Glitazone Effects on Gene Expression

Troglitazone, besides improving insulin action in insulin-resistant subjects, is also a specific ligand for the nuclear receptor peroxisome proliferator-activated receptor-g (PPARg). To determine whether tro- glitazone might enhance insulin action by stimulation of PPARg gene expression in muscle, total PPARg messenger RNA (mRNA), and protein were determined in skeletal muscle cultures from nondiabetic control and type II diabetic subjects before and after treatment of cultures with troglitazone (4 days 6 troglitazone, 11.5 mM). Troglitazone treatment increased PPARg mRNA levels up to 3-fold in mus- cle cultures from type II diabetics (277 6 63 to 630 6 100 3 103 copies/mg total RNA, P 5 0.003) and in nondiabetic control subjects (200 6 42 to 490 6 81, P 5 0.003). PPARg protein levels in both diabetic (4.7 6 1.6 to 13.6 6 3.0 AU/10 mg protein, P , 0.02) and nondiabetic cells (7.4 6 1.0 to 12.7 6 1.8, P , 0.05) were also up- regulated by troglitazone treatment. Increased PPARg was associated with stimulation of human adipocyte lipid binding protein (ALBP) and muscle fatty acid binding protein (mFABP) mRNA, with- out change in the mRNA for glycerol-3-phosphate dehydrogenase, PPARd, myogenin, uncoupling protein-2, or sarcomeric a-actin pro- tein. In summary, we showed that troglitazone markedly induces PPARg, ALBP, and mFABP mRNA abundance in muscle cultures from both nondiabetic and type II diabetic subjects. Increased ex- pression of PPARg protein and other genes involved in glucose and lipid metabolism in skeletal muscle may account, in part, for the insulin sensitizing effects of troglitazone in type II diabetes

Glimipride and GLUT-4

Sulfonylurea drugs are widely used in the therapy of NIDDM. The improvement of glucose tolerance after long-term treatment of NIDDM patients with the drug can be explained by stimulation of glucose utilization in peripheral tissues that are characterized by insulin resistance in these patients. We studied whether the novel sulfonylurea drug, glimepiride, stimulates glucose transport into isolated insulin-resistant rat adipocytes. After long-term incubation of the cells in primary culture with high concentrations of glucose, glutamine, and insulin, stimulation of glucose transport by insulin was significantly reduced both with respect to maximal responsiveness (65% decrease of Vmax) and sensitivity (2.6fold increase of ED50) compared with adipocytes cultured in medium containing a low concentration of glucose and no insulin. This reflects insulin resistance of glucose transport. In contrast, both responsiveness and sensitivity of glucose transport toward stimulation by glimepiride were only marginally reduced in insulin-resistant adipocytes (15% decrease of Vmax; 1.2-fold increase of ED50) versus control cells. Glimepiride, in combination with glucose and glutamine during the primary culture, caused desensitization of the glucose transport system toward stimulation by insulin, but to a lesser degree than insulin itself (50% reduction of Vmax; ninefold increase of ED50). Again, the maximal responsiveness and sensitivity of glucose transport toward stimulation by glimepiride were only slightly diminished. The presence of glimepiride during primary culture did not antagonize the induction of insulin resistance of glucose transport. The stimulation of glucose transport in insulinresistant adipocytes by glimepiride is caused by translocation of glucose transporters from low-density microsomes to plasma membranes as demonstrated by subcellular fractionation and immunoblotting with anti-GLUT1 and anti-GLUT4 antibodies. Immunoprecipitation of GLUT4 from 32Pi- and [35S]methionine-labeled adipocytes revealed that the insulin resistance of

GLUT4 translocation is accompanied by increased (three- to fourfold) phosphorylation of GLUT4 in both low-density microsomes and plasma membranes. Short-term treatment of desensitized adipocytes with glimepiride or insulin reduced GLUT4 phosphorylation by approximately 70 and 25%, respectively, in both fractions. We conclude that glimepiride activates glucose transport by stimulation of GLUT1 and GLUT4 translocation in rat adipocytes via interference at a site downstream of the putative molecular defect in the signaling cascade between the insulin receptor and the glucose transport system induced by high concentrations of glucose and insulin. The molecular site of glimepiride action is related to GLUT4 phosphorylation/dephosphorylation, which may regulate glucose transporter activity and translocation.

