
glucose readings on their monitors at horne') With experienc:e.
even patiems who lack neurogemc syll1ptom~ ll1a; be abte to
detect early neuroglycopenic symptoms. such a.'; tllIlli.;u!t;
thinking. before more severe cerebral irnp:!ll"Incnb IrHCnc:n,:
If the rise in plasma epinephrine !t','e!s that :l,xolllpames
hypoglycemia is not critically illlponall! r,)r reCv;efll/.ln;! 11'. Pl.'­
glycemia in patients with diabete:-.. U,)e~ th~lt Il1lpl;- riu; ~;dr~I;"f
gic blocking agents can be: safely USCU In patlcrHs v.I[11 ! DD\I'
The ability of these agents to block responsl\'e II1crea~es in ti.lUV
acids and lactate. and presumably other aspects of enuo~enoll~'
counterregulation. argue such a conclusion. • -
• REFERENCES •
'Simonson DC. Tamborlaoc WV. D~Fronlll RA. Sh~mtn fl.) In,ulrl' ~!lmp
treatmem redu~es counterregublory hormone resp"nse, w r.~p,'gr!c.:m';J <Po
type I diabetes. Alln Inurn Med 103: 18·P)0. 19R5.
'Kerr D. Diamond MP. Tamboriane \I/V. Kerr S. Shawin RS: Innuenc<' of
hormones. independently oi hypoglycemia. 1)[1 ':l1goiliv<, i"IKt,,,n. "U:T"'~
symptoms anJ glucose kinetics. Clin Sci 85: 197·2lJ2. 1'1'1.1. .
Waller P. Borg, MD. is a posfdoCiOraf /et/(m ill peliwln,
endocrinology, and William V. Tamborlalle. MD:>c(;5 fhe direc­
tor of the Children's Clinical Research Center (·md chieF of
pediatric elldocrin%g.\· (({ Yale UlIil'o'siry Schooi :\Iedinile ;;1
New Hat'ell. Conn.

Hypoglycemic Thresholds for Cognitive IN BRIEF

1
·:';t~I',~H~~~'·"P'..'··i"'" -'. "
Dysfunction in IDDM i ~;1)iis;s.hldY~cl>ncltideci that patients
;
., witK;poOrly;confrolled. IDDM and
J.D. BLACKN~AN. VL TOWLE. 1. STUIRS. C.F. LEWIS. rriat~hed control;subjects have similar
J.P. SPIRE, and K.S. POLONSKY

::C?$,~Eiye:im.p~~.IlI}.ent .atblood. glu­

Diabetes 41:392-99.1992.
. . . . ...... . ........ ........
Summary and Commentary by Irl B. Hirsch, MD
Objective. To determine the cognitive
threshold for patients with poorly con­
trolled insulin-dependcOl diabetes melli­
tus (lDOM).
Subjects. Ten nondiabetic volunteer
subjects and 14 age-matched IDDM
patients with poor glycemic control
(HbA Ic 11.0 ;:!: 0.5% [upper limit of nor·
mal 6.5%]).
Measurements. A stepped hypo­
glycemic clamp with a constant insulin
infusion and a variable rate glucose infu-
'j cose~l'ey6Is~between.3:5· and 2.5 rru\1
sion was initiated at 8:00 a.m. At the
beginning of the study, blood glucose
was clamped at 5.1 mM (92 mg/dl).
decreased to 3.5 mM (63 mg/dl), and
decreased again to 2.5 mM (45 mg/dl). A
meal was consumed. and blood glucose
levels rose to baseline and then to post­
meal levels. A control study with blood
glucose levels clamped at the basal level
was performed to control for practice
effects and the effec(s of fatigue.
The primary measurement was the
P300 event-related potential. a measure
I
c·(~~i;~~:~4·~:·~:g/~t):· Cqgriitive dys- I
.fun·ctlOnwas.:measured with P300 I
event-related potential and reaction I
rn
ti e:'!ijfesP9I1seto vi,sual·stimuli. I
. Th~~~: lIl~asu~ements of neurogly- !
·~.<<ip.~nra;:ar.e.::,mor.e~se:nSitiYe than
-i:~api~§~hlj. ~!WRt9pi~~~oreS. and cog­
I
,~:nltlv~;fuI!ctibn~tests;;.Differences in I
"sttiaY9~sign'n:i'i:iYexprain why this I
study's results differ from those of r
other reports. i
of cognitive function and reaction time in
response 10 visual stimuli. The P30{J
latency reflects the senjory and cognilivt"
processing time associated with decision

250 VOLUME 7 NUMBER 4 JUL Y/AUGUST 1994. DIABETES SPECTRUM

 = ME a aw

-
;.ng
~lty.
R.S. Sherwin
WP. Borg Metabolic Effects of Insulin-Like

-;yt!)o.

R.:
5. D. Boulware
D..:partments oflmemal Medicine 1!.ri'd·~
Growth Factor I in Normal
.lli­
eo().

'191;
p.:diatrics. Yale L"niversity School of
~Ic!dicine. N..:w Haven. Conn.. USA
Humans
........ ............. ............. ...............................
.... ............. ................................................................................................................... .....................................
. "" '" ~

Ue$ KeyWords
Abstract
.&lu­ Insulin-like gro·...vth factor I
259­
Since the development of recombinant DNA technology. there has been a rapid
Metabolism expansion of interest in the use of human insulin-like gro\l'1h factor I (IGF-I)
Glucose clamp synthesized by recombinant DNA technology for the treatment of clinical dis­
Counterregulation orders. This article reviews recent studies of the metabolic elTeets of recombi­
Insulin secretion nant human IGF-I in normal humans. These studies demonstrated that under
DB. Insulin-dependent diabetes mellitus euglycemic conditions, IGF-I had potent effects on glucose (hepatic and
dell

eo in
peripheral), lipid and amino acid metabolism that closely resemble those of
oulin
insulin, despite a concomitant inhibitory effect on insulin secretion. Hypogly­
;}(or
cemia produced by IGF-I infusions (free-fall study and glucose clamps) had a
.ci
different effect on counterregu!atory responses compared with insulia. The ciu­ '>~, ~
;) a.

cagon response was absent, gro'W1h hormone (GH) release was atteriuated~:
rau.

while norepinephrine levels were increased. Suppression of glucagon release

during hypoglycemia impaired glucose recovery. Paradoxically, aWareness of
hypoglycemia was enhanced with IGF-I, partly due to stimulation of sympa­
thetic activity, Studies performed under hyperglycemic conditions showed that
IGF-I inhibited glucose-stimulated insulin secretion, but that this inhibitor;
effect was partiaily overcome by increasing the hyperglycemic stimulus. ~for;­
over, despite the decrease in insulin secretion, glucose disposal was accelerated
by IGF-I. These observations imply that IGF-I might be effective in human
diabetes. In particular, normalization of the decreased basal IGF-[ levels,
which are characteristic of poorly controlled patients with insulin-dependent
diabetes mellitus (lDDM), in pubertal patients might lower glucagon and GH
: pro­ levels and improve cellular metabolism in muscle. Further studies are neces­
'man sary, however. to detennine whether IGF-I has a therapeutic role in this group
than of patients with IDDM who arc particularly difficult to treat with insulin.
.J.!ale
(dent
ible.
Introduction gro'W1h factor I OGF-I). More recentl .... the availability of
human IGF-I synthesized by recomb~ant DNA tech~oI­
The classic studies of Froesch and colleagues [1-7) ogy has provided the impetus for a systematic assessment
demonstrated that somatomedin C, the putative mediator of the metabolic actions of IGF-I in vivo. Zapf et al. [8]
of the somatotropic actions of growth hormone (GH) [1], . were the first to show that recombinant human IGF-I had
exerted metabolic effects in vitro that closely resembled hypoglycemic effects in normal rats that were not inhibit­
those of insulin. It was duly redesignated as insulin-like ed by an ti-insulin antibOdies. GuIer et al. [9] subsequently

:aleg Roben S. Sherwin. ~ID

Yale L'ni"crsity ScbM o().Iedicinc
Dq::tanmenl oflnlcrc.aJ ~ledi'inclEndornnolosy
333 Cedar Street. P.lIP I
!-:ew H~vell. cr 06HOIUSAI . -~: ....
 levels rose from undetectabie to about 70 ng/m! W![!uo
15 min. There was a striking reduction in islet hormone5:
plasma insulin fell by 31%, C peptide by 58% and £!ucaQ:on
by 40% (p < 0.0 1). Despite the decline in insulin secretion.
glucose uptake (measured by 3- 3H-glucose) increased 2- [0
• G:ucose
t Hepatic
t Amino ~ Free t Insulin
glucose fatty aCids ~ /. secretion
3·fold over baseline (p < 0.0 I) and glucose oxidation (mea­
uotake acids
production sured by indirect calorimetry) increased by 50% during the

{~L~u

IGF·I infusion. IGF-I also produced a general fall in circu­ Fig. 2. GL

lating amino acid concentrations (p < 0.05), an effect that bYp..)gl ycem i;]
I
I
Insulin
encompassed both essential and nonessential amino acids.
Unexpectedly. IGF-I infusion caused a pronounced (60%)
isk denotes a ,
. 1<::\"<::1 compar~
wb<::re:J.s the ,
dccrease in hepatic glucose production and in circulaunll
difference be:'
free fatty acid levels (p < 0.00 [). The nonprotein respira(O~ hypoglycem i;,
Rg. 1. Comparison of the pattern of metabolic responses to [GF-I r;: quotient (by indirect calorimetry) rose from 0.83 ± 0.02 infusion (p <,
:d insulin in normal humans. to 0.88 ± 0.02 (p <0.05), reflecting a shift in fuel oxidation
from lipidS to carbohydrate.
The overall pattern of response to IGF·I seen in this The abs
o::monstrated a similar acute hypoglycemic effect in study is remarkably similar to that seen with insulin. In served dun.
':1lthy human volunteers. These studies clearly estab­ experiments in which insulin was compared directly with the glucose
hed the unique position of IGF-I as the only other natu­ IGF·I in the same individuals [unpubl. obs.], only minor tained. star:
cUy occurring hypoglycemic hormone besides insulin. dilTerences were observed when the doses of IGF-I and ly, the rna.:
To define the mechanisms for the effects of rGF-I more insulin were matched, based on their ability to stimulate .. release was
ecL~ely, it was administered by the euglycemic clamp glucose uptake (fig. I). The similarity of the pattern or Conversely
xl' 'Ie to awake, chronically catheterized rats fasted for metabolic responses to IGF-I and insulin suggests that more prOll':
-+ h LIO]. The effects of IGF-I were compared with those botb hormones may act via binding to the insulin rcceptOr pared with
insulin using doses ofeach hormone that produced com­ (or bybrid insulinlIGF-I receptor) andlor that both hor· caused a gr
.Jrable stimulation of glucose uptake, that is, were 'biolog­ mones activate a similar cascade of cellular evems afte.r~. as greater;::
:aily equivalent'. Although IGF-I and insulin increased each binds to its own specific receptor. enhanced 5
ucose uptake to a similar extent (by design) in the rat, er band. c
.eiT effects on hepatic glucose production (as measured hypoglycer
'Y 3- 3H-g1ucose) were strikingly different In contrast to Effects during Hypoglycemia '(P300), wa
,suuo, IGF-I failed to suppress hepatic glucose produc­ Tbese.c
on or the levels of free fatty acids. This review discusses a To determine whether the effects of IGF-I on counter­ limited by
.ariety of recent studies that have examined the metabolic regulatory hormones were distinguishable from tbose of glucose ree
ITects of recombinant human IGF-I in normal humans, insulin, hypoglycemia was used as a provocative stimulus Paradoxic:
lUS avoiding the potential limitation of species differ­ [12J. For this purpose, infusions of recombinant human with IGF-I
~nces in t!::e response to the hormone. IGF-I. 0.7 mg/kg/min, and insulin, 0.8 mIUlkg/min. were tion ofsyr;
compared for 120 min in 10 bealthy volunteers (plasma ing to spe
glucose allowed to fall freely). Despite similar plasma glu­ could be a..
Effects under Euglycemic Conditions cose nadirs (2.6 ± 0.1 compared with 2.7 ± I mmoVll. diabetes r.
IGF·I suppressed glucagon and GH responses (fig. 2) and ness sync:
To examine the metabolic effects of IGF-I without the stimulated norepinephrine release compared with insulin: hypoglyce:
,~onfounding changes produced by hypoglycemic counter­ epinephrine was unaffected by IGF-I. \\!hen the IGF-l
regulation, 9 healthy human volunteers (age 19-34 years) and insulin infusions were discontinued, the rebound
vere given an imravenous IGE-I. 20 Ilglkg bolus followed increase in plasma glucose was delayed with IGF-I com­ Effects
0;; a continuous infusion of 0.4 Jlglkglmin for 3 h [1 I}. pared with insulin. This delay in glucose recovery was
Pl?-"~a glucose was clamped at euglycemic levels (5 mmoV mainl\' due to persistent suppression of hepatic clucosc Studie~
l) ;lghout the IGF·I infusion using a variable infusion produ~tion as a result of the failure of glucagon I;vels EO a.bove) de
0f exogenous glucose. During the IGF infusion. total rise significantly. insulin se

Sherwin/Borg/Boulware ----~~=---------------~~
Metabolic Effects of 'GF-I
 ;,F-r
.ithin
-,If
~Oll r-­
'tlon, -
'- to i
i I
-!
lea­ !
l- t---­
.g the I » /

I
,
',rcu­ Fig. 2. GlucJgon and GH resp,;;hjes to ,
hat hypoglycemiJ produced by IGF-LTheaster­
isk denotes a significJnt ch:1ngein hormone
'>
,-ids.
:;0%)
.lUg
level compared with basal values (p < 0.05).
whereas tbe dagger indicates a significant
ditTerence berwet!n tbe hormonal response 1O
o
r Basal
/:: v
HypoglycemIa
.ata­ hypoglycemia achieved by insulin or IGF-I
0.02 ;;:;f;Jsion (p < 0.05).
jon

l this The absent glucagon response to hypoglycemia ob­ sists during glucose-stimulated insulin secretion. healthy,
.In served during the free-fall study was also confirmed when nonobese subjects received an intravenous infusion of
'lith the glucose clamp technique was used to produce a sus­ either recombinant human IGF-I, 0.4 Ilglkglmin. or saline
llfior tained, standardized, hypoglycemic stimulus. Surprising­ for 3 h [13]. During the first 60 min, euglycemia was fixed
, and ly, the magnitude of the inhibitory effect on glucagon using a variable glucose infusion. Thereafter, plasma glu­
late release was substantially greater than that seen with GH. cose was raised to two difTerent levels of hyperglycemia
II of.; Conversely, the IGF-I infusion once again generated a (clamp technique) to evaluate insulin responses [0 a stan­
:hat : more pronounced rise in circulating norepinephrine com­ dard stimulus. In one group (n = 6), glucose was raised 50
)to"'-'. pared with insulin. In keeping with these findings, IGF-I mgldl above baseline and in the other (n = 8) 125 mgldl
be caused a greater increase in heart rate than insulin, as well above baseline. .". "
"iter as greater awareness of hypoglycemia, findings suggesting At the +50 mgldl step, first and second phase' C-pep­
enhanced stimulation ofsympathetic activity. On the oth­ tide levels were suppressed by 40% during IGf-1 infusion.
er hand, cognitive function during IGF-I and insulin whereas insulin levels were suppressed (by 30%; p < 0.05)
hypoglycemia, as assessed by corticaf evoked potentials only during the second phase. Despite the reduction in
(P300), was no different. insulin secretion, the rate of glucose metabolism was 2­
These data suggest that the clinical use ofIGF-I may be fold higher in the IGF-I group (p < 0.00l). At the higher
ater­ limited by its ability to cause hypoglycemia and diminish glucose stimulus (+ 125 mg/dl), suppression of insulin
e of glucose recovery due to inhibition of glucagon secretion. secretion was less remarkable; only second-phase C pep­
.Jlus Paradoxically, awareness of hypoglycemia is enhanced tide levels were significantly reduced. Neither first- nor
man with IGF-I, presumably due to more pronounced stimula­ second-phase insulin levels were significantly difTerent
'fere tion of sympathetic nervous system activity. It is interest­ from control values. Again, rates of glucose metabolism
sma ing to speculate that this pattern of response to IGF-I were higher during IGF-I administration (11.8 ± 1.2
, glu­ could be advantageous in patients with insulin-dependent compared with 8.9 ± 0.8 mglkglmin; p < 0.0 I; fig. 3).
)lIl), diabetes mellitus (100M) with hypoglycemia unaware­ These data demonstrate that IGF-I inhibits glucose­
and ness syndrome and defective sympathetic responses to stimulated insulin secretion, but that this effect is sub­
ulin; hypoglycemia. stantially overcome by increasing the hyperglycemic stim­
'JF-I ulus. Despite the decrease in insulin secretion in response
und to hyperglycemia, glucose disposal is actually accelerated
:om­ Effects During Hyperglycemia by the ability of IGF-I to stimulate glucose metabolism.
was These findings suggest that the insulin-lowering effect of
:ose Studies conducted under euglycemic conditions (see IGF-I is not likely to limit its usefulness as a glucose-low­
:Is to above) demonstrate that IGF-I is a potent inhibitor of ering agent.
insulin secretion. To determine whether this effect per-

" 99
 ~
Jj.
ii
":~
"~
80.­ co:
E T T In
:3
.& 60­
T
..~
'/~//
J ad
/ />

/1'/",//
- eff
In
//;i;' -
."
th:
-
)';.