GLITAZONES AND FLUID RETENTION

The glitazones (also known as thiazolidinediones or TZDs) are used in the treatment of Type 2 diabetes mellitus. They are the first class of medicines to primarily target insulin resistance. Rosiglitazone and pioglitazone are the two glitazones currently available in New Zealand; only pioglitazone is funded (under Special Authority). Fluid retention and oedema reported locally and internationally The Centre for Adverse Reactions Monitoring (CARM) has received reports of peripheral oedema, pulmonary oedema, pleural effusion and exacerbation of cardiac failure with pioglitazone and rosiglitazone. A review of the WHO International Drug Monitoring database in December 2006 revealed that reports of fluid retention leading to oedema and related conditions made up the greatest proportion of adverse reactions to glitazones. In clinical trials, fluid retention was commonly reported by patients taking these medicines; oedema was reported more often when insulin or a sulphonylurea was also prescribed.1,2 Development of oedema is dose-related and, in most patients, is mild to moderate.2 However, it can be severe as illustrated in reports to CARM. One patient was admitted to hospital with oedema extending from the legs to the chest while taking pioglitazone 15mg daily. Another developed oedema of the legs and abdomen, and shortness of breath on exertion three weeks after starting rosiglitazone 4mg daily. There was no evidence of cardiac failure. He recovered with frusemide treatment and discontinuation of rosiglitazone. Fluid retention may lead to pulmonary oedema and cardiac failure Fluid retention due to glitazones may lead to, or exacerbate, cardiac failure in some patients.1 Patients with ischaemic heart disease, valvular heart disease or

hypertension are already at risk of developing cardiac failure and it is thought that glitazones may increase the likelihood of this occurring. Risk higher with combined insulin and glitazones In clinical trials, heart failure and pulmonary oedema occurred commonly in patients taking rosiglitazone and insulin; this was more frequent than in those taking insulin alone. Patients with heart failure were, on average, older, had a longer duration of diabetes and were mostly taking the higher 8mg dose.2 Pre-existing heart failure may worsen In a trial comparing pioglitazone and glibenclamide in patients with moderate to severe heart failure and uncontrolled Type 2 diabetes, 9.9% of patients taking pioglitazone, compared with 4.7% taking glibenclamide, were admitted to hospital because of heart failure. As with rosiglitazone, this was more likely to occur in older patients and those using insulin.1 Heart failure precipitated in macrovascular disease The Prospective Pioglitazone Clinical Trial in Macrovascular Events (PROactive) study3 examined the incidence of heart failure in patients taking pioglitazone compared with placebo. Patients enrolled had Type 2 diabetes with macrovascular disease. Heart failure, and heart failure leading to hospital admission, occurred significantly more often in patients taking pioglitazone compared with placebo (11% v 8% and 6% v 4%) but there was no difference in the incidence of fatal heart failure. Mechanism likely to be fluid retention rather than left ventricular dysfunction Some patients have developed pulmonary oedema without evidence of ischaemic heart disease, or systolic or diastolic dysfunction. Marked peripheral oedema has been a feature in some case reports.4,5 Studies of rosiglitazone indicate that a dose-related effect on pulmonary endothelial permeability, rather

than alterations in left ventricular mass or ejection fraction, is probably responsible for the development of pulmonary oedema and, in susceptible patients, cardiac failure.6 Consider background risk, use low doses and monitor patients closely Use of rosiglitazone or pioglitazone is contraindicated in patients with NYHA Class III and IV heart failure, and not recommended in patients with symptomatic heart failure.1,2 It would be prudent to use the lowest possible doses of glitazones in patients with oedema and breathlessness without confirmed clinical evidence of cardiac insufficiency. Due to an increased risk of heart failure and myocardial ischaemia when rosiglitazone is added to insulin therapy, rosiglitazone must not be initiated in patients already using insulin.2 In patients taking a sulphonylurea who also require a glitazone, initiation of the glitazone should be at the lowest recommended dose with cautious increases only after appropriate clinical evaluation of the patient's risk of fluid retention and cardiovascular events.1,2 All patients (especially those with cardiac disease putting them at risk of heart failure) taking glitazones should be monitored for signs and symptoms of fluid retention and heart failure following initiation of the glitazone and again following any subsequent dose increases. If signs and symptoms suggestive of heart failure develop, prescribers should either stop or reduce the dose of glitazone. Patients and their carers should also be informed of the symptoms of fluid retention and heart failure.1,2 Macular oedema can be exacerbated by glitazone use Among patients with Type 2 diabetes, the prevalence of macular oedema is 15% in those who use insulin and 4% in those who do not.7 Post-marketing reports have been received of worsening diabetic macular oedema in association with

glitazone use, probably because of fluid retention.1,2 These reports led to a review of 30 patients who had macular oedema while taking pioglitazone or rosiglitazone.8 It was observed that these patients also had lower limb oedema. Eleven of these patients were observed for three months after glitazones were discontinued. Mean weight gain after commencing a glitazone in these patients was 13.5 kg and mean weight loss after discontinuation was 8.5 kg. Rapid reduction in macular oedema occurred in four of the eleven patients when glitazones were discontinued. Disturbances in visual acuity may indicate macular oedema. If macular oedema occurs or worsens during treatment with glitazones, this may be due to disease progression, but also consider whether the glitazone could be implicated. Patients should be advised to seek medical advice if they develop symptoms of visual impairment, and prescribers should give consideration to stopping the glitazone. Caution and vigilance warranted In summary, prescribers need to be aware that glitazones commonly cause oedema and related conditions. Pioglitazone and rosiglitazone are contraindicated in patients with NYHA Class III and IV heart failure, and not recommended in patients with symptomatic heart failure. Initiation of glitazone therapy should be at the lowest recommended dose; subsequent dose increases should only occur following evaluation of the patient's risk of fluid retention and cardiovascular events. It is recommended that patients be informed of the symptoms and be monitored, particularly for cardiovascular decompensation

METFORMIN AND VASCULAR EVENT

Type 2 diabetes is associated with a two- to fourfold increased risk of coronary heart disease (CHD), and patients with diabetes are often found to have increased cardiovascular risk factors, including dyslipidemia and hypertension. The simultaneous presence of high fasting glucose and complex dyslipidemia increases the risk of CHD events threefold. Glycemic control alone is unlikely to completely eliminate the risk of CHD in patients with type 2 diabetes; therefore, a multifactorial approach to the prevention of CHD appears necessary. The association of microvascular complications such as retinopathy and nephropathy with type 2 diabetes is well known, and the Multiple Risk Factor Intervention Trial (MRFIT) verified diabetes to be a strong independent risk factor of end-stage renal disease (29). Urinary albumin levels have been suggested to be markers of both diabetic retinopathy and nephropathy. By examining levels of this marker and the ACR, the present study will determine how treatment targeting insulin resistance and impaired -cell function might impact microvascular disease progression. Microalbuminuria (urinary albumin excretion rate between 30 and 300 mg/24 h) is not only a marker of renal and cardiovascular disease risk but also increases the risk of all-cause mortality (30). Markers of systemic inflammation have been identified linking CHD and type 2 diabetes. CRP, a sensitive inflammatory marker, has been linked with CHD mortality, most notably in the MRFIT (31) and the U.S. Physicians Health Study (32). Hypercoagulability and impaired fibrinolysis are possible candidates linking hyperinsulinism with atherosclerotic disease. Decreased insulin sensitivity has recently been associated with both elevated PAI-1 and fibrinogen levels, and increased levels of both insulin and proinsulin were associated with elevated PAI-1 (33). An association among CRP, fibrinogen, and microalbuminuria has also been described in type 2 diabetes (34).

In the UKPDS obese patient substudy, it is interesting to note that metformin, which some consider a weak and indirect insulin sensitizer of peripheral tissues, was the only agent to positively impact on mortality and cardiovascular complications. Rates of major cardiovascular events are expected to be low, and ADOPT is not expected to have the statistical power to detect differences across treatment groups. However, it is expected that comparisons of the effects of treatments on numerous traditional and nontraditional markers of cardiovascular risk will be performed. Effects of concomitant antihypertensive and lipidlowering treatment on cardiovascular outcomes will only be ascertained through AE reporting, because event rates in this patient population are unlikely to be high enough to ascertain treatment differences.

METFORMIN AND CANCER MORTALITY

The anti-diabetic drug metformin is associated with reduced cancer incidence. In a UK based study of 4085 type 2 diabetics who used metformin from 1994 to 2003, investigators compared the incidence of cancer in those diebetics to the rate of cancer in diabetics who did not use metformin. The risk of cancer was reduced by 40 percent among those who took metformin (1). In a study of 1353 patients with type 2 diabetes in the Netherlands, during 9.6 years of follow-up, cancer deaths were significantly reduced among those who took metformin (2). Among mechanisms for such a benefit are the inhibition of cancer cell growth and suppression of erb-2 oncoprotein overexpression and inhibition of mTOR (3-5). A search using the medical literature search engine, PubMed, shows over 800 papers addressing metformin and cancer ranging from human studies, as noted above, to animal models and tissue culture studies. This rapidly expanding area of laboratory and human evidence points to a role for metformin among diabetic patients. The call for clinical trials is well justified studies in diabetic patients. We performed a comprehensive literature search and meta-analysis of epidemiologic studies to assess the effect of metformin on cancer incidence and mortality in diabetic patients, using Pubmed, ISI Web of Science, Embase, and the Cochrane library until May 2009, with no language or time restrictions. Independent reports with sufficient information to allow risk estimation of cancer risk/mortality and a measure of uncertainty were reviewed and crosschecked independently by three investigators. Eleven studies were selected for relevance in terms of intervention, population studied, independence, and

reporting of cancer incidence or mortality data, reporting 4,042 cancer events and 529 cancer deaths. A 31% reduction in overall summary relative risk (0.69; 95% confidence interval, 0.61-0.79) was found in subjects taking metformin compared with other antidiabetic drugs. The inverse association was significant for pancreatic and hepatocellular cancer, and nonsignificant for colon, breast, and prostate cancer. A trend to a dose-response relationship was noted. Metformin is associated with a decreased risk of cancer incidence compared with other treatments among diabetic patients. Given the retrospective nature of most studies and the possibility that the control treatments increase risk, phase II trials are needed before large cancer prevention trials are launched.