,:// !ir
// /~ - Tt
Fig.3. EtTect of IGF·I on glucose·s(imu­ //1/' di
bred insulin release and the rare of glucose Control IGF·I
in
metabolism during a + 125 mg/dl hypergly·
cemic clamp.
hl
d,
m
Implications for 100M

Most data indicate that patients with IDDM treated

conventionally have subnormal levels of IGF-I [14, 15],
particularly during puberty. This may not be the case in
patients with advanced retinopathy [16], though this find­
ing has been disputed [l7J. This issue will need to be
resolved if IGF-I is to be used as a therapeutic agent in
""
diabetes. Moreover, low-molecular-v,eight IGF-I-binding IGF·! deficiency
xoteins (IGFBPs), such as IGFBP-l, have been reported
to be increased in experimental diabetes in rodents [18}
and in patients with non-IDDM (NIDDM) [191 and in
patients with IDDM from whom insulin has been with­
drawn [20]. As low-molecular-weight binding proteins
have access to the extracellular fluid bathing IGF-I­
responsive tissues, this might further limit the availability
of biologically active IGF-I in patients with IDDM.
It has previously been suggested that raised GH levels
in IDDM are partly a compensatory attempt to overcome
tGH
I \t Glucagon

}
a block in IGF-I synthesis caused by insulin deficiency
and poor metabolic control [2l J. Although it is uncertain
whether IGF-I deficiency has direct adverse metabolic
effects in IDDM, to the extent that it contributes to GH
hypersecretion, it undoubtedly contributes to diabetic hy­
\ Insulin resistance
I
I perglycemia. It has been demonstrated that stimulation of
the modest GH elevations seen in poorly controlled dia·
I
!
betes produces marked hyperglycemia and metabolic de­
compensation in patients with IDDM despite intensive
treatment with the insulin pump [22J. Furthermore, it is
conceivable that IGF-I deficiency also plays a role in the t Glucose
t Amino acids
hyperglucagonemia of poorly controlled 100M. Thus. it t Free latty acidS
J is intriguing to speculate that insulin resistance associated
I with poorly controlled IDOM may be partly due to IGF·l"
deficiency, which in tum promotes GH and glucagon Fig. 4. Hypothetical role orIGF-[ deficiency in the pathophysio[· ,
ogya~IDDM.
hypersecretion (fig. 4).

Sherwin! Borg! Boulware ~etabolic Effects o(IGF-1

100
 1 Despire the: parent:.]] uflGF-I fur imtf0ving mcL100iic wdl as improve cellular metabolism in muscle. so that de-
connolin IDDyL littk :s known of irs i!tT~r:(s in !!)D'L \·:ltiC.;-~3 1:1 inst;~~n ::CC~ir.:lc :t:C':::, t~T~c~:~,:C'. :t=~~~j~,..· ;Jw :~!...; ..
j
In tn;:: BB r:H. a mudd of spontaneous IDDM. acute rating insulin resistance. It is noteworthy that administra­
administration of IGF-f exerted a pOtent stimulatory tion of insulin may in a similar fashion augment the meta.
etTect on glucose uptake indistinguishable from that seen bolic efTect ofIGF-1. Insulin appears to have a rapid elTect
in nondiabetic controls [23}. This occurred even though in lowering IGFBP-l. thereby increasing tissue access to
these diabetic animals exhibited insulin resistance; insu­ free IGF-l [24J. Such compkmenrary effects ofIGF-I and
lin-stimulated glucose uptake wa~ reduced by about 30%. insulin might facilitate restoration of normal substrate
Thus, the metabolic response to in(J.Ised IGF-I was not metabolism in IDOM.
diminished in diabetic rats withirrlpaired
." .. '­
responses to
insulin.
These findings imply that IGF-I might be efTective in Acknowledgements
human diabetes. For example, administration of low
This work was supported by grams from the US Public He3.Itb
doses of IGF-I sufficient to restore basal IGF-I levels to Service (DK-2049; and DK-4573:5) and a feUowship gram from The
normal in IDOM might lower glucagon and GH levels as Juvenile Diabetes Foundation International (PL).

................................. ................................. ... ..... ................................................................. ............... ........................... ....................................... ............................ .

References
DaughdJy WK. Hail K. Raben ~IS. Salmon
WD Ir. Van den Brande IL Van Wyk Jl:
Somatomedin: Proposed designation for sul­
phation flCtOr. ~ature 1972:235: 107.
:! Meuli C. Froesch ER: Insulin and non suppres­
sible insulin-like activiry (NS1L.lcs) stimulated
tbe same glucose transport system lOi.l tWO sepa­
rate receptors in rat heart. Biochem Biopbys
Res CommWl 1977;75:689~9S.
3 Zapf J. &boenle E. Froesch ER: fnsulin-tike
growtb factors I and II. some biological acriollS
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8 ZJpf J. Hauri C. Waldvogd ~1. Froescb ER:
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wrs I and II in normal and h:;;pophysectomized
rats.] Clin In...estI936;77:1768-1775.
9 Guler HP. Zapf1. Froesch ER: Short-term met­
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Med 1987;317:137-140.
10 Jacob R. Barrett E. Plewe G. Fagin KD. Sher.
win RS; Acute effects ofinsulin·like growth fac­
tor I on glucose and amino acid metabolism in
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A: CirCulating insulin-like gro\Olh factor I in
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betologiJ 1989:32:753-758.
18 Unterman TG. Patel K... Kum.tr Mahatl:tre V.
Rajarnohan G. Oehler DT. Becker RE; Regula­
tion at' low molecul.tr weigh t insulin-like
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19 Suikhri AM. Koistinen VA. Rutanen Hi. Jar­ ~'"
vinen H. Karonen SL Seppala M: Insulin regu­

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like acti,ity of human serum. Eur 1 Biocbem ] Oin Invest 1989:83:1717-1713. lin-like grov.th factOr binding proteins. J Clio

t9.78:87::!S5-296. II Boulware SD. Tamborlane V.fV. Matthews LS. Endocriaol Metab 1980:66:266-273.

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Froesch ER. Frevchet P: Effects of bi.'lding of gro"th factor I 00 glucose. lipid and amino add Edge JA. Amid SA. Howell R. Chard T. Rees

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leus muscle of le:m and obese mice: Compari­ E133. independeot IGF-binding protein in diabetes.

son with insulin. Endocrinology 1979:1~: 12 Kerr D. Tamborlane WV. Rife F. Sherwin RS: meilitus and its relatioilShip to insulin: A new

72.3-730. Effect of insulio·like growtb factor I on tbe role for insulin? Clio Endocrinol (Ox!) 1988:

5 apf 1, Froescb ER. Humbel RE: The insulin­ response to and recognition of hypoglycemia in ::9:66 i-6 i5.

like growtb factors (GF) oi humlll serum: bumans: A comparison witb insulin. 1 Oin ~I Tambortane WY. Hintl RL. Bergman M. Gen­

-Ghemicalllld biological cbaracterization and Invest 1993:91:141-147. el M. Felig P. Sherwin RS: Insulin infusion

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CUr! Top CeU RegulI981:19::!57-309. growth factor I inhibits glucose stimulated in· proved metabolic control Orl plasma somata­

6 Rechler MM. Nisslev SP. King GL. MosesAC.
Van Obberghen-Shiiling EE. Romanus IA.
Knight AB. Short PA. White ~I: ~fultiplicalion
stimulatiog a.:tivity (SA) from BRDA rat liver
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insulin. J Supramol SINct Cell Biocbem 1931:
15:~53-286.
7 Guenlher HL. Guenther HE. Froescb ER..
Aeisch H: Effects of insulin-like growth factor
on collagen llld glycosaminoglycan syntbesis
bv rabbit articular chondrQC'.tes in culture. 8­
p~rientia 1982:38:979-980..
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Press CM. Tamborlane WV: Effect of diabetes
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elTect ofage. J Oin Endocrinol ~fetab 1986:63:
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16 Merimee TJ. apf J. Froesch ER: Insulin-like
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.,., Press~!. Tamborlane WV. Sherwin RS: Impor.
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diating tbe metabolic derangements of dia­
betes. ~ Engl J Med 1984:310:310-3[5.
23 Jacob RJ. Sherwin RS. Bowen L. fryburg D.
Fagin KD. Tamborlane WV. Shulman GI:
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1632-1636.

tOl

f
•
I ......................................................................... ............. ........................... ...

~ ­

Discussion

I Attanasio (UK): What is your explanation for tbe decrease in

IGF-Ilevels during puberty in children \l(uh IDDM?
patients with IDOM. Which method did you use for measuring IGF·
{in the circulation and which extraction method did vou use?
A. Tl
A.G
Sherwin (USA): The defects in these 'patienl~ can be corrected by Sherwin (USA): At different times over the vea~ we ha~e used
E. s:
~lj aggressive insulin. tberapy. so it seems thli,tJqpk:,Qf insulin at the level acid-ethanol extraction and then measured tot;l IGF·I. or radio­
of the liver is important in the whole phenomenon. There may also ligand·radioreceptor assays. Although the absolute levels were differ· J
be GH resistance in these patients. and of course insulin can have an ent depending on the method used. it was a consistent finding that if Tr
etTect on GH and its ability to generate IGF·1. lOOM was not wei! controiled the IGF·r level was decreased.
LeRoith (USA): In your human studies. did you conclude that the 30t!;::.:.
Hagenas (Sweden): Is there any compensation for the low levels
.1 oflGF in 100M by altered levelsoflGFSP: etTect of IGF-I on the various parameters was mt!diated through the anc'
insulin receptor or the IGF·I receptor? He::;
Sher....in (USA): Patients who are deficient in rGF·' actually have
Sherwin (USA): Again. the data are lacking. Some of the effects Isl"3.'!
higher levels of IGFBP·I, though the levels of IGFBP·2 may be

I slightly decreased and {GFBP·3 is largely unaffected by diabetes. My

intuitive feeling is that the changes in IGFBPs do not compensate for

lowered IGF·r levels. but insufficient data are available to be cer·

are probably mediated through rGF·I receptors and some through

insulin receptors. The effect on the liver is most probably mediated
through the insulin receptor or a hybrid receptor. and the effects on
b Ur.i:~
Ins;::
A~~
c BI0:~
tain.
fat cells through an insul in receptor. Tne etTects on peripheral glucose
Isr:l:.'
J Strasburger(FRG): I was surprised by the levels ofIGF·I that you
described in normal young people and adultS compared with levels in
uptake and amino acids are probably mediated through IGF~I recep­
tors.

J Key

Hu:'

Sic:::
12:
Soc:
Bio'
1

l!5~

C'".~

lin

,
102. Sberwin/Borg/Boulware . Metabolic Effects oflGF·I
 LETTERS TO THE EDITOR
The Louisiana State Medical Society is a voluntary association of
physicians providing leadership for the advancement of the health of
The Misuse of Anabolic Steroids
the people of Louisiana and serving as the premier advocate for
patients and physicians.
Walter Borg, MD
Lately, we have been hearing many disturbing reports
The LSMS is dedicated to support the physicians of Louisiana in of disastrous consequences of anabolic steroid abuse by
continually improving the provision of quality health care for its citizens elite athletes. Alarmingly, in addition to those performers,
by creating a structure which: other people also misuse those hormones to improve their
appearance or “just to feel better”. The growing steroid
abuse by teenage girls is very concerning, too. We have to
Advocates an appropriate physician- patient relationship based on
educate our patients that anabolic steroids are extremely
ethical, intellectual, and scientific principles and the authority of the dangerous, unless prescribed for a genuine medical reason
physician in defining what constitutes the practice of medicine, and monitored by a competent physician. It is important to
let patients know that the long-term negative consequences
Figure. Aerial
Educates photograph
all members of the
regarding initial,
trends andtemporary USthat
other issues Army 24th
affect heavily out-weigh any short term gratifications of abuse.
General Hospital in Bizerté, Tunisia, North Africa, built in the spring Those consequences include hypogonadism, gynecomastia,
them personally
of 1943, and/oraprofessionally,
dismantled year later, and moved to a former cigarette prostate cancer, dysmenorrhea, virilization, hepatitis,
factory in Grosseto, Italy. Note in the foreground the prominent
accelerated atherosclerosis, mental problems, infertility,
wartime insignia
Communicates to of the US and
members ArmytheAir Forcepublic
general on thetheport wingtip of
a banking C-47 military air transport plane. and short stature.
recommendations of the Society, its purpose and the essential role of Anabolic steroids are class III controlled dangerous
physicians
RESPONSEin health care, DAVID M. BROUSSARD, MD:
FROM substances. Unfortunately, their danger is underappreciated.
Most steroid abusers obtain them from illegal sources.
However, there are worrisome situations when patients are
Monitors and attempts
I greatly to influence
appreciate agencies regarding
the clarifications and the essentialof
additions
Dr. Diaz to our work. As with any history, some facts and getting improperly prescribed steroids. Endocrinologists
role of physicians in the provision of healthcare, and are best trained to prescribe and monitor treatment
stories are more solid than others, and this one certainly had
its challenges. For me, most interesting has been seeing the involving steroids. However, there is a national shortage
Provides services
personalities andthat support physicians
characters personally
of yesterday and in today’s
echoed of those sub-specialists. Still, no physician should ever
professionally.
anesthesiologists. prescribe steroids simply to make patients feel better. In
the practice of medicine physicians have to strictly follow
Dr. Broussard is a staff anesthesiologist in the Department of scientific principles, legal rules, and ethical guidelines.
Anesthesiology at the Ochsner Clinic Foundation in New Orleans, The physician’s role is not to please their patients, but to
Louisiana. treat the disease and do no harm in the process. Not all
physicians who succumb to patients’ wishes are rogues.
Some are simply misguided and inexperienced. Medical
societies including the Louisiana State Medical Society and
PEER-REVIEWERS NEEDED the American Association of Clinical Endocrinologists are
mounting substantial efforts to prevent such situations. The
public has to be educated that the abused drug is a vehicle,
The Journal of the Louisiana State Medical and not the direct cause of a disaster. Many people abuse
substances out of ignorance. But any person who knows the
Society is a peer-reviewed journal
negative effects of illicit drugs and takes them anyway will
dependent on the participation of bear the grim consequences of such personal choice.
physicians in the evaluation process For the more information on this issue please refer to:
of all manuscripts. http://www.steroidabuse.gov/; http://www.usdoj.gov/dea/con-
cern/steroids.html; http://www.drugabuse.gov/Infofacts/steroids.
html; http://www.aace.com (Publication Section).
If you would be willing to lend
your expertise or would like more Dr. Borg is a Yale trained endocrinologist practicing in Lafayette,
Louisiana. He is a Delegate of Lafayette Parish Medical Society and
information, please contact the Public serves on the Reproductive Medicine and Socioeconomics Committees
Affairs Department at journal@lsms. of American Association of Clinical Endocrinologists.
org or 800.375.9508.

J La State Med Soc VOL 159 July/August 2007 179

JulAug 2007-Journal.indd 179 7/31/2007 12:32:32 PM

PROFESSIONAL REFERENCES:
YALE UNIVERSITY 1
PROFESSIONAL REFERENCES:
ACADIANA REGION 2
CURRICULUM VITAE
3
LIST OF PUBLICATIONS
4
EXAMPLES OF CITATIONS:
TEXTBOOKS & PAPERS 5
INFORMATION ABOUT
SELECTED JOURNALS 6
ORIGINAL PAPERS
7
ABSTRACTS
8
REVIEWS
9
ABSTRACTS
10
 ABSTRACTS – Adrenal Disorders
form. The rest of classic cases present as simple virilizing
as in case 1. CAH is an autosomal recessive disorder;
however no family history is identified in many cases and
a good physical exam can lead to diagnosis in girls. The
baby in case 1 was asymptomatic but had severe prenatal
virilization which required surgery after birth. On the
other hand salt wasting CAH can present early in life with
salt-wasting crisis as in case 2. The diagnosis is more dif-
ficult in males in whom genital ambiguity is not present.
In case 2 family history of CAH was positive and the new-
born screening was positive.
Conclusions: Our index of suspicion for CAH need to
be high since the severe forms can be life threatening.
Newborn screening is available in 48 states, allowing for
much earlier diagnosis of CAH, especially in boys where
genital exam is normal. Unfortunately, newborn screening
cannot yet help differentiate between simple virilizing and
salt-wasting forms of classic CAH, making close follow-
up of electrolytes in post-natal period extremely impor-
tant.
Abstract #101
FACTITIOUS HYPOADRENALISM
Walter P. Borg, MD
Objective: Importance of the diagnostic paradigm
which incorporates somatization and factitious disorders
into diferential diagnosis.
Case Presentation: 50 year-old female with past
medical history of multiple medical problems including
“thyroid disorders”, and “hypoglycemia”, has been
referred for Endocrine consultation due to suspected
“autoimmune endocrine dysfunction”. In addition to the
convoluted past medical history patient gave a history of
present illness virtually consistent with a textbook descrip-
tion of primary hypoadrenalism. Although she had no
medical training, she has prepared herself a voluminous
quasi-medical chart. The results of past and current ancil-
lary studies have been consistent with the diagnosis of pri-
mary hypoadrenalism. The appropriate treatment has been
instituted. However, a clinical course and patient's behav-
ior became atypical. Ultimately, she has been hospitalized.
Testing performed in a controlled hospital environment
did not confirm presence of any significant adrenal abnor-
mality.
Discussion: Physicians have an ethical duty to exert
due diligence in order to establish a true reason for which
a patient seeks medical care, rather than assume that all
patients must have an underlying serious organic disease.
Somatic disorders have to be vigorously sought out by all
available technical means at the disposal of medical sci-
ence. At the same time, however, an astute clinician shall
–2–
remember that there may be many other explanations,
besides organic etiologies of the puzzling clinical presen-
tations. Such alternative reasons should be considered par-
ticularly in cases where protean and multifarious
subjective data are accompanied by only scarce or bizarre
objective findings. Most experts agree that early discovery
of somatization or factitious disorder is associated with the
best prognosis. Such approach is not only in the best inter-
est of the particular patient, but it also serves society by
conserving limited medical resources.
Conclusions: Since physicians are traditionaly
trained to trust patients, even in cases characterized by
uncanny presentations, doctors tend to consider very
uncommon diagnoses rather than factitious disorders or
malingering. However, a proper diagnostic process calls
for proceeding from the most likely diagnoses to the least
likely ones and not to skip over factitious disorders.
Abstract #105
MEDICAL THERAPY OF CUSHING’S
SYNDROME
Teck-Kim Khoo, MD, Deepak Kumar, Pharm.D.,
Cheng Ean Chee, MD, and William F. Young, MD
Objective: To present the medical management of a
complicated case of Cushing's syndrome from ectopic
ACTH production.
Case Presentation: A 70-year old male presented
with Cushing’s syndrome from an ectopic ACTH source.
He had been treated with ketoconazole which resulted in
hepatitis. He was transferred for consideration of bilateral
adrenalectomy. Before he could undergo surgery, he
developed pneumocystic carinii and cytomegalovirus
pneumonitis requiring mechanical ventilation. His condi-
tion was felt to be too tenuous for surgery at that moment,
therefore his hypercortisolism was managed medically. He
had a 24-hour urine free cortisol (UFC) of 51728 ug, a.m.
cortisol 189.5 ug/dL, ACTH 529 pg/mL. The ACTH was
not suppressible. CT and octreotide scans did not reveal
the source of the ACTH. A pituitary MRI was normal. He
was started on mitotane with dexamethasone coverage.
Etomidate infusion was started on hospital day 7. This
decreased his a.m. cortisol to 54 ug/dL and 24-hour UFC
to 1092 ug. Aminoglutethimide was added on day 13 and
metyrapone 10 days later. This normalized his serum cor-
tisol and 24-hour UFC. He underwent bilateral adrenalec-
tomy a month later. The source of ACTH remains occult
at 1 year post-op.
Discussion: In patients with ectopic ACTH syn-
drome, the ideal treatment is surgical removal of the
source of ACTH. If this remains occult, bilateral adrena-
lectomy is usually recommended as the source can remain
AACE Meeting 2007
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&Jycop ~ wu ~ 2..16lkl i.a tbt eMlbo{ m:aca:! JrnOPr 1lr.:iI1Dc:mIK
in Dd ~ p~ ~ ..., due llI!01tly to • Wt:'JtItat!oa: or die ~
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l>..;5-UUN R:EGULATtON OF IU:NAl PROTEIN SYNTHESlSANO OEGitAOATlO'i Dfc:arn:, HOR."tO:fES Jt!tC'O't.A'n ~COSE-Ot.PDm£N1' I14St.'1.!.l(
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~~~~tr.MN,
AC710N c M9nt~QI.-RI~1;nrttb, J. Eq_n and J. RO~h·.
KIA, KIH and C.riatric .-dlci~_. JHU. a.ltlDQr_, KO
Vdy lide inIotmJ:tlon ~ ;rv;vbblt! t1!pt'dtnt; tM tq\I~ oi pt'CIfeW\ Hov.l th.~.p.utl~ aq.l'\t~ that could l'\orsalit. b4ta

~istn '" the: ki<l~. We pixcd !t.Iti1'Ij'>Ii", ~en in the lett i'tI'\aI ¥ein eell ~••pon$e to 91uco•• would be ot cOnsid.rabl.

;1{V) 4tld femoral v,ery (fN 01 ~ (~ w;1h " ~ ~ ben.ei~ i~ t~. er.at~nt o! non Insulin-depe~~.~t

~ ill the leI!~,aJ.wtr;-v lOci biticwe study, On tf'Ioe study <by. iN:.toeylll\i:nt'c ct~e~;.s ~!!lt~. Clucaqon-lik. p.ptide-l {~~J and

vcen OCG) wuinMed ~ny 10 rne.uure:~ now.and IH ~~ qlueos. in.ull~troplc ~~lde (~I') are L~ovn i~cr.eln

fPh.d was i.niused ~fy. Seri~l KV and fA ~ were ~ ~ hor=one. Vhict .nhAne. inaulln ••cretion but only in

tn_ pre. .nea or el.vet-« blOOd 91uco.e. In thi• • ~udy

vod dvrinJ: .. lh intnten~ infu~1(H'\ 01 ei~ iMulirI ONS. "-61 01' ~~ GAL.
(1-61. Left fW iNulin cnoceotr;J!1{II'\ d¢ubkd durin! iNS from >41 ~a 10 921:23
w. used a rat i~sullnoA4 e.ll lin. !RI~ IO"&-lS} to
s~udy the "~enl ••• ~.rlYlnq the inter.etlen of
1)."-4 tp,<O.OS). bvc did not: ~t! d\mfIC V\l_ FA iru4Jlin -.nO ~ lne~eti~. end qlueo... In tn••• ceLl. eLP atl.ulat~
~tntiOl1S ~ -SO pmolIl.,d -S.~ ~~ and d"1d nee l~.Ull~lteceetiQn with hell . .xl . . 1 eoneantratlo~ ot
c.r~JI! in eitMi 1JfDl1P. At1f1O~ ~ ~tr1II:ion .and ~ ~
IIt.1.l ~ -6S,urno1ll ~d - 3,0 ,.,moLkl",m.n'" 1'dPKfM;y vod did fIOI; ~
.u """"** .t. ')x10 )of wlt..'l C'LJI' ~11'l'9 t;\Io ord.r DC' _9Tlit.ud • .ore
potent t;."1.,,'t C:? 'l"he tvo bonK)n" ha .... e<With-. attt\'C't.a
and both $t.i.ulate in-ulin .ecr.tion.by decre4s1nq th6
~ tNS IX SAL ttl'h ~ ~ rde~ ~ by SO" in lNS (from
ra-quir-« ~ene.rati!)n 0:: 9Iuco•• to prodl.OC. halt ~
0.17;0.0:2: 100 O.Oft!:,O.02: JII"I"OI.q".mtt", p<O_05i, but cfld not ~ in: SAL 1I&xll1W1:1 inSulin .erereticn ~ by 1nct'."1r.q 'the aax1~
ro. 11 to.01 \1'$ {).. 1)::0.01 ~.1t&" .min". p_N$l. i'hrc ~t' did notduftsi! it!. 'lQlO\.lnt (It' iMiJlin ...cret..d. GLP .C~$ in " 'iluco_­
either t;I"OUP fO.14~0_Ol Yj. 0.16-::0.02 and 0.111::0.0) 'IS. 0.11:0.0:2: dependent. "J'ln.r tOo reor\l.l..t .0',,* c.ll. to .ite=.~. ~
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i~d.l..VL~U~l Q.tls~ The 91uco.. r~ir.~.nt Cor C~
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a.INlCAL RESEARCH. VOL. 42. NU 2. 1994

 Lack of Ge>dor IlUfcrmas in Bnm Glucooe

M+bof""" S, i • ad ~

yamia. AJ;NE O'CONNOR', ROOER J. NAGY",

BRIAN ROBINSON", ODd PATRiClC J. BOYLE",~, 11M.

Women h.ave _ I y been DOt-.f '" roI...... bypogIycemia

with row.,. syrnp<oms Ibm men. We po!tuIared !hat ,..,.w
dllfuen<:<s in brain glucose metabolism exist -..bid! """""" for ,
Ibis clinicol impr...io.. T", females and 12 males bad e<rdnl l
~ glucose d i f f = and blood 80w (I{I)
equilibriutn} lIlGS1lted as their glucose ..... ~ from 4.72
to 2.50 mM in five 1.Z5h steps. At eod> ""I', ')'llII>COms of
bypoglyumia ....... swred and blood fo< ~
bermoncs .... ooIleaed. M.... V>lues (±SE) for ""'.........
iappear t>ekJw (dala in bold _ V>lu.. sigDificandy diffen!m
Ifrom baseli.ae fu< "'" g<nol.,.., p<O.P2, • _ _ p-O.(J7).
F....... Mole 1
Epi S"" Bnm £pi S""
;"".,_ ,,~:~_::- :c ~:~.z::;-; e~~;~;:;:::::::t Et :::::::-.0.
GIuros< . Hype: ::.'3 ;:,:;!o:: P::.:,,::::: ;,;.:;~ <~'(; i

Il.Iin.
...z,:c.· •.:c''":·.'.',::::-:: ::.. ..:;::'..::',::~~.:.: t,:::.s;;:::c ....::.,,: ::~.: ;
PfI-I­ taIIIIi ~ ,,;r.l. ... ,~:. r;) :-'~) ~',c.~?_ 132".1: te-,-,;:-::, o~ E?l ,;:!C

,72 31.7±2-7 61±8 :5±2 39.5±3.7 lOS:!;30 6±2

4.13 32,8;tl.7 37.8±Z.3 liO±69 6j: 1
3.61 26.S±L2· ~2_S±'l~ -"'±1.S3 11:t
3.05 25.'±U 29.'±l.J 1093;:169 :!:
:!:
Coatraty to our hypothesis. there w~e 00 differences in the
eve! or glyumia required to impair brain gllICOS< metabolism
(P=0.927). ioitiote epinephrine ...,.erion (p=O.195), ...
recip.... symp<oms of bypoglycemia (p - 0.361) in females
mal... Thus. gender does "" play • major role io
etennining the onset of cenrraI nervous system med.iated
.....egulatory c"'l"'1lS<S ro bypogI)'<emia.

444 Hypoglycemia Enhances TlSSUC:Exttact.ioo 4.\6 I

of Glucose from the lnter>litial Spaa: or Lonl VeDtromedlal Hypotbalamus

Human Skeletal Muscle and Fat Despite Coontemgulalioo. GluC':opeDia ltiggers Counterregulatory Hormone
DAVID MAGGS. RALPH JACOB" and ROBERT S. R.I• ....,. WALTER P. BOR~, MONICA A. BORG,
SHERWlN·. N.w Haven, CT. GERALD I. SHULMAN'. New Haven. CT.
The cowllem:gulaoory response to hypoglycemia is V.",.romedial hypothalamic nuclei (VMH) "'" heliev-.f w
be~ 00 """"'" the actioo of insulin by reducing glu<:<:Jse have a role in [be detection or coordination of
uptake and increasing lipolysis in peripheral tissues. To counb:l1:egularory responses w hypoglycemia. To test this
directly .xamine these effects. microdialy,js probes were hypothesis, we delivered 2-deoxy-glucose (2-00) via
inserted into ~uadrjceps muscle and adipose ti.s.sue to bilaterally placed microdialvsi. probes inoo the VMH of
measure intctsbtial concentrations of glucose. IactaIe and conscious cb.rorlically catheterized Sprag.....Dawley rats.
g1y""",l. Ten beallily noo-OOcse subjects (aged 24 y--. Tbe goo! .... 00 pr<>ducc cellular gllICOpeDia locaI'-I It) the
range 17 to 29 years) were studied in the basal state and VMH. Rats with microdialysis probes placed inw the
during a 3b insulin clamp (3 mUlkglmin) aI eitber f.ootallobes serv-.f as a oootrol group. The table below
euglycemia (EU; 5.0 mM) or bypoglycemia (HYPO; 2.8 sbows Ihe plasma glucose (PG). glucagon (GN),
mM). PIasroa coonterregularory born1ooes wen: uncbanged epmepbnne (EPI). and norepinepbrine (NOR) level.
during Ell aod iDcTeased at last 2 fold during HYPO. In dunng Ibe VMH (n=7) and frontal lobe (n=6)
skeletal muscle and adipose tissue basal coocentratiom of microdialysis perfusions with 100 mM glucose and !be
interstitial glucose were Jower than ~,= same =tration of 2-00 (in random mier).
levels (coosistenl. with tissue uptake). H .
itsclf (EU clamp) did not alter <he ~laIionship betwcea VMII II..oobt
interstitial and plasma coocentrations. In COIltrast. HYPO G*­ Z-1lG ."::~ .
produced a much ~ fall in muscle (72 ± 9'k) and fal PC (~!) 6.&.0.3 12.3.tl).ga
6.7,j).l 6.7..0.1
01'1 (oglL) 120-<10 38h88' 1\9..9 110±7
(68 :I: \0%) dialysate glucose as compan:d 00 plasma (42:t EP1 (oM) O.6±lll 18.2±3.3* 0.7:<0.2 O.6±O.2
3%, p<.01). Basal intcrstitiallactate and glycerol levels, NOR (oM) 1.1..02 6. !±LZ' I.hOA 0,9..0.2
unlike glucose. were higher in muscle and adipose thao In
plasma (e<>nSist<nt with tissue ",lease) and neithes EU!IOr ·p<O.05 ''S. coolrol. As sbown ahove, local perfusioo of
HYPO allered this relationship. Howcnr. during HYPO 2-00 (bu. 00< glucose) mOO the VMH ca"""" a striking
inter>litiallocwe and glycerol were mari=lly higher thao '''''''''''''' '" plasma glucose and ~aIll<y bonnoooe
baseline and EU levels. Cooc!usions: I. In !be interstitial • levels. 2-00, however. had 00 effect wben delivend 00 !be
spaoe of skl:1etal muscle and adipose tissue HYPO dc!>Ict<s C froIItallobes. Conclusions: 1) GbltXlpetli. JocaIi:z.cl:lIO
glucose and iDc= lactate and glycerol. 2. Thus. !tYPO 'I .be VMH .riggers the release of glucagon and
per 50 iDc= glucose extraction by peripberal insulin catechoIamines; and l} The oeurons """;ng g1ucopenia
semitiv. tissues in !he face of counb:negu!atory bormoDe may be "tuaI<d
in the VMH.
action.

142A

 I _ _ _ _...J!!<p>Iic HyposI~ is U..o\e .. _

3 I$~.u ~ Tr.t.:lSplanQoon ~
,- e:.u-r.pt,.;oa ill 0-;.... Ooc:<
"=:-_-:-:-_0:-' E?oephriDo - - ",J S~ R=g:nitioo
Our. ., HfPOi.'l'=nia aAVID M, ~"DALI.". DESMO....a 1'.

l
~ DAVIS', CHltIS SHAVEIlS. DOSS NE,>,L. ERIC

All.!:N. PHllllP WIl.UAlIIS.Ii_ lN,

The _ of;lW stud)' .... ., ~ --t.pati<

, hypog;lyc.ett'l.b -could roo.:afy tht- effcc::. of1JliJd h)'~""""""'" QQ the
: b~1L Swdtc:s wen:: c~~ Oll nver:tiJld.1'.;u.u:d ~ cJgp... Exh
ROONEY. R. PAL'L ROBERTSON<. Mi~ M:'/,
tJ;.r:pmed ep~ (E.:PO ~n .u:d. S}1'r.ptoCl :::u.ware::c:u
~wi<1g hypQgJ)'o;::::x.iJ, <1t1: ~ IJI paCcnu with tonr-st.ul4ing: Ty;>e I
di~ (IDDMl. ~ ~urion (i?TK)
l':LLOnt;t.i.n:.J !oni~ aormagtJ~ :;and t.:llmi~ $eVen!
esr..abtishes iI.lld

hy~ in;:.ar.ients 'kith, lOOM. V;'lmbtt iaQg~ restO't':.ltion of

<rudy _ _ of >II SO"",, . - period... «) . . . """",,1

1 . period. aM,a 180 m.ic EC:Sl ~ hu:u:lia wu ia:filsed :It.a. rZ& of l-S
: .:lUfkdmin Uuo ,,~ 'fei:n iD ~ ~ grourpL lD QrftC
, """'" ~ n=I) p...... ~ .... <!=pod" 11±J "'!fdI" \be
~Il)'ttll"j.l (JYe"r ilUl'ly ye:n ~ i.lT.prov¢tn.('!lt$ in qii.'1I!phr...tlC
:.mdlCf symptom ~ O,rf..ng !rypogl~~ is IlO(
We perii>n=! ~ ~)1X>iI:=mi< clmlp$ 7 PxT, m
mown.
(dur:lrioo IDOM!7!:3 yr~ 49:=11 rm::HU.hs post-trl.n$pU4t). 8 100M
m:ipi=a
i bmo aad U"ct'. ;n J st'lCO'Od (L.Hy: p4) cJ.ucase W'2i$ ia!uscd. i.tteo bam ~ts (Gt.nn-oG n::t:lyr) -3nd 6 be:U!:hy controls 10 ~ wbet.~
'I <=tid aod V<!'!dlr.I! ,...<!rios '" cbmp til< !:nil! " ~2 "'!fdI md I:pi~~.aad iympuxn ~'11<.!.~;:es.$ are impt'OYed by
\be""", JlII«>K .. $tl mp'dl (Uiyl- laul/tinl ~ cf =--"fly«::llU. Bodl P'lTx lIld lDOlo! Iu4 osubUsIled
i ':p<:ipbctolly 10 c!:lmp
a=!)
gTtNp (LC: b:ad m
bo4h ti'vcr were cb:t:ppc:d
:1t t p.;:ose!.eve! of ~tow:r.n.k d:o'sf-~on as ~ by RR \o'arUooo I'P:tTx 6:::! ....
IDOM 9:::.!..~..1.i >15, J..O:d V:tlSJ.i...2.~":o ,P.tT.l- LiO;;;j.l "', lDD~
3 =J m,i~_ P!~ ill$u.iin icrds ~cr.e s~ (1';5.:toJ'W~) i.3
L::~.J, oor.eal:> L1l), ;md. ill subjc:eu ~:t ~~ of
e3C.b~. Hcp;uicgtucose~~.\HG2}was~us:m.J:J­
!1 JH g!uc:Mt. R.c:w.lu from the ~y f;t::ltC final 60 a.ua:s of c.cl:t study !':;~YO~y=nl;: ~~ Scq~ti.:d 4$ mJr.uu: jl~cs.c.i'~ of
70. 60. 50 md.;.o ~dl wet: ~.1!:d meu\ {!:5~ EPt t't:$1)On.se
Iw= HC t.C
;t.')d:;;yrcptOm(S.tJs.core~~ ,
I E?t inimD 12 ~ ~ E.l
1 S('3.iu Gi~ (ms'dt) 71;t.3
~ Tx 5l=! tS1~ 391;:!l 39-t~S
. Lh·crGlUCCIe tmgidO 11:t.:'; ~J
IDOM id 11l=!3 104-"'0 221:Ji
£;>~ (pg/mil 2';1:::35 279::113 IOlll:l!O' Co..'iT 71:::;11 269=39 ~9"-= t 743::.33
)l~(P!iml) !31.t26 Z1O:t98 )12",. $; SCORE :0. W !!2 =:J
Cortisol (p,gIdl) :!.otO.~ 3.I;t.L" 10.6;,1.1" Px Tx {} :L9±LO 0-"',1::1. t 8~"
GI_(pglmil ~ 41;:.16 lODM 0 !l&::f).4 Ui::ll,8 l.i:l9
HOP (mgt<glminl 05!.O..t O~." (0," 0 1"::;),6 52::;),9 7.9:0.6
• p<O.O.!l \IS Uly ~k.l:I. E:P1 w.;u i:~tly g;te:IU:r in hTx than i.-, IDO~;u 60. $0 ~
GlueD« of :;0 mydl evoW li:a!c Of 00 ~gubtary n:spoMe. .+O:::igf<U {p<:O-Dl1. txlt :m13ir..ed lignii'i:om!y tGwet' III P1:Tx dun in
t)e.;.-e3.Si.ng the: giUl;()$t lC"o'rl a !he liver- to :SO mgiJJ f:rIkd to Irigp::r In ~th)' COl'tC"OLs __ brx.b 50 3ll4.tO ml"U {p<tH1'2}. S~ s.c:xes at aU ~