Dual PPAR gamma agonist

Type 2 diabetes mellitus is a disease of complex pathogenesis and pleiotropic clinical manifestations. The greatest clinical challenge in this disease is the prevention of the long-term complications, many of which involve cardiovascular outcomes. The peroxisome proliferator-activated receptor (PPAR) alpha and gamma isoforms of the family of nuclear transcription factors are pharmaceutical targets for therapeutic intervention because they can potentially ameliorate not only the hyperglycemia of diabetes, but also the dyslipidemia that is characteristic of this disorder (low high-density lipoprotein cholesterol, high triglycerides, small, dense low-density lipoprotein particles). Novel drugs with dual PPAR alpha and gamma activity have been under clinical development for type 2 diabetes, and they have shown promise in early studies with regard to glucose lowering and improved lipid profile when compared with the PPAR-gamma-specific thiazolidinediones. Unfortunately, the dual PPARs available to date have some of the PPAR-gamma-associated side effect profile, including fluid retention and weight gain, which have limited the further clinical development of higher doses that show improved efficacy. This review will briefly summarize our understanding of the pathogenesis of type 2 diabetes, the role of the PPAR family of receptors, and the potential for clinical use of this novel emerging class of agents that serve as dual activators of both PPAR-alpha and PPAR-gamma. The discovery of the crucial role of peroxisome proliferatoractivated receptors (PPARs) as regulators of lipid and glucose metabolism has raised interest in the development of synthetic ligands as potential tools for therapeutic intervention in type 2 diabetes and the metabolic syndrome. PPAR activators primarily improve dyslipidemia, whereas thiazolidinediones are potent PPAR activators that improve insulin resistance. Important research

programs to develop agonists that combine the therapeutic effects of both PPAR- and PPAR-selective agonists, creating the expectation of greater efficacy and other advantages in the treatment of type 2 diabetes and the metabolic syndrome, have therefore been undertaken. Among these dual PPAR/ agonists, compounds that belong to the glitazar class are in the most advanced stage of development. However, although they demonstrated beneficial impact over selective PPAR agonists by improving both lipid and glucose homeostasis, safety has been a critical issue and has led to the discontinuation of their development because of adverse toxicity profiles. However, the target-related mechanism responsible for the identified safety issues and the relevance of rodent toxicities to the human situation are unclear. Therefore, future development of dual PPAR/ agonists with selective PPAR modulator activity appears appropriate and should be feasible.A fourth class of "dual", "balanced" or "pan" PPAR ligands, which bind two or more PPAR isoforms, are currently under active investigation for treatment of a larger subset of the symptoms of the metabolic syndrome.[2][3] These include the experimental compounds aleglitazar, muraglitazar and tesaglitazar. In addition, there is continuing research and development of new PPAR modulators for additional therapeutic indications.

Amylin Analog Treatment

Pramlintide is an injected medicine for people with type 1 and type 2 diabetes that helps control blood sugar levels after eating. Pramlintide (Symlin) Pramlintide resembles the hormone, amylin that is normally released along with insulin from the pancreas. In type 2 diabetes, amylin levels may be reduced. Some people get certain side effects (such as nausea, vomiting and low blood sugar) when starting pramlintide, therefore the starting dose is small to allow the body to adjust to this new medicine. In short, pramlintide lowers glucagon during a meal, slows food emptying from the stomach and curbs the appetite. Side Effects Some people get certain side effects (such as nausea, vomiting and low blood sugar) when starting pramlintide, therefore the starting dose is small to allow the body to adjust to this new medicine. In type 2 diabetes, the initial dose is 60 micrograms (10 units on the insulin syringe), taken before meals. After 3 days, if you tolerate the medicine, the dose may be increased to 120 micrograms (20 units on the insulin syringe) before meals. Pramlintide is available in a vial and pen form. If treated with insulin releasing pills and starting pramlintide:

Reduce the insulin releasing pill dose by half or more.. Inject pramlintide just before eating; it is taken three times daily.

If e treated with insulin and starting pramlintide:

Reduce mealtime insulin dose by half or more to prevent a low blood sugarIf using an insulin pump, extending the meal bolus to 1 or 2 hours may prevent early post meal hypoglycemia and late post meal hyperglycemia related to the delayed stomach emptying. Inject pramlintide at the same time you inject insulin, but at a different injection site. Do not mix pramlintide with insulin in the same syringe. The most common side effects are:

Nausea Vomiting Headache Low blood sugar, if also taking insulin

Direct rennin inhibition in type 1

In type 1 diabetes, many patients who initially develop microalbuminuria subsequently revert to normoalbuminuria (18,19); therefore, the association between spontaneous or therapy-induced changes in albumin excretion rate and the subsequent progression of nephropathy is less clear Better Renoprotection with Renin Inhibitors Compared with Angiotensin-converting Enzyme Inhibitors/Angiotensin Receptor Blockers? From a nephrologists point of view, renin inhibition seems an interesting new approach for preventing the progression of CKD. Just like ACE inhibitors and ARBs, DRIs were shown to diminish renal vascular resistance and increase renal blood flow. On the other hand, they reduce the filtration fraction by predominantly dilating the efferent arteriole. The net result is a decrease in the filtration fraction without a change (or even an increase) in the glomerular filtration rate and the fractional sodium excretion. These effects were seen in animals3739 as well as in humans,40,41 and may provide renoprotective benefits similar to those of ACE inhibitors and ARBs. Moreover, particular advantages may result from direct renin inhibition if the angiotensin-independent profibrotic role of renin (discussed above) is to be considered16