:DC.~~~~ We:conclud::ttw.b)~~ cut"lng: b~I!"c.=:cil w~ ~ significa::.Iy ditfe:e::t belw~ Px.Tx.:u:d

.;~o 1Sde~ (lIl ~ gfuc.csc~:md l:I:I::d:b:patic
CO!'f'T It".d'~ l'.igt;:r in P'xTx ~ tDD!\t (p<i).OI t u. CQn~h;sioo,
:u!5:.lin~ nOr.::'.ogi::=ia:.W.r::' ~ :::l.:uplant:U.lD~ C:Ye!'! in panents
g!~ pby lirilio lJ< """'"' in <l>e~"'l' _ '" wi:h e.r,..u,lW;eC :;...~c ..iys.fuc,:;tion. !clt to i:t:l~.-od epioephrioe
ll".odt:r;1f:e byrogt~fcemia ~.:IAd :lCr:'~I.t3t!OO ef symptQr.l reco1n.i!i.on durinS HlsuJin­
:"r:l..."C~J" 1", •

<. 1 Sust:1ined LipoI~";' 11 Ur¢y R~hle i"""'_,

l -_ _.....J, i'cst-H~=nie InsuIlJ> Rcis= bI
! H""""". CAR.'-ID<'E FA.'IE.U. SIMOl''E PA.'.IPANELLI.
, ~CO CIOFETl'A,. PAOLA DEL SlJ'DACO. l'>IAtJRO
, LEPORE.. GE.'<OIlA B. BOW'. P=gia. I
C~ borm_ (CRHl =:I.aurl "poi~~is
(UP) Iarg<!)' r=!i:w:s !he iac=sa! bc;>.u:c gJu= prociu<:::011
(HOi') and "'l'Presso:! gIumse unliz:mCl1 (GL') du~
~'pogiy= (ll), To test <he ~;>o<hesis thaI ~ UP
,modi= also post-H lllSUlin ~ (post-H,.IRI, •
,*;><=ulil>::ru<~=nie dam;> ..." " pcribtmed III 6 vol""""",
~-6 h fo~il:g 3 ~ of _ imWin..ugi),t<m1.l (E) (sn.:!y I. SI)
or insulin-h)7<1iy""nia (ll) (plasma gluoos<:. 1'0. 30::0,1 m:"O
.....auo::d on :; ~.s (swd:ic::s 2""*. $.4-1. ~ order), 51
,,,,,,,Iy ..... H. S3 WiIS OS 52. bin UP ill """""'" "'. and >iter II
, ~-a.s blocked boy of"1i a.c.:ipunox- $4. w;u ~ S3-. but t:l C$t3.b1Uh De

, tipd _en
j <XtT.l;mti-LIP ~_ of ~ 10% intr.ilipid~ ~
. ioJiu,ed 31 r= '" mUmc inc=.s<o III pl""",- FF A. gI)=roI 0UId
Ilip-ox) of S2. Results, Comp.,...; ,~ E. H _
: pon-H.JR (lIGO iIl=saI from ·1.1=0,2 '" 22={),4. Gt;
~ from l.S.l:!:;;.6 10 lU=2,1 (S2 vs 51. ",\tI1q/mm.

q,IH PERFCSIO:'I with ECF 01"" ADDED GLrCOSE, p<O 05). In 53. FFA, g1)'CQ'I)/, .ad Lip_ ~ a&r
!) m..'t1 lSm.'4{ 100 m.\1 =1'''"''' ep<O as). ...l>cn:1s l PG and CRR ...". srmiIar (P=NS)
:J.=.'!' :::=..l. a=4 (" 52), In 53. "",-H.JR o=Iy~: HGO ~ II)
EP[ln.\t) :li.~6 ~8~.:"- 68=L~" ·10=.0.4, sl"""""'!"''''"'' from a l = (GNO) to J.6±Q.; 1 (1.1':
"OR:n~.tl Ii-k::L9 ::,~J.5'" L9-:.0,;1'" 0,51 in 52). 0.... in=oscd II) ••(bJ,1 (2.1±Q.IS in 52). Gil
G ;-;HH!:Lt 1'%::158 .!.5!.=.."?1 t~9-t ina=:«I to 21.!I:!::l.6 (all ",'"<Ymm. p<0.001 " 52). ~
A stnkln1! il'lnibi!.lor; or" C'l';!cno[aJxune.:mJ gluc:tgcn due to 20% e:ffc::t of acipirnax pc Sit QQ i.ns;ilin ~ DO( doc to
:-de.:l..$e w!.s ol:l.scrved In bOw~ VMH groups ~rfwed ...,ith
ducesc!'. Ctlni!'lusions! 1) The V~H roll${ sense
ITA/gly=oI ~ (SI .,. S2l, \be "'" a:aributioo of UP
flyposlyce~13 fer fuil acuy;).tlon of cateCholamine and '" post-H,.IR ..... -54% (S3 minus S4) Dlod.,...,., CRli
-zl\!Cl\!On secrec.O:L 1) The Gorninmt gluccse sensor for _ UP POt oaIy pI:lr-o • key Cit !'Ok dunos Ii, but :abo
h:1?Oi!yccmICCOU.1u::ricgul:ttlOn resides in the VMH,. bzaely mcdi.'!.I<o post-H,.IR by ~ HGO. GN<;,. aod
~ o:cCaI:i... and utili'nlrio<> of gh=se.

lA.

3A

I
 195 I,Uctatar _ Loca1Iy iDID 11>0 197
1"=--,--:---'
The c!1ec: of f:<t!":I"ertCUJ L.lct.tC' on. CC':-ca.;a]
function C!:urin~ Hypo~I:-'t..l:.er'..i.l i.e IDD ....1 L,C
V.ub'.mcdlaJ H~~~

1 f~at.trT"'e&ul.tJoD D1lrtD'- SirtemJc By P1 ccmla.

H01l'.=y Sobjeru. HRO"lIT.'" KI"G, ~L"'RlE . FR"-"CE
~'.::'!'ICA A. BORG, ROBERT S. SHER"'Th, ALTER P.
KO:-;C, HLU11ER P.'RKL", L... :-; ~L'CDO:-;.-u.D'.

I BORG", WIll.lAM V. TA.\{])ORLANE", GERALD I.

I, ROBERT TATTERS.UL. :'iorri.n~~ ex...

Haven. cr:

SHL'l..\tlA..."'l-_ New
__ v.e have previollsly reported ~( c!.c Jlu.coseasor

ic-.. _7:;.= l::-?cCes.:s :::.r.: t::-_<1:'''~(XLS laC"...J:e F:-:"'~" c::-!:::n:

.:-..:::.~""'C. C!:..:.:-~; l:.y-;;c-s!yc.ae:-:-..:a ""''as tes::t<! In 9 ("5F,. ;-":..:!.;-,-~ . .r

gatin, horClOnal responses to llypo,IYcemla as loatcd
..be: yc:ntrOl:Iledi.l.l bypothalamaa (VMl-1) aDd that loa.l a.:;d 9 iDD\1 (5.\0 I""""::;ec:.s C'lJ..."':.;::S in F~ 0:.:-:.;::.: ?.~.::::.;
J
VMH &1acosc: pcrl'usio1l bloc.b eoe,tatepatory bormoDe I Tr.;ne (RT), A;;&':~:"y Bi"lx; S~ R..~cc.s.e ( ..o\.BR) ...:::: P;,.:.;
=pon= To ckt=i•• .,hotllct 1M. b):Prod"'" of a:I=­ 1d"....e:".C';". ,"::-e cs~ as ~e.J5'.;_r'!"S cf ce:-:brai f.x.:::cr. S:':::j~
mell.boliso. I.cute. eu fuoctlon W1~ the: VMH &J aD

I/ :~~?:~~:/~~:~o;::~~~:~~:,~~,~~c"~-:~)~

alt..aua.c.vc: for t1l1COSC. we deliv~ lr 01'" D-~ctatc locall.y

to Il:c VMH. durio, systemic b~,I:ycelll1_•. H?'r th~,
J
purpose, we com.bined bil.tc~ \ MH D1J~I.IYSIS
periusion (100t:t.'-A: L-l~tc or au. .o~-metaboh:z.abl~ D­ I.' ~":'1 oct.:::: il:::r...!: ."'"JS ~~.. 5eC. ;1: :te oOef ~Cr::-2: S-l::::e
~sot:lcr) .. with • cll"lyeemlc-bypo.tlYc:c:::ttlC cl.a.aIp tec:!uli.quc , Ce::-eb:-a.: fo...::::;;::::x t...-s""J w=~ pe.~_ ... ;eC or.. e3~ 1:i.xx:: ,g:::.:..::s:e
) ;::..:::c_ _ ...::x IDu~! s-...:~;.x:::::s l·:-:,:-.).·:d::o s:g:;:5::::!;:: .:.:..~-:::::-!'S ::::
11:1 consaous cbro:ually atbrtenu:d rIU. Thc"'bIblc below
COtDpue$ the effect of 1QC3.1 VMH perftLSioa. of L-lactatc

I~~;i,:r~"~~~~~;-,~~~~~'I~~~,~~~~~;1.Lg~

A1ld D-13CtJ.tc (control) 0:1 plasma epinephrine ~I).

corcpiocphrine (NOR) and ,Iuea,oll (G~) c:ic".uous
daring systemic bypo,lycemia (-p<D.OS VI 0011001):
""MlI 'PERFUSION """'th "LACTATE.: 1.1 BG c::- .-- -~-
0

f·...... '" V' . .R-1_ r_~

..I P .;.Jo ...:r::~c:.' :r:::...... s --' DD'.1
L.Ge.... (u;;sj D·Ge.... (-:l :::

I~~::7;~7:J-~:;f,~f~~~(~'~~:;::~~

EP1 (D~I) . 8.3.3.Z" 53.3%9.1

l\'OR (.M) 2.9%0.8' 1l.2:2.5
GL';(agiL) 6Z:43" 49:S=8.S
Local VMH perfusioQ wilh l-I.cuto decreased I··~-.~ .S"'.. _}~, r. 3-..: ...., _ 5 r._\.1 :I.! 6r:.e r~ "~a-_tr'~
counterreculnory bormol1c R3poOSCS to h~,lyccmi.l. by
80-85% as compared to tbe QOIHnC:l.I.boll'z.ablc: D-Iac:tatc ,. ... ,,_. •..::': :;;6 -.'-
C01ltrol. Hormonal snpprc:uiol1 with L-Iactato was
accmnpao.ied by .. -5-fold increase: in the: aooul1t of

1
eXOIcnous ,1ucose io.fused to mailltaia .. stable:
b.ypoglycerr.ic: plue.au (p<O.05). Conc:lllISioo: The t1llco.sc
seosiog mecb.allism in the V;\iH n:3ponds to I.cute, LDd
thus is DOl specific for t11lC~. This unpl:C3 that lhe VMH
maya.rt ;u a. fuel sc:l.!lOr Rtbcr ths.n &.$ • ~:lCO:SC sensor.

!
,

196 !.acI:ue r.scues Cognitil-c: Functioa wi Impact of NoctlIrual HrPOItycemLa oq

--.....JCountcmgula!ory ~ ~ liypogIy<cmia. HJPOIlyttmic: CopittYc {)y$fIlI1CDOQ. the

ALBERTO MARAN", CRISTINA CREPALDL TATIAN FoDowl..bC Mornme: III mDM..

LUCCA, L-\." A. MACDONALD", srEFA."O DEL PRATO".
Sul>stx>::o _o<beLJhan_du=<. maJ' ~~ and
countcm:gula!ory ~ To itt·~pltj
~~ .~ rr~y_~._a:' ~ ~ substmc in
p = of law blood ~ we studied lyoluntt<n (6MlIF,lS
=1 yrs) using ~crmjc rbmp (1.5 mUII;!min
intnvooow iasulin; plasma &lucoso (PO) reduced to 50±1 rogIdi
! 160 min.) in "'" diffuol oo;uKm: 1) ~_.;udL.wiI!I .
I 2) with)'!'Uf>_\nft;sioJL(Na::~)O """,V'qImUl) stan«!
I the 0QSd. of S}-m;x.oms of Irjpoglycan.ia.. _Sl~. ~
aporiClCal at !irniI3r g1uccsc Icvclr (aurooonUc S4=1 V'S ~±l
"'8idl. =rogIy""pcnic Sil:!:l V'S 53±l q1d1) buI. ~
~.=t<d ..by.l'cr.~ ( = at 160 min 2.6:!:I YS U:1, p-O.02
and O.4o!Jl,4 V'S 4.U1, p-O.01)..~ ~_"""""
similar glucose I=1s (PO SS±l V'S S!.!:1 0llVd\) but """".~
_ by IocI= (AUC 16S± 21 ... 314~S pmoVmIllW min.
c. FAI-o"ELLI. D. PARAMORE. T. HERSHEY, C. TERKAM?, S.
CRAFT ond P. CRYER." SL \.cuis. MO U.S.A.
Awilaolc data are conflicting on the elinically and rnedwtis::ically
n:IC'VItII question. Do glyccnic ~ for- hypoglyccnic cognitive.
-c:IysfiJncrion,. like those for eowu.::rregulatoty actiwtion and symproms..
shin to Iowcr pl&sma glUC<lse ccnc<ntt>lioas following '" episode: Dr
h~ycemia? To ,.,. d1< bypom..is dIa'.1ower pi""", glucose:
conctnaztions are required to cause hypoglytcnic cognitive
dysfunction following recent antecedent hypoglycemia II patie.-ns
with roOM (~ w~n; median. age,. dwottion of 100M.. BMI and
HbA~ - 24 ye=. 13 )Un. 2S.0 4'=>' and S.!I% respccti"ly) were
- on two ~ ""'" wi<h clamped n<>a1><T>OI (2l3OMl300h)
hypoglycania (HYPO, 2.7±O.1 mmoVL) and once with clamped
noctumaJ euglycemia (EU. 6.1*0.1 I:UDoVL) in t'2Ddom sequence..
Hypcrinsu\incmic, SI<ppcd hypoglycanic (- 6.1, '.7, 4.2, 3.6, 3.1 and
25 mmoVL) clamps we< performed d1< following mornings st>rtinS
II 0300h.. Cogniti~ function lc:StS included measures of pattern

1
p-O:01:i>=k 2.6:!:O.S .. 4.1 ±O.7 """,11m!. p-O.O(5) with !!!
diffu'!'.CO'!.in ""!:>£~CJ2~ ~ (PO 56:3 ... SS±2, p-O.6.
=ognition and mcn>O')' (Dc\ay<d Non-Matd> '" Sample).
infotm.ltion proc.e:uing (Paced 5mal Addition). and dcc.brative
"""""'Y (lnuncd..., and Ddoy<d Pu.grspb R=Il). ~ on
AUe 5-4-4=Ill V'S 500±75 pmoIhnl. p-(5). Cqp>itiYe Iimctioo! all _ dc1eri0<>te<l ,;gn;tiant!y during morning stepped
. in boch stlIdics (slawio!! of '"'JlOI"'" .. PG 55±2 .. ~
::2) but • \css == impoirme!Il 0<:<>lfT<d ~>mt<-' d IDSCC
khoioc =ctioo time :It 160 min. 22 ±I2 YO TI±J I, p-O.Oll- We
hypog/ytemi< clamps. Followins noaumaJ HYPO V1. EU: I)
Inaat>cnU in _ time 00 tho Oe\aytd N....Mmb '" Sample wi:
(to r<Ni vah>co of 2093'<221 vs. 23~ISI mscc) were rcduo:d
, conclude that • rise ill baom &4a" 1ho de, ,., « (-tom). 2) Incs:uhClit:ll in the m.mbcr of c:nws on !be PICCd Serial

1 \hyp.>gIyt=ie'
p~ca1
~ fUocrion
=-
S}mpI<lmS ~ICUIdy -
m>d J="'ZO • ftu1hcr ~
durina
hyposIy=aio. ~ _ .. m
Additloo task (to fiMJ ~ of 1.. 1~1.J V1 10.,3..:601..$ cr.on:) were
ml"""\ U> ~ 0.D2). l) The number of bits r=dIcd ;" the I'angroph
Rcca11 _ w= noc _ sianif\canlly. 1beoe data inc!i<a1e 1hM
~ ~ fucllb< hyposI~ braia.. 10_ p\am& Il~ CO"""",,"""d ... rcquirod 10 impair some

I I>p<CIJ of capUtive funcri<m followinc r=nt o n ' _

ia in .. with 100M.

A numera\ beside an author'. name i'1dIcaIes • duaJI!y oIlnIerwt. See page 1A.

J 55A
 Complications, Hypoglycelllld dilU
___inc and lau' [1.,,-aliOM of uCUlt Art' t.: n3blt
ttp.ifiCJn{ :\on-GlucOW" Fum Durin&: ,",cute H~lycnni2.
t£AJU( E\A:--:S'. ALBERTO ;\IARA."':. Jill lOMAS: . AS'DREW
ft.R...'ET', RAHtELA AJ~IAll. STO':'iNY JOSEPH'. DAVID HOP·
I.L'iS'. STEPHA~IE A).t1El 1• I Dq}/ of .w~drCln~. KITrg.:S .WcdicaJ
.klUi LonJon CA'! [)cpr o/.\,.:JlClffe. L',nv of Pa.irrnr, lro~\'
C..,tnr;. w ';'-'f,,".:nllo,M\;lll~hln~ Inc hwrun br.Ufl can U:IoC non·,Iuc~
.-.cnl..:~. ty,.;h :u IX~IC ;and Ii;C'\OIIlO:S. t,-, 1oU?J'Of1 mcubohsrr: ~ functton.
"''''''c m'''~(I~~ whc1:hcT the ~h,,"~oC prccut'SOI'". :lbn_. UII be:
-'.vI.. u~ "'-c uudlC\l hc:2lth)" mak subJO:u. IUoIng .1 st~ bypo­
~(TI1;C h:-opmnsuilncmic cUmp mfusing eithc:r 2 mmol:'k@;'mift .abninc
~.u n"~). uhnc ISS n,,"",IOf}O \lfTIiOl.'kg;mln bCUlC (l: 11-7). \\1: mea­
...-cooJ CO\;f\tet'l'~'~torV hormone: ~. ~'mpeomt by qudDOMIirt
.-J .:,-,~nlllt.c 1~n.:UOlr:· h~ a 11IInl.~UL1')· I" .:hoM".~ ~uon UIlIC" feRn.
~ \\'orJ, (o.'Ilo)r.1OO CoIO'l'·\\'-'rd. Tr•..,1 ~ktng Am.:! B J.nd Ji:lierup·
~ ICS~"I AbnlllC !c .. cls rose \\.uh AL ~56;J;I~tO 597~4) ufT)QLI buc:hn.e
• p...,) 001 H !'$lfohc::l! umOl1 ~.J.k. p-...t) 00 vs All txutc also
pc:lit..
-..: ..'unn~ .-\L po.!.ll.:;nJ. ~I 3 II =0 15 ~.1 I ~s....-o :::0 mmoll :-.os jP-o OO).;vId
~j!:.n I;h....:ow th~ld 2 ltb:O II mmolil Durin, L.lacwc rose wnh­
• M) mUlS (0) SI~ iUtc of ~ )6--0 I..! mmoL1 (gluc:~ IhttsboLd :5.0
~ 1) Du:-'n~ '" L lhc:K ...·ere no J.tT~C$ ia ilucose ~ldi foc epi.
Iqftnnc (3 ..I~ nJ IU .." J "'~~ IJ .l1Ifl\.1l1 .... L ..... !'-Is. pa"S) 01" other bar·
_ r.;spon,..:,. ':'':\.~ slu.::at.'UfI whh..""h t.."11Jo:U to sun al..l h"ber ~I~
1roril) }I=O 1:<. u :::nt)rO)1'l mm.lI·1. AL ". NS. p....o IOj Glucoscthre!.h·
~ (,)l ,:m;lhJlltlo ..In...! ":'"'t,:llI!r\·1.' J;.,rUllI.:f>Olr Ufl a\l t~b ......"1""C ;11:50 uzuf·
IKIC\J (lou! SYlnj)conl:>. 3 31s0 16.~ 3 ~=O:!o mlOOll ..-\L '.,) z...;S. paNS
CIT. 3 o~~ IS 0"$ 3 05=0 15 mmoL·1. AL ''- !'Os. p... ~s) In ..- ontr1St,. Dput
~lJ.ons of b..-w.:- III L Lo~ gt\ll!OSoe k~ds fOf ho.w"manc rcspaua.
~S:lnJ dci.:lycd CRT ("<0.001 v.:J:"<iS for 1.11) We ':O(\I;lude ~ ala­
___ u not ..Ib!e to be dcl,\ered .and.", mc:ubohscl to act as. ~ SlgniffC.Ant
..csTbn1 mo:ob.lh.: Iud In nufI. and thai W.:: c:ic:"al1\)OS of lxbte are pan or
... c:..,., rno:rrc,;u!;u,......- r.;s~~ ~ arc (00.' ttlC lO SlIpport ..::~I rncubo-­
"""' .. ::~ :\;n~·li"tl
....(tcd F.pift... "hdne RC"Spop~ 1.. 1I~·poi:.lyeaC"!Slis llurin~ SIcc-p in
.Io401~co''"ftlS ft"ilh illl);\1.
r"l.;l PORTER. STEPItEr-. $TICK. PETER O·LEAR'i.
W.OELEIXE LOWE. GEOFFREY BYR."E. TIMOTHY JONES".
Dqttvrtrlo!l!:.:J0.' Sleep ."(~Jlo"l!~ond EnJocn·nologr.: PrincCJS MIV"gtUTt
#l.Jdpilal for ClulJren. Pdtlr. ..:..
tlYJ:IOI:lyccmia occws CQmmOnly ckt.ring sleet' Stud\C:S 1ft IDD~ adoIes·
~ tu\·c found mal modcr.Jtc hypoglycmu.1 ~ no ctrcci CHl sl~ atdti­
~ 01" hcarc falC To cunUne ~ 1,1eep is .usoctalCd with rcdu«d
~ICTtC"ui.:lIOr:o ~ n:spocuc-s m adolo=nu...... " studoc-d 7 100M
-.bJ«u I a~ 1$::1 ~r, HhA I..:: ~ 1rO S";.) on:!. OCCJ,j;IOru aW311;e dunrtw: the:
6r!' ;anJ aslc-cp at night Studlcs ""l:Te Jq).1r.Jle<J by .11 le3S'1 10 weeks and
_~ .n r.lnJ'Jnl Qt<,)cr LSIR" an Insuhn .:~ technKlIK cxh ~bjl;C1. had
... Jlucos< tPGI wh,h~ at 5· 6 m~' 101" Ihi" befOre Induo:,ng hypoclyc~
.... ;0 min trudlr :!.K :;0 I mmol1) For !he night ~ud". slcq .... ~ rnoni­
~ "';I(h EEG. BX;. EMG ~ ECG EplrlcpnnllC". oorcpmcpbrine.
""....111 hornlOflC.I:~JI"1IS<)1 3nd frc-c uuuhn kvcll .... eK me=ula.!. ~ the­
"dT,I~t st\.Idy. h;'"PUl!ly\.""C"n1ia "..as induced dunng Su~ 3·oJ SIc:c:p. ~
_ac I'MJ dlffctc=flo.:cs b<twc:cn the 2 studior::s With tq?ld to PC profiln oc free
-:1m lot"ods l5.:!=6'1."s oJ~:6 mUlL. !by 'is Right). No WbJects WCK ~wak·
at during th.: o)\c:m.gbl stud)'. Eplr.ephn~ IC"Ods rose s'gnlfu::antly during
k b~'lX)llyc;crrm: pN.u In the alAo·u.c study lAo·hen cornp..uNlO the SIUdy
~ 1190 3: +! \·s 23_2 % 22 Ptt'mI. p<O.OO2)_ Only on.esubject h.ad anc:pi.
wpht1-llo; respvnK ,., hn;to."IYL"\.'"fI1U when ~k.-cp R,ses'll gtUIAo·\h honl"MX"loi:
~ c;OftliOlln·c\s WeK not different bc':WC'Cn!he SfUd,.e!. awUc and asleep.
H.c:ar. r:&l( ".;..... "'!lubr durinJl. lho: (lR\:"bmpLng phase ~nJ ;II the n;odn of !he
~~I:-..:emh." pllol....: ... h""11 ;Lsl.......-r but rose sL.:.n,fl~"nll)" d\lnnl:. hypo-­
~ecmLa ~wakc_ T1'Ic bel of 31\ cptnephnne ~ to !he same dcgrct' of
~i"'l!t)"cc:m ... ,Junn~ Sugc J"oJ deep ml,ht. In part. c.,pl.un the vcaicr
,.-ro"Jlen,c Of'1O\;tumll aauprvscl to) diurnal hypoglycem.;l in adolcsc-cnlS.
A numeral beside an author's name indtcates a duality ot interest. See Duality of Intere3t Information beginning on page lkxxllii_
V" ,~,
0157
to Act as R«urrtnl bu"ograie Hypogl~·ctmia aad IOO~t S.pprHS
CouDttrl"t'2:ulslion CuStd by lonlu:cd 2-0G Prrfusion of th..
Vutromcdial Hypothalamu.t.
~tO='HC.-\ A BORG. GER:~LD I SHL"L:\IA:-;·. \.\"ALTER P BORG·.
WILL1A'-1 \' TA.\.tBORlA:-:E·. ROBERT S SHERWrs·. ".('\00
Ha...en CT
\le rrpor1.:d wt Ioc..1.I \c:TllI'omahai hypott\al.1mus (VMH) glllCOpCnu
tnggcn COWlLc-rn:p.uon To tval..u:e the- mecharusms of ddectrvc COWl.
t~~ oused by 1.&tt"OJ'C'l1C hypoglyccm~ and IDO~I ~ lco• .... (
dd,... crcd m:Crodi..1I)'11S 100m.\.1 2--deoxY-alucosc (.2-DG) 1010 Ihc \·~tH
,,13
to producc localized ccllular glucopc::ttl.a in the: absence of systmVc- hypo_
!Iyccmia. 3 groups or a.....uc chroaic3l1y caIhctcrilcd roIlS ....ere StUIhe.1 1 j
recurrently h~-pogl;,crm!e ooodi.lbctie Ba (r.-6I. ~) ei"..roNo.ily h~po:r .
,"I~cem>.: d.t..l~LC BB.;lnd)1 nondlabcti.: BB (n-S) controls tn-51 The
uble ~')o ... s tho: cfflX[ of \·~tH 2-DG pcr"f":Slon on j)Us.rna 9Ll1<=j)hr.ru;
(EPII. noreplncph,.,n~ (:"jaR!. md a1UC3gon (G:"i) lc\ch. presented lS the
U1<:rc::.ue ltxne b;:.s.chne ("p<O 05 VI eCHluolj·
!:f':R!2%I~trmia IIl.Illi UntmI
EPlln.\i) ! 3::0 S· 8.1=.2.8· 2·?:5..4.0
lIiQR{n....l' ()..I::O I- 2 0:::0 oJ "'3=1.0
G:-'·ln~·LJ ::~-=..I. 2,..1· I ~,:l..:' I
In hypug.1Y\.·cnHc ralS buth gluc;lV;on aoJ ~I!\:hob.lm~ ~ Iv
n ..l11 ¥-luo,;09<-·m.:1 WCTc: nca:rl:o' toulll' suPPcc:5S(;d. In \[)!>;\t ~:S. \i:\IH :::
DG ~\)j"\ bJled lO pro\Oll;co gluc;lj;'Jn rdease.... n.:~a'i alcchul.llTllllc
relc:asc: was drmlIu5hed. CoocJusioas: 1) R.tcurtc:nlly hYM1)<ClUic nundL­
~;wd ehmrllcally hy\XrglycC"mlc IODM r.1lS cu,ml ur.palred bonnoJlIC"
rdost: dunnK, VMH 2-00 p:rlw:iQfl~ 2) Rroun:nl hypogl}"c~ sup­
prnso the Jlbihl)l of!he VMH to reco~ 8~ oc acuvale cowuer­
regui.:lIlCHl. and )) impllred rcsporuc:s to 2-00 In IDOM may be com:pk,
nl~ol .... ing. !he "'MH. o.--c:dl. and bypcrglycemia JWT $,' Th\l'li. ampairoJ
"'\JUII~ub!Jon dunng IlICC"ft$I'iC II1SUhn tn::atmcnt of 100M rna.... r~ull
fn)l1l :ollcnuons of the VMH OC lIS dlwl p.lth·...·.)lS ­
0158 0160
Effen of I.)ur31ion or Recent. AnlectdcP,t HyPOKlycaemis un
Re-spons.n fo Subsc-que1Il Hypoelycaemla In HumaD~. .1-10.,­
C:\.R..\lISE FA:"l"ELLI. SIMONE "A.."IPA~ELll. MARCO CIOFET.
;0":.
TAo CA RlO LALLI. PAOLA DEL SI~O."",CO. MACRO LEPORE.
PAOLO BRUNETTI. GER.E.\UA BOLU·. PO"7J.gia. Iraly
II is accepted mal rec\lfTml bypoglyCJ<mia (hypo) may IDduc;c h)'PV . "
~. bul !he bumbc:r and/oc dIuuioa of aneecc:denl hypo ~Ircd
to extr1the cffecl are noc: blown. To ass.css me: effect of duratiDli of f"C"Cent.
oantccL:dcn1 hypo on E"C$pOQ:SC:5 of COW1~ ~ (CR.H) ;ulf.!
"'ymploms tS:omp) lO, and onset of copmi'ic dysfunc:uon tC0sD"rl1 dun:1~.
hypo. g nom~1 ... olunlec-n ...-en:: studied \\.1th the: hypefu\$L.:hnaank:.t:y;:--.
eb.mp {piasnu glueo~. ?G . ....,~ dccrcucd JtC"V""1K' ire,n SO lu :U m:\11,
on ~ different OCC~1Om at IlTIOfIth rnlcnals (StudiO I -"'). On the d.ay pnu:
10 studies. c:,ther C\.Igl)c«rrua (SI). ur I t..t$Uhn·~td h;o-po {PG.2 7 m\!.
11 00-2} 00 h) (52). or:! h)olJU (13.00·15.00 h and 21 OC).!3 00 h) (Sh or
) hypo (OK 00-10 00. I) 00-1 :5.00 ;vId 21 00-23.00 h) lS+) 1Aoen:" pcrforrnc..!
In S~. U1o;r~ ,n CR·H IlllllaCed ~ 1000·cr P'(i (i.c. ~kb w,=" h.ghCTl
~ m:P.,mal rtSpOQSCS of adrenahnc. gll.l.ClJOO. r;rowm hormooe aOO COl"­
tls.ol were all lower ('p«1.0~). bw ncimer ~c nor ~ycopen'c
Symp and Cog[)y1. ~ of 12 diffmnt tcm) wttt affected 'is S~
WO:-."S)· In S3. aDd to b.rJer e:x!ml in $I, not: onty CR-H. but also 5ymp
(both aulOrlotrUc and noeurott1yc:opcnlC) and CoaDys had thresholds grater
~ muuTUI rn.poMe!i lower!J"wl in SI ~ $2 tp<OO:5). Thus. the dUr:LI.
I.on orr.:cc:nl. :onlttc:denl h}--po IS the ma.n dctCfTTUl\aI1l ofw ofrt"1pons­
d of CR-H. 5ymp ;zOO COJ,Dys to subsequent h)o-po A s,niPe eplSOd.: or
hypo dIJc,L nul .ndu..:c hypo.> UlI3waraJCU. but onl)" mIld ImpalrmClI.I m CR­
H ~:s Muh.ple:. r«alC ..-p.sodC"$. are ,-.:qulred. 10 tnd'ta::c h:i"l"
UTUWarencu Thett LJ a hlCBrtby of loss ofrapoosn 10 hypo af.cr mull.­
pk q,.socks of JU:enl. :anlecedent hypo. i c. ~ of CR.H lfC Ius!
flN.,;vId responses of Symp aDd CogOys second.
•
l
41A I
.'
1
=-
 :.supplement
decreasod W ~tIy I"d'tOftd co oonna1 kvt::h. GradlCl'lt ccllo, <dlo
pl1tW" image1wt:.te J£:qUired in:st.dXJa,S rwming tbroup tbt primary visual
"""'" (VI)< imago """ ~ by ~, ,;g..t .........,. """"" •
fixed reeWo of in~ u.rxltr the two st:imuhls eondi%IoOs... lor basdinc,. visu­
al ~ nsulred in a sipifica:nl ~ itt fMRJ tigoaI dw: W!S toea}­
iudrotheVi tegloL As ~oodgtt.aeO$Cw;d~ bdo....-1'!i ml/dL.the
rneM tMlU ~ decreued to 1= than 6Q'I'.4 of lbc ba:seliat: Y3fuz!:
(po--O.OJ). Upon ~, to euglyra:rtia. the aaV.11lioo tnDmSily ~
(p-O.03). 1'(C()Ye!:'tt13 WI. of !he origitral basil fil.tRI res:pomc: (\be diffa­
ence from huelinc \\IU no( signifk:anl)_ No significaat change in fMRl $1$""
n.al wu ob$l'!'f'o'ed in corurol st'l.'dies of \1')e :same subjects. where cugly«mic;
byperim.ulMrtia wu rnain~ for l to 2 bouts.. We coochuk thai. hypo-­
glycemia ~ the fMRJ response to kloc1I1 tdiva.tioo oflhc visu.a1 cortex.
These <bta ruggest ttut tMRl may offer a mc:J,!l$ of dyn3mica11)' monilOring
the dfecu of bypoglycemia on specific bt?in fUnctioos in humans.
<'
.'
<
EIf«tl or H)~lycemlJ_ on Br1ia A<D...U.n ud Functioll. ia. Mu
STEPHANIE A AM1EL', M(RAJ<DA ROSENTIlAL. VINCENT
GIAMPIETRO, EDWARD BULMORE. DAVID HOPKISS-, MARK
EVANS. C!!RlS ANDREW. LIDIA YAGUU, STEPHEN W1U1AM5,
LDndon. United Xb'lgdcnf
The brain ~ 00 gl~ for oxidative ~tstn and function and
hypogly.:eml<l with cognitive dysfu.rKtion is a kared ~ ~lfect of insulin
trcaanent. \l,"e ~ the etreas of acuk: ~ty<oemil on ~ tnm
acn.."atioc during petf~ ofcognitive tasks. using futw:tioaal Mapctic
I R=amce tmagio>& (tMRJ)< Righ. Iwld<d volul>l=s p<tfQ<m<d we duro
ing cugly<"""'-h~ (90..,.j 43 mgldI.. - 6) and proI""""" <u~
lyeaemk 190mgldl, n ~6) <Wnps. Regioo>I b<ain ~ .... ......,..
by Bioo<i Ot.!fICO Ltvei Dc:peodcnl Imaging (BOLD). Simpie R.tacrion
TlITJI! (RT) was not signitlcantly ~ by b~ {mean claange
4±23 V$ ~t2:t15 m i.t:t pnlwnaed cui!ytt:m.i.a. p-OSl but Choice Rcactioa
J T:unc (CKr) ~ signif~1y (by ~29t;tO vs +29±l1 au. m pr0­
longed cugly<...... p>ilO~~ lMltl dwi"I! sa showed oofy • ...all mer....
in 90LD signal in the fisht ~1t1llYl (5 "'oxd Max (FPQ) 1.011: p>O.OO2..
I
p>O.OO3) but i.:.l C1tr, then\' wu a larse: illcrI:a$c in Jignal during hypo­
gly«rnio. in "'l,ft ParielAl""",,,iaOOn CoI=(23 wxd ~IFPQI
p>OJ)OO02. p>O.O(3). Choioc Re:actiou: invol"c:s $O'I$Ot)'-m.otoc mel cogtU­
bve ekmea(S;, the t'om:ler ~ted in Sit. Thus it wa:s: die cognitive-=spe:ct
""' .... m"" ru=pdble to hypogl"""" p.raUd«l by ~ activa­
"00 in rorucal I&I'Cil$ iavold in I'l'IO<cIr plaMin&: and inLeIJ.cctuaI dfort..
BOLD measures ~ rtgional OX.ygmabOti ud these sn.u1ies dculoo­
strate ~ fI"l('I'.:hat'I..i.sm& by which. the ecrcb~ eocu::.:r; respoods during 8(;U[¢
rniJd hypoglyctmla.. :it s;(ep ~owatd& devising wars TO JICOICCl bWn funcbOll
in hypoglycemia.
ons
Do~ AEHfcedeot R,KUl'f'ellt liypoglynmia: Alter BraiD £CF
GI~ l..neb ()urlq: Acute H~"m. tn Dbbctt:s?
RALPH I IACOB, XIAONING FAN. YING ZHU, RORY I
McCR1M~ON. ROBERT S SHERWIN. Hew ~ cr
We ha>. ~ly ~ "'" ~ of dl.beti< ".. to _
h}"POSlycetnia lesseusd1C ~ ee«ts of mild ~011 brain­
$tt!fft (lafed« wUiculus) ftmction. To dct:::nni:ne .bdbc:r ~~ to ne"U­
ro~dy_.. during~cculdbe~by"'=-d
J _ <!<Ii"",),"""" "" blood b<ain _ ".perfom><d~
etarnp JtW!tn in) zroups otnu: 9 ~ ~ On) diabet­
ic Illl na (llypo-OM, g.lyat<d ~$"%). 11 chronially hypa"­
gly<:<mk diabetic ..~ (HYl"'-OM. '2%~ ...d 11 ~ """"'''
(5,."")< Ml<rodWysuprob<:< ,....~Iy ~ .. " " ' _ . " , .
liculus.1D The morning of eadt SlUdy by~ wu ~ in Hypo­
DM rattto mau:h buriil'tC g~ in the H)'VC'f~DM JKlVP..AR.mimJb: were
studied awake Nld ~ J>bJ;,na aad ECf ~ ~ (raM) at
baf¢line ted during the final 60tnin of.lh b~ cUrnp .e sb:rwn
il'I th¢ w,1C! below. 01UI an: mean ± scm; t,p<OM vs.. eonttoIs.. Mild bypo­
gl,ocmia ~ .. dmn.at.ic dccfeU(; .in bnitl ECF JIucose in all an~
wbi.:'ll W1.S ~tt:ty ~ 1:ban the dcclioc m pbsma Jevds. In
H)'l."'Ct~OM ll!ts bnin ECF gJueos.c ~ hypGglycemia w» 50%. iower vs.
N(lI)-DM cont:fQts. Rt,ctt:rrenl bypo-gty<:etuia d.id DOt 1'CSI'OR Inio ECF ,Iu­
CQ$t to IItOt'T'Il3it valu=. ~ly, brZn ECF L.c1ale was mucla bipcrtbJn
EO' sl= dwi"I! hypogl"""" in oil _ Ho_ bnin ECF lao·
u[¢ i.a tbe Hypo-DM rats (3.8.tO.5mM)was signilicaatly increased ~
TO Hypoet.OM (2.4tft.l) I.l\d eOlW'Ol.l (.!.6±0..2).. ~Iusioas: Mild hypo­