Metformin and acarbose in type 1

Acarbose, an alpha-glucosidase inhibitor, is a new antihyperglycaemic agent which has been proposed as add-on therapy in Type 2 diabetic patients not wellcontrolled with diet alone, sulphonylurea, metformin or insulin, and in Type 1 diabetic patients with large meal-related plasma glucose excursions. Numerous controlled studies investigating the clinical effects of acarbose in Type 2 diabetes versus either placebo or, more rarely, versus a reference drug (sulphonylurea or metformin) have been published during the last 10 years. All placebo-controlled studies have demonstrated the superiority of acarbose, at a dose of 150-600 mg/day, in decreasing fasting and postprandial glucose levels as well as HbA1c concentrations (mean decrease of 0.7%), whether acarbose was given as first-line therapy in diet-treated diabetic patients or in combination in individuals already receiving a sulphonylurea, metformin or insulin. Only a few controlled studies have compared the effects of acarbose with those of either sulphonylurea or metformin, yielding controversial results. In Type 1 diabetic patients, a small reduction of HbA1c levels was also reported after addition of acarbose to insulin therapy, which in some cases allowed a slight reduction of daily insulin needs. All these favourable biological effects occurred without exposing the patient to hypoglycaemia or weight gain. A few studies have also reported favourable effects on postprandial lipid profile and some other vascular risk factors. However, it is not clear whether the extra cost of acarbose, when compared to that of older oral antidiabetic agents, is justified since no study has yet demonstrated its potential benefit on the complications and long-term prognosis of diabetic patients. The alpha-glucosidase inhibitors (acarbose, miglitol, voglibose) have been studied extensively in Europe and Japan; two of them, acarbose and miglitol, are

available in the United States. Taken orally, they inhibit the upper gastrointestinal enzymes (alpha-glucosidases) that convert complex polysaccharide carbohydrates into monosaccharides in a dose-dependent fashion. These drugs slow absorption of glucose; the slower rise in postprandial blood glucose concentrations is potentially beneficial in both type 1 and type 2 diabetes. In older patients with type 2 diabetes, acarbose may also increase insulin sensitivity [1]. In patients with type 1 diabetes, acarbose therapy decreases the amplitude of postprandial glycemic excursions and lowers hemoglobin A1C (A1C) values

Drugs acting on PI3 kinase

The phosphatidylinositide 3-kinase (PI3K) pathway is very commonly activated in a wide range of human cancers and is a major driving force in oncogenesis. One of the class I lipid kinase members of the PI3K family, p110, is probably the most commonly mutated kinase in the human genome. Alongside genetic, molecular biological, and biochemical studies, chemical inhibitors have been extremely helpful tools in understanding the role of PI3K enzymes in signal transduction and downstream physiological and pathological processes, and also in validating PI3Ks as therapeutic targets. Although they have been valuable in the past, the early and still frequently employed inhibitors, wortmannin and LY294002, have significant limitations as chemical tools. Here, we discuss the case history of the discovery and properties of an increasingly used chemical probe, the pan-class I PI3K and mammalian target of rapamycin (mTOR) inhibitor PI-103 (a pyridofuropyrimidine), and its very recent evolution into the thienopyrimidine drug GDC-0941, which exhibits excellent oral anticancer activity in preclinical models and is now undergoing phase I clinical trials in cancer patients. We also illustrate the impact of structural biology on the design of PI3K inhibitors and on the interpretation of their effects. The challenges and outlook for drugging the PI3 kinome are discussed in the more general context of the role of structural biology and chemical biology in innovative drug discovery.

Thyroiditis in type1

Diabetes is becoming the leading cause of death in developing countries. Asymptomatic thyroid dysfunction is more common in diabetic population, particularly in type 1diabetes. High frequency of Hashimotos thyroiditis in type 1 diabetes cases has also been reported. The present study evaluates the levels of TSH, TmAb and lipid parameters in 36 type1 diabetes cases. TSH was significantly elevated in cases and TmAb was identified in 7 of the 36 cases studied. Presence of TmAb and elevation in TSH were more pronounced in female cases. Serum total cholesterol as well as LDL- cholesterol levels were significantly elevated and Serum HDL-cholesterol was significantly lowered in type 1 diabetics. Elevation in serum total cholesterol was more conspicuous in cases with thyroid antibodies. Diabetic patients have a higher prevalence of thyroid disorders compared with the normal population (Table 1). Because patients with one organ-specific autoimmune disease are at risk of developing other autoimmune disorders, and thyroid disorders are more common in females, it is not surprising that up to 30% of female type 1 diabetic patients have thyroid disease. The rate of postpartum thyroiditis in diabetic patients is three times that in normal women. A number of reports have also indicated a higher than normal prevalence of thyroid disorders in type 2 diabetic patients, with hypothyroidism being the most common disorder.