gIy<emia produ«$ pro/OIIlId red...."", ",lnin ECl' glucose ~
-ADA Professional S&ction Membet see Ouaflty oJ Interest Infonnation beginning on page 68.
I
which lU'e ~ ~cd in ~ n:gatdless of &l~emie t:onttol
~'" hypogl~edCNS ~ ,"",,,,<ItTC>l byp<>
glyeen:Ul can not be simply explained by iDctu.std glucose ddivay TO bnin:
ud may be .. ~ ill put dac;: tQ increased mcubolii: d:fllCien<:y .nd!or ~
of~ as III aJu::mau:: fiK't ."
110""
j>lHat.o ECf
16.01:1.1 t 4.1.:1.2 t J. tto.2 0.06:t0.0IIS':
\S.t:t.l.3 ; 3.4-!ll.7 ; 3,j~,1 O.O'.h::O.Ol,"
Util} 15=<)3 U±/lJ On±l)~
0239
Local VMHiJ.-Adrtllel"2.te Blo.ck.Jcle Impain tbt Epinepbrine
Rrspoa.s.e to VMH ClueopeaJ_
WALTER BORO·, MONICA I\. BORG, WILU"M V< TAMBOR.
0231 LANE-, ROBERl S< SHERWlN'< N.., H..... IT
Vcn~ bYlxKfud.amie 1.U.Ii,;!cl (VMH) play m c:MCflUaJ role in h:ypi>
gly<:<mk ~ T~ """ 1ht ~ lb.. local jl-~
~ IS tnvolv(d In t.h:i$~. wedd.i~ I j3-~c
an~gro.i.$l via mk.:rodiaIysi#. probes placed bi.Lw::ully lnl.O the VMH of <.Vn­
Kious S~D4wlt:y aa. 1'be: VMH was local!y ~ with ~ active
and an ~¥c (1$ a eotU't'Ot) (onn of Pruprarolol along with 2-deoxy-gJu.
e<»e (1-OG:). We havt previow:ty shown thai 2-DG ~ auses VMH
gtucopc:nia 2lId ~ bonnxIe re:lt:2St. The table: below shmt.-s:
or
.... dI«t I'rnpnu>olol on _co in pw.n. glucose. epin<pbrinc (EPl).
and &1_ (GN) during 2-00 _ VMH 81~ Data ... po­
KnlOd. me incret1se above bitsdu.e (*p<O.O:S 'FS control). loal VMH ~
bloc'Wc re4tIced (be rise in plas.:'tu gIJJeOSe' UlJ:$(lr:f by 2·00 by 55%. This
~ffm wa$ uv.mty ..ttributcd to. ~ ~~ ofEFf ~b= in .. sep­
A£'IU: SCI of ex~ we p<rlus.::d dv:: VMH with the ~ agocist
l$opmtdO'lot ~I a.kme ca1.!$tl:d a rapid jwrold ux:rcasc in plasmt
glucGW in l!Odjunt"Uon with I- marlted rise in plasma epinephrine..
Conclusion; J>.~ie tte:W'Q~ion .....ithin the YMH is an impor_
!.W rnodubtat of the adrenotnedull.aty response to VMH gl~
~~~~lo.~l p'~~2';~~-,~~__
L'"
GhHOH(m.\I) 3jd).1
...
~"
9.6=1).5·
.Efr (JL"I) 4.9::tt),4 )6,iS±LS"
GN(nWL) 242<3. 337±22·
ne EfTeet o( Vapl Coolin, on tbe COUtJlUT'tgUi.alory RnpoOK' to
Hypo:lyumia Dlirio& M.ild HJ'"Ptrlns1J.l1tie.tn.ia
SYLVAIN CARDIN-, PATRICIA A< JACKSON, DALE' S<
EOOfRTON,MARGARlITC SALVINO, WANDA L SNEAD. JON
R- HASTINGS, MELANIE E SCOIT. PHILLIp E< WILUAMS,
Nashrill,.. TN
We ~y demonstnted Ihal!he bepatic gJucose $QSO~,," not CS5C&
t;:rJ: £or ~ CM~1.a1Oty ~ 1.0 bypogIye:mU.a ~ by hish Jevds
Qf m,wm. Si.acc hip in:AI,lin levels pa ,i.IC IWgmmt the CNS fCiPQBW !Q
hYPOi1yoania.. the. question arises as IQ ~ l'.epatir: ~IUCO$C Je'I1Si03
wwl.d play. role to. the dr£,::m¢ ofbypoglyoemia in tbe ~ or .. low
insulin kYtf. We JlUdied twO' p>UpS of ~ l$b fiSted ~ with t0ol­
ing coils ~y placed on both V1gUS tla"Ves. Each JlUdi ~ of.
100 ~ equil~ period.. 40 nUn bod period znd. ISO min h:ypi>
gl""""c ... period. GIu=e _Iower<d nsin&. il_~....
inhihitOfud low dose insulin infJ.$ioo (0.7 mUIkw'm1nt. The pIasma. insulin
bet ~:I> Ij,tJ JlUtml and \he plasma gfucose ievel feU to 11 pWcau
of 57:::t:3 mw'diln bo«h groups... The coollil, roils werc perfused witb a >~
{Cent rf'"1)or. ~2O*C(CooIIl""7)e:t.uIol solJ.1ti.oo tor Oe tasI 90 mio.ordie
1eR period. 'hpJ ~ c:au$t a ~ iDcrcax in 1i':.e beIrt raf¢ (79:-12
"do • &at 0 bcatsltniJ1 in Coot) Nld block.od tb¢ btPOgJ~ induud iDc:nas«
IJ\ ~ ~ p<M~ hU:t29 vs 2SCltJ9 pg/ml In Com). The
-""'lI" ......... '" j11ucasoo - . .,,~ Ipt!ml), ~
cinc~),_ (,oglCJ),gI"'"'''~(~min~ and ",.....
(p.roolll) ill !he: control group 'tVt!fe .B±9. 62.5:tIS6, n 1=48, 4.63:tl.()3:.
-O.J9,;t;{).24. IOI:t:IS. and in die CwI ,",nap wet"e 3'h:1, 837±135, 9Jrl9.
6..28,i;l.Ol"'• ..o..so±O.2(). and 7h29 n::specti"d.y. E.\&Kd ori tbc:se dm, we
cmcbdc tba.l, eYCQ in ~e ofhiib, insulin conc:au:-ari04t, atretCDl siS'­
oaIlina via tbe vqus nct'Vf:$ is SlOt ~ (or a DOrTI:'..:l.! CO\ll::ltcTn:gular.ory
I"I:SpDUS¢ to h~ccmi&. ·pr.O.O!
A56
,,',
PROFESSIONAL REFERENCES:
YALE UNIVERSITY 1
PROFESSIONAL REFERENCES:
ACADIANA REGION 2
CURRICULUM VITAE
3
LIST OF PUBLICATIONS
4
EXAMPLES OF CITATIONS:
TEXTBOOKS & PAPERS 5
INFORMATION ABOUT
SELECTED JOURNALS 6
ORIGINAL PAPERS
7
CHAPTERS IN THE BOOKS
8
PATIENTS’ EDUCATION
9
ABSTRACTS
10
 Dr. Walter Borg
news@advertiser.com

The Daily Advertiser

Lafayette, LA: 12/04/08
Dr. Walter Borg news@advertiser.com

The Daily Advertiser

Lafayette, LA;
Thursday, Thursday, June5, 2008; Accent: Page 1C
The Daily Advertiser
Lafayette, LA;
Thursday, Thursday, July 10, 2008; Accent: Page 1C
Dr. Walter Borg

news@advertiser.
com

The Daily Advertiser

Lafayette, LA;
Thursday, October 11, 2007; Accent: Page 1C
Acadiana Health
July 2007
Acadiana Health
August 2007
The Daily Advertiser
Lafayette, LA;
Thursday, August 16, 2007; Accent: Page 1C
The Daily Advertiser
Lafayette, LA;
Thursday, September 13, 2007; Accent: Page 1C
 t , ,, , , l r ' . \,ltt,}
{
Wotchoutfor Google,
onlinemedicolodvice
Millions of peoplesearchthe
Intemet to find answersfor health-
care-relatedquestions.Due to time
restrictionsimposedby managed
care,phltsiciansno longer areable
to fully educatetheir patients.
Therefore,Internet searchengines
suchasGoogle shouldbe consid-
ereda blessing,right? Wrong.
The Internet provesto be at
the sametime the best and worst
of modern inventions.There are
nn'oimportant reasonsfor this sit-
uation. First, much of the medical
information easilyavailableon the
Web is misleadingor evenfalse.
Second,a personeasilycan mis-
understandthe meaningof the
true but complor scientific publi-
cation written for specialtytrained
healthcareprofessionals.
A Google-tne sealchon any
medicaltopicwill yield hundredsof
resuks.Usually,thoseresuhswill
includea mix of numerousWeb-
basedinfomercials, technicdPaPe$
fiom medicaljoumalsandsome
sites.It
legitimarepatieneeducation
is impossiblefor a personto safely
walk throughthis maze.The
infomercialsitesareprtti"tlrtly
tridsy.The unscrupulous oFbeat
medicalentreprcneu$harrcleamed
it is easierto selltheir productswhen
dre apparentpuqpose of their Web
"oducationofthe public."
siteis
Thanls to modernsoftumre,
an)ronecaneffortlesslycreatean
impressirre and legitimate-looking
Web site.Under the guiseof'public
service,"silly medicaltheoriesare
promotedand promisesarc made
that no honestphpician errerwould
endorse.Common innocentcom'
plaintsareocplainedascausedby
"new diseases"
made-up that are
inventedto be treatedby advertised
products.Suchdishonestmarketing
effortshavebad consequences.
Akhough manypatientswill not
buy the promotedproduca,they
will tal<eseriouslyfalseinformation
conained on thoseWeb sites.
Nanually, they oEect to be
treatedaccordingto the same
Internet theoriesbv their local
Acodiono Heolth flune 2OO7l
o
(f
-
WHERE
TOGO ONLINE
Potientsshouldnot rely
z
on Google-typeseorches;
Insteodthey shoulduserep-
utqble medlcol Web sltes
such os WebMDor www.
powerolprevenllon.com.
doctors.To their surprise,they are
prescribedtreatmentsthat areat
"knowledge"they so
oddswith the
diligendy collectedduring an
online search.Sadly,somepatients
trust the information from unveri-
fied online sourcesmore than from"
well-trained,licensedphpicians.
Patientshaveto be partnersof
their physiciansin medicd deci-
sion making. However,to serve
the bestinterestof their patients,
physicianshaveto stricdy follow
scientific principles,legal rules
and ethicalguidelines.
Accordingly,good doctorswill
not recklesslyfulfill patients'wish-
esthat contradictthosedirectives.
Unfortunately,manypatientsbuild
their ocpectationsabout medical
careupon misleadingcommercials
or misinterpretedscientificpapers.
This leadsto unwarranteddissatis-
faction with their physicians.
One thing to keepin mind is
that all reputablemedicalWeb
siteshavedisclaimerstating that
'the information containedthere
should not replacethe opinion of
a physician."Thisis good advice
and should not be ignored.
WakerBorg,M. D., ir a Yale-
ta i nedmdorrinologirtVracticing i n
L{ayen I{eserzwoztle
RprofucttaeMedicineand
Soaoecon omict Committeeto1f
ttmaican .lsoaattan of C/n ical
Ezdorinologir*. IIc ako ir a Delegate
oflafryeae Parirl Medica/Soa'ety to
Loabiana StateMedica/Soaety.
PROFESSIONAL REFERENCES:
YALE UNIVERSITY 1
PROFESSIONAL REFERENCES:
ACADIANA REGION 2
CURRICULUM VITAE
3
LIST OF PUBLICATIONS
4
EXAMPLES OF CITATIONS:
TEXTBOOKS & PAPERS 5
INFORMATION ABOUT
SELECTED JOURNALS 6
ORIGINAL PAPERS
7
CHAPTERS IN THE BOOKS
8
REVIEWS
9
ACTIVISM
10
 AACE/ACE Liaison with DHHS/CDC
Walter Borg, M.D.
www.drwalterborg.com
On August 28, 2008 Dr. Walter Borg (Member of Reproductive
Medicine Committee of American Association of Clinical
Endocrinologists) and Dr. Steven Petak (President of the American
College of Endocrinology) have been appointed by the leadership of the
American College of Endocrinology (ACE) and American Association of
Clinical Endocrinologists (AACE) as ACE/AACE Liaison with the US
Department of Health and Human Services (DHHS) Centers for Disease
Control and Prevention.
Walter Borg, M.D. is a Yale trained Endocrinologist practicing in Lafayette, LA. Dr. Borg has authored
over 20 scientific articles published in peer reviewed medical journals, including Journal of Clinical
Investigation, Proceedings of the National Academy of Sciences, Diabetes, Journal of Clinical
Endocrinology and Metabolism, Journal of Pediatrics. He also coauthored several chapters in books and
review articles. Dr. Borg serves on the Reproductive Medicine and Socioeconomics Committees of
AACE. He is one of the authors for Reproductive Medicine Section (RMS) of the AACE publication
The First Messenger. His duties include coordination of the efforts of other RMS’s authors. He recently
edited the AACE Position Statement on Bio-identical Hormones. In addition, Dr. Borg actively
participates in the endeavors of Socioeconomics Committee and contributes to Socioeconomics Section
of The First Messenger. Before his appointment as AACE Liaison with DHH, Dr. Borg has represented
AACE and ACE on the US Department of Health and Human Services and Centers for Disease Control
Workshop on sex steroid hormones in Atlanta, GA. Dr. Borg’s AACE activities include also serving as
the AACE key legislative contact.
In addition to his involvement in the AACE endeavors, Dr. Borg serves as an Executive Committee
Member and Delegate of Lafayette Parish Medical Society to House of Delegates of Louisiana State
Medical Society. Dr. Borg has been also appointed to Louisiana State Medical Society Council on
Socioeconomics.
“AACE Mission Statement describes our organization as a medical, professional community of Clinical
Endocrinologists that is committed to enhancing its members’ ability to provide the highest quality of
care. Indeed, as physicians we are engaged in the special mission of healing and in that calling, we
lobby, first and foremost, for the best interest of our patients. In this context, I believe that all AACE
members share one very important concern: They worry about their steadily decreasing ability to
provide high quality medical care - accessible to all patients. Such ability is clearly declining recently
at alarming rate. All those disturbing trends occur in the setting of the greater than ever societal
distrust towards physicians (a phenomenon known as "Anti-doctor backlash”).
The greatest sin that organized medicine has committed in the past was its total lack of interest in the
socioeconomic, regulatory and political aspects of medical practice. Consequently, the medical
profession became controlled by profit oriented third party payors, greedy malpractice lawyers, and
inept or even corrupted local bureaucracies. Today, we have the last chance to regain the control over
our profession -in the interest of our patients. I will work hard to make sure that our organization will
not repeat the very same errors that many medical societies committed before us. In order to restore
sanity in the medical field we need to relentlessly pursue legislature and regulatory agencies, as well as
educate the public. As physicians we were trained to accommodate, and not to negotiate or demand. We
have to accommodate needs of our patients in increasingly hostile environment. To do so we must
negotiate and demand that not mere viability but the prominence of clinical endocrinology in medicine
is established once and for all.”
Re: Meeting in Atlanta - good news
PageI of 1
Subj Re; Meeting in Atlanta - good news
Date: 3118120086.12:28 P.M. CentratDaytightTime
From: Stevenpetak@yahoo.com
To: DrWBorg@aol.com, stevenpetak@ya icc crlirr
CC: petak@aace.com

G r e a t w o r k a s u s u a l W a l t e r* !
Thts ts a great opportunity and we will proceedahead with a closer relationship.

Steve

On 3/18/08 2:50 PM, "DrwBorg@aol.com" < DrwBorg@aol.com> wrote:

DearSteve,
FYIenclosedis a my preliminary reportregardingmeetingin Atlanta.Initiallywe wantedto simplyapproach
the government by writingthema letter(thatmostlikelywouldend-upin theirarchives). Howevei,i 6elieve
that the opportunityto meetthe governmentalofficialsfaceto face was muchbetteridea.Indeed,as you
can see from the reportI have.beenapproachedby the workshoporganizerDr. HubertVesper(0S Oeptot
HHS:CDC branch)who wouldliketo havea closercooperation withAACE.He wouldliket6 sei uo a
meetingwithAACEleadership (possibly duringourOrlandomeeting)? lt wasclearto me thatas muchas
they appreciatetheir relationshipwith TES,they are very interestedin establishingsteadyworking
relationshipwithAACEto havean accessto moreclinically orientedopinions.
SinceCDC branchis very interestedin establishinguniversalreferencerangesfor sex steroids-this would
give us an opportunityto bringto theirattentionthe issuesyou havediscussedin your papersincluding
Ayala,C., et al., Serumtestosteronelevelsand referencerangesin reproductive-age women.EndocrFract,
1999.s(6):p. 3?2-9.
Pleasefeelfreeto call me anytimemy cellnumberis (337)577 0033.
Walter

Create a Home Theater Like the Pros.Watch the video on AOL Home <http://home.aol.com/diy/home-
improvement-eric-stromer?video= 15?ncid=aolhonn0003000000000 1> .

Monday, March 24,2008 America Online: DrWBorg

 Page I of I
Subj: Re: IMPoRTANT- Problemwith www.PowerofPrevention.com search engine
Date: 31112007
3:03:'12
P.M.CentralStandardTime
From: blawjr@endo_con9liltentg.qom
To: Drw_Borg@la!-clfn
CC: pe€k@texas.net, watrom@aace-sao,Ooneldbclsn!a!@!0€!€ar0,,BHQqbn@aql.eam,&bcney@aace.com,
djones@aaae.cqm, tcor|ey@aase.cam,
RM|IABREL!!@qpJ,eg,rn

Greatjob, Ashley!Ihanks also to Walte is potentiay -very

embarrassing situation
to ourattention- yourpenchant
for detailis truly
awesome!
Birl
:
QuotingDrWBorg@aol.com
> | agreewith Dr. Petak.I testedthe searchengineand it now worksfine. I
> am glad that our ITT supportwas able to actuallylinnitthe searchto POP Web
> Site. lt is much betterset-up- than usingdisclaimers.

> Thankyou very much for addressingmy concernsin such a promptand

> efficientfashion.

> Sincerely
> W a l t e rB o r g M . D .

> ln a messagedated 31112007

2:39:54P M. CentralStandardTime,
> petak@texas.netwrites:

> lt seemsto work alright!See if anyoneelse has problemsstillbut I think

> it is ok.
> Steve

> AshleyHornwrote:
> The search engine on _http://www.powerofprevention.com_
> (http://www.powerofprevention.com/) has been modified to use one
> providedby Google.The entire
> search stays on our site so we are betterable to controlwhat it displayed
> to visitors.Pleasegive it a try and let me know if this is acceptable.

> M r . W . A s h l e yH o r n
> Directorof lnformationSystems

**********lr***tk******** ***************

AOL now offers free

> emailto everyone. Findout more aboutwhat'sfree from AOL at
> http://www.aol.com.

Thursdav.March 1. 2007AmericaOnline
 PageI of7

Subject: Re: Coding Manual Forum

From: Jay Cohen
Date M o n d a y ,D e c e m b e2r 2 , 2 0 0 87 4 2 A M
To: drwborg@aol.com

W al t e r ,

Y o u rc o m m e n t sa r e t h o u q h to u t , c o m p f e h e n s i vaen d r e l e v a n t a, s u s u a l .
Thanks!

I think it is importantto figureout the basicphilosophyof the AACEon-linecodingmanualfor it's

initial version, then have a plan [even before the initial version is released]for ve-rsion2.0 and
3'0' Microsoft/Appleand other comapaniesknow that early versionsare nol perfect
Ino such
thingl, but put out a best versionknowingthere is more to accomolish,

Happyholidays!

Jay

J a y C o h e n , M D , F A C E ,F A A P ,C E C
ffi
The EndocrineClinic,PC
5659 South Rex Road
Memphis,TN 38119
W:901.763.3535
F:901.763,3594
----- OriginalMessage-----
From: drwborg@aol.com
To: kmiller@aace.com, MHARRELL@nbhd.org, iaycohen1@comcast. net, williamconway@aol.com,
endocctodd@bellsouth.net, hlando@yahoo.com, mlaufgraben@lifespan.org,
blawjr@endoconsu ltants.com,"anne-marielee" <anne-marie.lee@allina.com >,
uslilavivat@hotmail.com,"arthur lurvey" < a rthur,lurvey@palmettog
ba.com>, tmallik@cox.
net,
eric@orzeck.com, "sethureddy" < sethu_reddy@ merck,com >, seibel@ix,
netcom.com,
stokesjhnd@aol.com,metabolism@comcast. net
Cc: jyoung@aace,com, rmharrelll@aol.com, mcacia@aace.com
Sent: Monday,December22,2OOB1:05:35 AM GMT-06:00 Us/CanadaCentral
Subject:CodingManualForum

S E L E C T E DC O D I N GM A N U A LF O R U MC O M M E N T SB Y W A L T E RB O R G .M D

(Chai4,Dr.JayCohen(Vice-Chair)
TO:Dr.MacHarrell andmembers
andstaffofAACESEC
FROM; WalterBorg,M.D.
C/O:MelissaCacciaandJeniferYouno
Re:CodingManualForum
Date.12121108
Via Email and Fax: (904) 353-8185

I believethatouronlineCodingManualhasa greatpotential. Thisis a realchancefor MCE to createa unique

databaseproduct- that ultimatelymay havemuchlargerscopethat merecollection of the billingcodes.For
instance- in the futurewe can considerpossibility
of linkingclinicalguidelines
(andsimilarcoretexts)intothe
specificdiagnoses, symptomsor procedures.Thatway the CodingManualcan becamethe ultimateEvidence

Fridav.December26.2008 AmericaOnline:
 PaeeI of.
Subj: RE: PP Lecture(OZl28l07)
& Pros vs. Cons of IncreasedPracticeEfficiency
Date: 2125120072'.12,27
P.M.CentralStandard
Time
From: Arthu r.Lurvey@ugswlp.com
To: DrWBorg@aol.com, jyoung@aace.com, RMHARRELLl@aol.com, acohenl@midsouth.rr.com,
WILLIAMCONWAY@aol.com, blawjr@endoconsultants.com,
aml@endocrineconsultantsnw.com,
eglevy@bellsouth.net,mallik@bellsouth.net,
eric@orzeck.com,
sethu_reddy@merck.com,
Drselinger@aol.com, ZELLERWP@aol. com
CC: sgarrett@aace. com, petak@aace.ccrn

I t h i n kD r . Borg'scommentsare especiallywell thoughtout and well written.

Art
ArthurLurvey,MD
NationalGovernment Services.Inc.
5 1 5 1- B C a m i n o R u i z
Camarillo. California93012-8645
Phone:(805)367-0509
Fax:(805)367-0764E-Fax(888)314-2115
email:arthur.lurvey@ugswlp.com
'fhe
information contarned in thrs electronic message rnay be conideotial, is inteaded only' for the use of the recipient(s) named above,
and mav be legalh privileged. Ifyou are not the intended recipient of this communication, you are hereby notified that use, disttibution,
or copl"ing of this message is strictl-r' prohibited. Iflou have received this communicatioo in erot, please imrnediately renrm it to the
sender and delete the odgtnal message and anl copr of ir from vour computer s,vstem.Ifyou ha!'e any questions concerning this
message, please contacr the sender. Thank 1'ou.

---Original Message-----
Fromr DrWBorg@aol.com [mailto:DrWBorg@aol.com]
Sent: Saturday,February24,2OO7 2iZOAM
To: jyoung@aace.com; RMHARRELL1@aol.com; acohenl@midsouth.rr,com;
WILUAMCONWAY@aol.com; blawjr@endoconsultants.com; aml@endocrineconsultantsnw.com;
Lurvey,Arthur; mallik@bellsouth.net;
eglevy@bellsouth.net; eric@orzeck.com; sethu*reddy@merck,com;
zELLERwP@aol.com
Drselinger@aol.com;
Cc: sgarrett@aace.com;petak@aace.com
Subject: Re: PPLecture(0?'128/07)& Prosvs. Consof IncreasedPracticeEfficiency

I considerthis particularpresentationto be quite poor. However,it involvesmany very importantissues

which haveto be addressedas follows:
Any theoretical strategy can be used appropriatelyor horribly mlsused.The concept of /ncreased
Efficiency in EndocrinePractice(includingutilizationol Physicians Extenders) is a prime exampleof
such "double edged sword". lf used properlyit can be eltremely beneficialfor the practiceof clinical
endocrinology. \Mlen misused,it cangravelyhinderthe qualityof endocrine
care.
Prqper Use of Effic,ienc-J.Concep!
The proper utilizationof IncreasedEfficiencyConceptmay be a very viable solutionfor many economic
problems affecting practic,eof endocrinology.Ultimately,we have to fight for changing the current
grotesquereimbursementsystem.However,in the meantime,we haveto adapt - in order to surviveand
be ableto putup a goodfightfor thequalityof accessible care.I trustthatvastmajority
medical of
physiciansintuitivelyunderstandbasiccanonsof professionalism. Eventhough- they may not be familiar
with AMA Code of Ethicsnor RonaldRotunda'sseminaltexl on this matter.As medicalprofessionalswe
have an obligationto be economicallysuccessful,not only to simplysustainourselves, but also to be able
to gervethosewho are lessfortunate.lf we fail economicallywe will become"lessfortunate"ourselves.At
this pointtherewill be no one to helpour needypatients- despiteall the politicalrhetoricto the contrary.lt
is sad that this simple truth is not understoodby today's society. Modern public tends to perceive
"occupation" fullof greedyworkers,ratherthana nobleprofession.
medicineas an
The full discussionof the properutilizationof EfficiencyConceptis obviouslybeyondthe scope of this
brief text. The bottomline is as follows:Emphasison properpatientstriagingand leveragingone's
expertise by using well-trainedand supervisedphysicianextendersresults not only in better revenue
generation. lt alsoimprovesqualityof patients'careand Endocrinologists'
qualityof life.
undefined.February25,2007 America Online
 Page1 of I

Subj: Re: First version of PCOSLecture for the meeting of Texas Chapter of AACE
Date: 712512008 4:17:34P.M.CentratDaytightTirne
From: dr.verso@phxendo.com
To: DrwBorg@aol.com

DearDr. Borg,
I was impresssed_
with yo{ltowepoinlrresentation that I finallygot aroundto viewing.I would like to inviteyou to
co.e an,jnG-this talk-inFn ila-ndi ineTiealbf Septem6iji).ba'n ybu thinkof a diug companythat can help fte set
up an AACEdinnermeeting?
ToniVerso.M.D..F.A.C.E.
President.ArizonaAffiliate

Monday, July 28. 2008 America Online: DrWBorg

 PaseI of 1

Subj: RE: [Reprocom] FW: Final version of AACE Bio-identical Hormonesposition Stat...
Date: 71171?OO 8 :70 1 : 0 3P . M .C e n t r a tD a y t i g hTt i m e
From: rsherins@comcast.net
To. DrWBorg@aol.com

Dr Borg,

You'rewelcome. I offered my commentssincerely;my praisefor your work was well deserved.

Richard

---Original Message-----
From: DrWBorg@aol.com [mailto:DrwBorg@aol.com]
sent: Tuesday,July u, 2007 7:08 PM
To: rsherins@comcast.net
subjectl Fwd: [Reprocom]FW: Finalversionof AACEBio-idenfical
Hormonesposition
stat...

DearDr. Sherins,
thank you very muchfor your commentsand supportof the Bioidentical
HormonespositionStatement,your
kind wordsare greaUyappreciated.

Sincerely,.
WalterBorg,M.D.
llember, Reproductive MedicineCommitteeAACE
iiember, Socioeconomic CommifteeAACE
Dobgate, Lafayette Parieh t$edicalSociety, Louisiana State MedicalSociety
Borg lnstnute - Endocrinology: Adun Pediatric and Reproductive
5O1W. St. Mary Blvd, Suite 120, Lafayetle, LA 70506
Phone: (337) 593 9309;www.borginstitute.corn

Get a sneak peek of the all-newAOL.corn

Monday, July 23,20A7 .,\mericaOnline: DrWBorg

 Page1 of 1

Subj: Nomination of Walter Borg for election to AACE BOD

Date: 1018120073:28:24P.M.CentratDaytight Time
From: MHARRELL@browardhealth.org
To: bdaly@aace.com

earBettyet al:
I would like to nominate Dr. Walter Borg for election to the AACE BOD for 2008. Dr. Borg is an active and influential member of my
qr]-diave devoted countless hours to AACE
o9j9ec-_on9ryrj9_a[_d_q9q!$_C..9[rFj!tqe
'ga;rzStidsidiyearsio-coriii.-Sincereli, ' s onir$e pEil2 years. tle wiil1;;-fiab*d6i-n-6ur
- -affii
R. M-dcT
Hari6il"MD,FACP,FACE
TPORTANT: The contents of this email and any attachments are conftdential. They are intended for the named recipient(s) only.
you have rcceived this email in error, please now the system manager or the sender immediately and do not disclose the contents to anpne
, make coDiesthereof.
* esafe scanned this email for viruses, vandals, and malicious content. ***

Monday,October08"2007AmericaOnline:Guest
 Page1 of 2

Subj: Fwd: IMPORTANT:Patients'Opinions about us

Date: 6 / 9 / 2 0 0 86 : 0 6 : 5 8A . M . C e n t r a D
l a y t i g hTt i m e
From: DrWBorg
To: ARichardVP
CC: MLYALE

Get tradesecretsfor amazingburgers.Watch"Cookingwith TylerFlorence"on AOL Food

ForurardedMessage:
Subj: R e : F w d : I M P O R T A N TP: a t i e n t s 'O p i n i o n sa b o u t u s
Date: 6 1 7 1 2 0 0181: 1 9 : 5 2A . M . C e n t r a D
l a y t i g hTt i m e
From: hlando@yahoo.com
To: DrWBorg@aol.com
Sentfromthe lnternet(Detaitsl

Walt,

Lo jjrLlg. _rP" PglntI reallyneverei/enthoughtor to be honestknewabout.I readthe comments fromthesiteforthefirsttime

andfindthe negative onespersonally horribie.However theydo bringuii tTr'e
factthatevenif we thinkwe arecarefulabout
patientcommunication, we arenotalwayssuccessful.
Usingpatientcareextenders
seemsto be moreof a problem thenI thoughtas theyaretrulythat- an extension
of us andwhat
theysayanddo reallydoesreflecton us whetherwe arethereor not.
Anotherproblems seemsto be thatwe c€nnotsatisfythyroidpatients
who havenormaltestsbutfeeltheyarehypothyroidand
probablyreallywant"natural"
thyroidor T3,whileourteaching (Endo,AACE,ATA)tell usw-edo noi neeOto give
andsocieties

Finallycomestherealization thatnoneof us areableto getaroundthe problemof time. In orderto be successfulweneedto

seemorepatients in the practice
anddo moreprocedures in thepractice,
withmoreextenders - whetherstaffor pA, Np, CDE,
all of whomreflecton us. Anythingthatmakesthe patientfeeluncomfortable
fromwaitingto an unkindwordto notmeeting
expectationscanundomuchof whatwe cando . Alsothemorewe do in theoffice,the morewe looklikewe aretryingto 6arn
moneyratherthantreatthe patient.

I suspectthatthesmallerthe practiceandthe lessdonein theoffice- lab,Xray- the betterthe gradesbutthe moretime

to the patient.
available

Obviously,
I don'tknowtheansweror my scoreswouldhavebeenperfect.Maybewe needto sendouta surveyto thosewith
the highestscoresto seeif thereis a secretwe arenotseeing.
Thanksforthe info.

Howard

-- On Sat,6/7/08,DrWBorg@aol.com
<DrWBorg@aol.com>
wrote:
> From:DrWBorg@aol.com <DrWBorg@aol.com>
> Subject:Fwd:IMPORTANT: Patients'
Opinions
aboutus
> To: hlando@yahoo.com
> Date:Saturday,
June7, 2008,7:15AM