How Thyroid Dysfunction May Affect Diabetic Patients The presence of thyroid dysfunction may affect diabetes control. Hyperthyroidism is typically associated with worsening glycemic control and increased insulin requirements. There is underlying increased hepatic gluconeogenesis, rapid gastrointestinal glucose absorption, and probably increased insulin resistance. Indeed, thyrotoxicosis may unmask latent diabetes. In practice, there are several implications for patients with both diabetes and hyperthyroidism. First, in hyperthyroid patients, the diagnosis of glucose intolerance needs to be considered cautiously, since the hyperglycemia may improve with treatment of thyrotoxicosis. Second, underlying hyperthyroidism should be considered in diabetic patients with unexplained worsening hyperglycemia. Third, in diabetic patients with hyperthyroidism, physicians need to anticipate possible deterioration in glycemic control and adjust treatment accordingly. Restoration of euthyroidism will lower blood glucose level. Although wide-ranging changes in carbohydrate metabolism are seen in hypothyroidism, clinical manifestation of these abnormalities is seldom conspicuous. However, the reduced rate of insulin degradation may lower the exogenous insulin requirement. The presence of hypoglycemia is uncommon in isolated thyroid hormone deficiency and should raise the possibility of hypopituitarism in a hypothyroid patient. More importantly, hypothyroidism is accompanied by a variety of abnormalities in plasma lipid metabolism, including elevated triglyceride and low-density lipoprotein (LDL) cholesterol concentrations. Even subclinical hypothyroidism can exacerbate the coexisting dyslipidemia commonly found in type 2 diabetes and further increase the risk of cardiovascular diseases. Adequate thyroxine replacement will reverse the lipid abnormalities.

In young women with type 1 diabetes, there is a high incidence of autoimmune thyroid disorders. Transient thyroid dysfunction is common in the postpartum period and warrants routine screening with serum thyroid-stimulating hormone (TSH) 68 weeks after delivery. Glucose control may fluctuate during the transient hyperthyroidism followed by hypothyroidism typical of the postpartum thyroiditis. It is important to monitor thyroid function tests in these women since approximately 30% will not recover from the hypothyroid phase and will require thyroxine replacement. Recurrent thyroiditis with subsequent pregnancies is common. Conclusion Thyroid dysfunction is common in diabetic patients and can produce significant metabolic disturbances. Therefore, regular screening for thyroid abnormalities in all diabetic patients will allow early treatment of subclinical thyroid dysfunction. A sensitive serum TSH assay is the screening test of choice. In type 1 diabetic patients, it is helpful to determine whether anti-TPO antibodies are present. If these are present, then annual TSH screening is warranted. Otherwise, a TSH assay should be done every 23 years. In type 2 diabetic patients, a TSH assay should be done at diagnosis and then repeated at least every 5 years.

High protein diet and increase in diabetic risk

Despite a high prevalence of type 2 diabetes in South Asian Indians, the impact of diet in this high-risk ethnic group has not been fully explored. The association of macronutrient intake and diabetes in South Asian Indians was examined in this cross-sectional study. A population-based cohort of 146 South Asian indians aged 45-79 years without existing cardiovascular disease living in the San Francisco Bay Area was recruited between August 2006 and October 2007. Macronutrient intake was assessed with a food-frequency questionnaire developed and validated in South Asians. Diabetes was defined by use of a hypoglycemic medication, a fasting plasma glucose level >/=126 mg/dL, or a 2hour post-challenge glucose level >/=200 mg/dL. The association between energy-adjusted macronutrient intake and diabetes was explored using multivariable logistic regression models.Forty-one (28%) participants had type 2 diabetes; 20 were unaware of this diagnosis and were classified as having diabetes by laboratory testing. In a model fully adjusted for age, sex, waist circumference, and hypertension, there was a 70% increase in the odds of diabetes per standard deviation in gram of protein intake/day. There was a trend toward increased protein intake and diabetes in the subset of participants with previously unknown, laboratory-diagnosed diabetes. Results did not vary significantly by sex, body mass index, or dietary pattern. Higher level of protein intake was associated with increased odds of diabetes in this cohort of South Asian Indians. Diet may be a modifiable lifestyle factor in this high-risk ethnic group

High protein diet and CKD

A dietary protein intake of 0.8 g/kg body weight per day, the RDA for this macronutrient, is a level that has been achieved in studies of diabetes and CKD. Reduction in albuminuria and stabilization of kidney function have been reported with dietary protein intake at the RDA level. Nutrition surveys indicate that most people eat in excess of the RDA for dietary protein. (Moderate) Key studies that evaluated reduction or alteration of dietary protein are summarized in Table 42. Based on 2 meta-analyses, low-protein diets reduced risks of loss of kidney function (GFR or creatinine-based measurements) and/or increased albuminuria (measured as urinary excretion of either albumin or total protein), with more pronounced benefits in DKD than in non-DKD (Fig 21). 179,180 More recently, even a modest limitation of dietary protein (0.89 versus 1.02 g/kg body weight per day) substantially reduced the risk of CKD stage 5 or death (RR, 0.23; 95% CI, 0.07 to 0.72; P = 0.04) in people with type 1 diabetes and CKD stage 2 (inferred based on levels of albuminuria and GFR; Fig 22). These patients (85% to 89% during the course of the study) also received ACE inhibitors and had similar control of blood pressure and other risk factors irrespective of diet group assignment, indicating that reducing dietary protein provided benefits beyond established medical therapies.181 Benefits of limiting dietary protein intake are more evident in type 1 than type 2 diabetes, but fewer studies have been done in the latter population. Based on the available evidence (Table 37 and Table 38), the Work Group concluded that limiting dietary protein will slow the decrease in kidney function and progression of albuminuria, and it may prevent CKD stage 5. At the other end of the spectrum, high-protein diets are a particular concern in patients with diabetes because they increase albuminuria and may accelerate

loss of kidney function. Glomerular hyperfiltration and increased intraglomerular pressure are well-recognized mechanisms of kidney damage induced by excess dietary protein. Based on both human studies and experimental models, higher protein intake appears to have more pronounced effects on kidney hemodynamics and kidney damage in diabetes.187-196,463 Emerging epidemiological evidence indicates that higher protein intake (20% versus 10% of total daily calories) is associated with loss of kidney function in women with mild kidney insufficiency (defined as estimated GFR < 80 and > 55 mL/min/1.73 m2) and development of microalbuminuria in people with diabetes and hypertension.197,198 Therefore, in the opinion of the Work Group, people with diabetes and CKD should avoid high-protein diets (20% of total daily calories). Some common fad diets that recommend high protein are Atkins, Protein Power, the Zone, South Beach, and Sugar Busters. Although the nutritional challenges of a duel diagnosis are daunting, it is possible to delay the progression to kidney failure, and MNT plays a significant role in this effort. To understand the nutritional challenges facing people with CKD, it is important to review some of the functions of normal kidneys. Healthy kidneys perform all of the following functions: 1. Filter waste products and excess fluid (A diseased kidney leaks protein, which results in protein malnutrition. Uremic toxins can also accumulate and decrease the appetite.) 2. Release the enzyme renin, which is important in blood pressure control 3. Produce the hormone erythropoietin, which helps produce red blood cells, preventing anemia 4. Activate vitamin D, increasing the intestinal absorption of calcium and phosphorus

5. Maintain acid-base balance, which can also affect nutritional status Previous SectionNext Section Common Goals The nutrition recommendations for diabetes can be complicated, and the recommendations for CKD add further challenges. However, it is extremely important for RDs to help patients integrate both sets of recommendations and realize that they share common goals. These goals include controlling blood glucose and blood pressure to prevent further kidney damage and cardiovascular disease (CVD). Sodium guidelines as presented in the 2005 U.S. Dietary Guidelines ( 2,300 mg/day) should be adequate for all healthy people and should be the maximum for those with diabetes and CKD.4 This aids in blood pressure control. Previous SectionNext Section Protein Perhaps the most controversial nutrition issue in diabetes care in recent years has been protein intake. Knight et al.5 found in the highly powered Nurses Health Study that a high protein intake, particularly high intake of nondairy animal protein, may exacerbate renal function decline in women with mild renal insufficiency. Uribarri and Tuttle6 hypothesize that high-protein diets are toxic to the kidney because they increase dietary content of advanced glycation end products (AGEs). AGEs are formed in the browning process, or Maillard reaction, when proteins combine with carbohydrates at high temperatures, denaturing the protein. Glycated proteins accumulate damage with time. For example, the increased rate of glycation of collagen during hyperglycemia is implicated in the development of complications of diabetes. Therefore, one goal to preserve kidney function would be to reduce AGEs in the diet. Uribarri and Tuttle 6

suggest that protein of animal origin is a major source of AGEs. Their recommendations include limiting protein intake to the recommended dietary allowance (RDA) of 0.8 g/kg per day, or about 10% of calories, emphasizing nonmeat proteins of high biological value that are low in AGEs and using cooking methods that minimize accumulation of AGEs, such as steaming, poaching, boiling, and stewing, instead of very high-heat methods, such as frying, broiling, or grilling. The American Diabetes Association (ADA) also recommends that people with diabetes and nephropathy limit their protein intake to the RDA.7 Meat proteins have been encouraged in CKD because of their high biological value. Proteins with high biological value contain all of the essential amino acids in generally the same amounts as required by the body. Meat, fish, poultry, dairy products, and eggs all contain proteins of high biological value. However, there is another way to measure protein quality: the protein-digestibilitycorrected amino acid score. In this method, the amino acid score of a food is compared with the amino acid requirements of preschool-aged children and then are corrected for the digestibility of the protein. Using this score, casein (milk protein) and egg white are 1.0, soybean isolate is 0.99, and beef is 0.92. Thus, soy foods also can supply protein of high biological value. Previous SectionNext Section Carbohydrates and Fats It is still important to take in enough calories so that protein is used for anabolic processes and not for energy needs. If protein is limited to 10% of calories, then carbohydrates and fat will make up 90% of the diet. It is established that carbohydrates are the preferred source of fuel for the brain and central nervous system, yet carbohydrates do have the greatest influence on blood glucose. An issue in nutrition that is gaining support is the use of the glycemic index (GI) or glycemic load (GL) of foods. The GI ranks foods related to their effect on