> DearHoward,
> You havereceived
diversifledratingon _www.RateMDs.com_
> (http://www.
RateMDs.com) . Pleaseexamineyoursand other
> AACEmembers RateMDs profile.We

Friday,June20. 2008AmericaOnline:MLYALE
 PageI of 1

Subl: Re: IMPORTANT:Patients'Opinionsabout us

Date: 6h1120087.49:24 P.M.CentralDaylightTime
From: tmallik@cox.net
To: DrwBorg@aol.com

.DJglQ!_Eorg"l!_?ygloq'e$_ygg for takingthis project.lthas shownus how vulnerablewe are.l agree with my colleaguesthat
dlred responselo lnose unhappypatrentsare not necessary.On the other hand we must proactivelycreatequarterlyreviewby
our patientswhich will help us to evaluateour practices.lnfuture meetingswe will createpracticalquestionaresfor that
purpose.Thanks, Dr. Mallik
-- DrwBorg@aol.comwrote;

> DearColleagues,
> | beliethat Howardmade seriesof absolutelyexcellentand very specific
> Doints- and we need to exDandand followon them.

> | absolutelyagree with Eric that "this issue still deserves to be

> discussedin some manneralthoughI don'tbelievethata direct responseto the
> posts is worth worrying".

> | respectfullydisagree(but only in part)with Sethu.I have emailed him a

> separateletterof my admirationand supportand expressedmy deep sorrow
> that I have to disagreewith him even partially.HoweverI have to do so. The
> information is alreadydisseminated on Intemetandthroughvariousblogs.lt
> is in our face, we cannotrun from it. I believe lhat this importantissue
> has to be addressedin accordancewith the famous StockdaleParadox:

> "Retainfaith that you will prevailin the end, regardlessofthe

> difficulties-AND at the same time - confrontthe most brutalfacts of vour current
> reality,whateverthey mightbe."

> Obviously- we should ignore(and do not proliferateany more)the specific

> anonymousrantsthat defameus or our colleagues.Any discussionwith
> cowardlyanonymousaccusersis consistentwith givingthem somejustification.
> However,we need to start addressingthe anti-endocrinology backlashheadson.
> _www.ratems.com_(http:/ ^rww.ratems.com) and similarsourcesmay be a useful
> tools.We need to start studdingthe generaldissatisfactionspatterns and try
> to remedythem.Not doingso wouldbe a mistake.Our inactionwill comeback
> to haunt us. One disgruntledpatientcan do a lot of damagetoday - more
> thanwe are willingto accept.

> Kind Regards

> Walter

> In a messagedated6/8/20081:13:48A.M. Cenral DaylightTime,

> eric@orzeck.comwrites:

> | agree lhat specificcommentsregardingthe patients'postings

> shouldnlbe sentin this medium.Butthisentireissuestilldeserves
> to be discussedin somemanneralthoughI don'tbelievethata direct
> responseto the posts is worth worrying about.

> Eric

l
tradesecretsfor amazingburgers.Watch"Cooking
with
> TylerFlorence"onAOLFood.
> (http://food.aol.com/tyler-florence?video=4?&NCIO=ao|fod00030000000002)

Mondav.June 16"2008 America Online:DrWBorq

 Pase1 of 2

Subj: RE: Reaching Colleagues about Matters Academic and lssues Ethical
Date' 101161?008
9:46:36A.M. CentratDaytightTime
From: BAckerman@dermpathd iagnostics.co'tl
To: DrWBorg@aol.com

Dear Walter.

Hgw.ve,ry g.ood it was of you to take the time to write such a thoughtful and gracious letterr We are of one
mind! Michael Crichton, a graduateof Harvard Medical School, got it right! Nothing is more offensive to
individuality than consensus.

Thanks once again and best regardsto you from

Bemard Ackerman

ABAibi

Biarna lshibashi
ExecutiaeAssistant
AckermanAcailemAo.fD ermq.topathology
145East32nilSfieet,10thFloor
NezuYork, llY 70476
Olfice(977)522-2226
Fax $77) 889-8268
bishib ashi@atneripath.con

From! DrWBorg@aol.com Imailto:DrWBorg@aol.com]

Sent: Tuesday,October14, 2008 12:15AM
To: Ackerman,Bemie- MD
Cc: Delarose,loanna
subject: ReachingColleaguesabout MattersAcademicand IssuesEthical

October 13, 2008

Via Fax: (212) 889-8268
Via Enuil: abernard@ameripath.com
j delarose@dermpathdiagnostics.com
A, Bernard Ackerman, M.D.
Director Emeritus
Ackerman Academy of Dermatopathology
145 East32nd Streeti lOth Floor
New York,NY 10016
Re: Reaching Colleagues about Matlers Academic and Issues Ethical
Dear Dr. Ackerman, "Reaching Colleagues about Matterc Academic and
It was a true pleasureto receive your very enlightening publication
Issues Ethical - In Spite of Censorship by the Atchives of Dermatology". Your courage and perseverance in fighting
the scourge of editoiial cinsorship iJ most laudable. I applaud your unwavering opposition to the pervasive and
ignorance-fueledtrend for over-simplifi cation of scientific terminolory'
The specific problems that you addressin your Letters to the Editor are from the realm of dermatology. However' those
issues have an important universal aspect that applies to all matters scientific. Your commitment to substance,ethical
past - you
standardsand inteilectual honesty is viry inspiring. and so much neededtoday. As it was always a case in the
stand tall among your Peers.
In spire ofthe rhetoric to the contrary - majority of academiccommunity have forgotten that the one and only purposeof

Thursday,October 16, 2008 America Online: DrWBorg

 Page 1 of I

!ubj: Re: ReproductiveMedicineCornerpaper- for FM Mar/Apr0Z

Date: 2l7l2OO79:49:59A.M.CentratStandardTime
From: RHCobin
To: DrWBorg,endodoc@bellsouth.net,
samara.ginzburg@mssm.edu,petak@texas.net
CC: lclawges@aace.com,tchaney@aace.corn

Ihi: 's s lgygty review. Becauseof its size and depth of coverage,I'm wondering whether it is more
ffi Tdf nEwslet@Eom-m'iEft:-..-.
RhodaH. Cobin. MD, MACE

Clinical Professorof Medicine

The Mount Sinai Schoolof Medicine
New York, NY

Immediate Past President,AmericanCollegeof Endocrinology

Past President,American Associationof ClinicalEndocrinologists

-----OriginalMessage-----
From: DrWBorg@aol.com
To: RHCobin@aol.com; endodoc@bellsouth.net; samara.ginzburg@mssm.edu
Cc: lclawges@aace.com; tchaney@aace.com; petak@texas.net
Sent: wed, 7 Feb 2OO72:45 AM
Subject: Reproductive MedicineCorner Paper - for FM Mar/Apr 07

DearColleagues,
enclosedis my ReproductiveMedicineCornerpaperfor March/April2007 issueof "The FirstMessengef'.After
carefulconsiderations,I decidedto focuson the under-appreciated
but very significantproblemof androgens
misusein clinicalpractice.
Thankyou.
WalterBorg,M.D.

PS. I am goingout of towntodaybut lwill try to checkmy emaileveryevening.

Check out the new AOL, Most comprehensiveset of free safety and security tools. free accessto
millionsof high-qualityvideosfrom acrossthe web, free AOL Mailand more.

Wednesday,FebruaryA7,2007 America Online: Guest

 Page1 of 1

Subj: Re: Final version of AACE Bio-identical Hormones Position Statement

Date: 711612007 11'.54:42
A.M. CentratDaytightTime
From: dr.verso@phxendo.corn
To: DrWBorg@aol.com

Dear Dr Borg:
_ttnink U]jSd..gcument l . I am Justgoing to suggestsome grammaticaldifferences:
On Page 2, line 10, I would hyphenatehalf-life.
line22, I would punctuatewith the common beforewhich and the 2nd comma after indeed.
line 24, I would change payorsto payersalthughi realizesome spellit the otherway.
On Page 3, line 7, I would use a collon insteadof a periodafter Safety.
line 12, I would hyphenatewell-designed
line 20, I would get rid of the extra space betweenthe and hormonal.
On Page 4, line 33, I would get rid of the extra space betweenof and saliva.
On page 5, line 8, I would put a comma afterexperience
On page 6, I would capitalizethe firstletterof all of the bullets.

I have nothingto say about the content;you did a masterfuljob.

Toni Verso

> From. DrWBorg@aol.com

> Date:2007107115
Sun AM 12'.22.03EDT
> To: RHCobin@aol.com,wfutt@ix.
netcom.com,Wayne.Meikle@hsc.
utah.edu,

> Subject:Final verslon of AACE Bio-identicalHormonesPositionStatement

> Enclosedplease find the final versionof AACE Bio-identicalHormones

> PositionStatement.
> | appreciatethe help of all Membersof the Committee.

> Sincerely,
> WalterBorg, M.D.
> _Member, ReproductiveMedicineCommitteeAACE_
> (http://www.aace.com/org/committees.php?comm=REPRO)

> _Member, SocioeconomacCommitteeAACE_

> (http://www.a ace.com/org/committees.php?com m=smac)
> Delegate,LafayetteParish Medical Socie$, LouisianaState MedicalSociety
> Borg lnstitute - Endocrinology:Adult, Pediatricand Reproductive
> 501 W. St. Mary Blvd, Suite 120, Latayette,LA 70506
> Phone: (337) 593 9309; _www.borginstitute.com_ (http://www.borginstitute.com)

> **************************************
Ggt a sngak pgak of thg all-ngwAOL at
> http://discover.ao |.co m/rnemed/aoIcom3Otour

Monday, July 16. )0A7 America Online: DrWBorg

 Page1 of4

ln a messagedated 1211212006
6:27:04A.M. CentralStandardTime, RHCobinwrites:

Nice work Dr. Borg.

I would propose both on website and in First Messenger.

R h o d aH C o b i n M D , M A C E

ClinicalProfessorof Medicine
The Mount Sinai Schoolof Medicine
New York, NY

lmmediatePast President,Americancollege cf Endocrinorogy

Past President,AmericanAssociationof ClinicalEndocrinologists

-----Origi nal Message-----

To: DrWBorg@aol.com

Sent:Tue, 12 Dec 2006 7'.22AM

Subject.Re: AMA Callsfor RealityCheckon Bioidentical
Hormones

Very impressive on such shoft notice.

Where do you propose we publish this? First Messenger?As a "white paper" to be distributed to our
members by email and posted on the website?

Steve(Petak)President,
AmericanAssociation
of ClinicalEndocrinologists

ForwardedMessage:
Subj: Re: AMA Galls for Reality Gheck on Eioidentical Hormones.
Date: 10'.24:16
1211212006 P.M. CentralStandardTime
From: RMHARRELLl
To: DrWBorg
CC: jcarlin

Walter: Well done. Thanks again for an infornnativepiece. Best, RMH

( D r .R M H a r r e l lC
, h a i r m a nS E C A A C E )

AMA CaUs for Reality Check on Bioidentical Hormones.

Walter Borg, M.D.

In November of 2006 American Medical Association (AMA) has passedthe resolution urging FDA to increase
"Bio-identical Hormones" (BH)
regulation and oversight of so-called [ ]. This resolution has been introduced
by AACE, Endocrine Society, and American Society for Reproductive Medicine. AMA asks FDA to:
purity ofall compounded "bioidentical hormone" formulations;
o conduct surveys for and dosageaccuracy
. require mandatory reporting by drug manufacturers,including compounding pharmacies,of adverse events
"bioidentical hormones":
related to the use of
"bioidentical hormones";
o create a registry ofadverse events related to the use of
. require the inclusion of uniform patient information (wamings and precautions), in packaging of
compounded bioidentical hormones.

Tuesday,Decembert 2" 2406AmericaOnline:Guest

 PageI of4

Subj: Re: "Patients'opinionabout ua" - from Theoryto practice.

Date: 6124120086:10:05A.M.CentralDaytight Time
From: hlando@yahoo.com
To: DrwBorg@aol.com

Walt,

Nicelywritten.lt outlinesthe problemareaswell. Oneotherthought.Therearemoreareaswherepatientexpectations exceed

to Feffiem: moSfiyaSethbecairSeof our "friends"on the internet(andhereI meanotherMD's). We see many
our-abifities
patients
whowe knowaregoingto be potential problems fromthe momentwe beginto takeour interviews - theyare herefor
suchdiverse problems as fatiguefromadrenal "failure",
the useof "natural"
hormones, the needfor "T3",
chronicfatigue
syndrome whereour longsuffering primarycareproviders havegivenup,hairlossin the postmenopausal female,obesepatients
whofeelthatthereis alwaysa hormonal reasonthatwe justcannotfind- justto namea few.

Maybewe needa lessonin howto approachunrealized expectationsin ourofficeand if theirareothermeansthanthe direct

ofjust saying"NO"to theirwishesdespitetryingto educatethemon thefallacyof theiropinions.
approach

Justa thought.

Howard

-- On Mon,6/23108, <DrWBorg@aol.com>
DrwBorg@aol.com wrote:
> From:DrWBorg@aol.com <DrWBorg@aol.com>
> Subject:"Patients' opinionaboutus"- fromTheoryto Practice.
> To: RMHARRELLl @aol.com, jaycohen 1@comcast. net,tmallik@cox.
net,WILLIAMCONWAY@aol.com,
endocctodd@bellsouth. net,hlando@yahoo.com, Arthur.
blawjr@endoconsultants.com, Lurvey@ugswlp.com,
eric@ozeck.com,
dprice@lfsus.jnj.com, sethu_reddy@merck.com, Drpmrosman@aol.com, ZELLERWP@aol.com,
seibel@ix.netcom.com,
alee@aspenmed.org
> Date:Monday,June23, 2008,11:55PM
> THEORY:
> Paradoxically, disturbing Internetpostingshavesome
> value.Onlythe
> fittestcansurvive,and fitnessincludes abilityto learn
> fromone'serrors.As
> painfulfor ouregos someof thoseanonymous rantsare-
> theymaybe signsof a
> realproblem- that shouldnotbe ignored.I arguethat
> AACEshould
> acknowledge existence ofthe followingphenomena andhelp
> ourmembersto practically
> dealwiththem.These phenomena include:
> 1) Expectation Chasm.Thereis a wideninggap
> betweenDatients
> desiresand expectations vs. the realityof evidence
> basedendocrine oractice.
> 2) Scientificllliteracy.Americans pride
> themselves on being
> scientifically
sophisticated, andon livingin theageof
> science.Nothingcouldbe
> furtherfromthetruth.Muchof the generalpublichas
> littleunderstanding
> of science,and doesnotacceptourmedicalmodel.
> Moreover, the publicis
> increasingly seekingalternative and pseudo-scientific
> modelsof care.
t 3) AntFDoctorBacklash.There are two rootcauses
> of thisphenomenon:
; a) Disappointment with medicalpromises. Thereis a
> deeDsense of
> societaldisappointment arisingfromthefailureof certain
> overly-optimistic

Wednesday.June25. 2008 AmericaOnline: Guest