postprandial glycemia but may be affected by cooking method, fiber content, or mixture with other foods in the context of a meal. The GL is the product of the GI and the number of grams of carbohydrate in a particular serving, so it may be a more useful number, but there are few well-controlled clinical trials validating this concept. The ADA revised its MNT recommendations in 2006 to state that both the amount of carbohydrate and the type of carbohydrate affect blood glucose and that attention to the GI or GL can be helpful in controlling postprandial glucose levels.7 Foods with a lower GI or GL include fruits, vegetables, and whole grains. However, these foods may be significant sources of potassium or phosphorus, so as kidney function decreases, careful manipulation of these nutrients will be necessary. People with CKD have a risk of CVD 1030 times higher than that of people without kidney disease, placing them in the highest risk category.8 Therefore, just as in diabetes, CKD patients should follow the National Cholesterol Education Program Third Adult Treatment Panel (ATP III) guidelines stating that total fat be 2535% of total calories, with saturated fat < 7% and trans fats < 1% of calories.9 It is essential to limit saturated fats and avoid trans fats. Polyunsaturated fatty acids, such as omega-3, inhibit platelet aggregation and inflammation and affect blood lipids. An increase in monounsaturated fatty acids, such as olive and canola oils, favorably modifies lipid profiles and decreases cardiovascular mortality.10 It is therefore important to include both poly- and monounsaturated fats in the diet. However, further research is needed to strengthen the link between these fatty acids and markers of diabetic kidney disease. Although evidence in CKD patients is weak or opinion-based, patients who do take fish oil supplements as directed by their physician should do the following: 1. Avoid brands made from halibut or shark liver oils to prevent vitamin A toxicity.

2. Choose brands that contain 12 mg of vitamin E per gram of fish oil to prevent oxidation of the product. 3. Alert physicians about any bleeding difficulties they experience and discontinue supplementation before undergoing any surgery.11 Previous SectionNext Section Micronutrient Assessment At Stage 3 CKD, assessment of anemia, calcium, phosphorus, parathyroid hormone, albumin, cholesterol, and nutritional status should begin.3 As GFR decreases, it becomes necessary to limit phosphorus to maintain serum levels within the normal range. Hyperphosphatemia carries serious consequences, including secondary hyperparathyroidism and soft tissue and vascular calcification. Phosphorus additives are used liberally to enhance flavor, especially in meats and processed cheeses, refrigerated bakery products, and beverages. Although only 60% of dietary phosphorus is absorbed, nearly 100% of phosphoruscontaining additives are absorbed.12 Because manufacturers are not required to list phosphorus content on the Nutrition Facts panel of their food labels, assessing the phosphorus content of patients' diets can be difficult. Patients with high levels of phosphorus often need to take phosphate binders several times per day to meet their individual needs. Different formulations of phosphate binders are available, and their correct dosage is based on the results of laboratory analysis. Fruits and vegetables are rich sources of potassium, which usually does not need to be limited until Stage 3 or 4 CKD and in fact sometimes require supplementation, depending on GFR status. Periodic blood chemistry tests will determine whether restriction or supplementation is necessary (Table 1).

Patients with CKD often feel overwhelmed when presented with the fact that they have to control both their blood glucose and their blood pressure levels, as well as balance macronutrients, sodium, phosphorus, potassium, and fluids. The support of an RD who understands both diabetes and CKD will help patients succeed. Strategies that decrease the rate of decline of renal function include diabetes management measures to help improve glycemic control and the use of antihypertensive agents and sodium restriction to improve blood pressure. Cholesterol-lowering agents may be used in conjunction with ATP III dietary guidelines. Protein is limited to the RDA, and accumulating evidence suggests that cooking methods to reduce accumulation of AGEs may be indicated. As kidney function declines, phosphorus and potassium intake may be modified. In addition, steps to treat anemia may include dietary sources of heme iron or the use of pharmacological agents. Six basic goals can be adapted from the National Kidney Foundation Kidney Disease Outcomes Quality Initiative Guidelines for Diabetes and Chronic Kidney Disease 13 to slow the progression to kidney failure: 1. Intensive glycemic control 2. Antihypertensive therapy, including pharmacological agents and a modified version of the Dietary Advances to Stop Hypertension diet, which the U.S. Department of Agriculture recommended in the 2005 Dietary Guidelines for Americans.4 The diet may need modifications in protein and potassium content for patients with diabetes and CKD. 3. Cholesterol-lowering therapy involving diet and pharmacological agents 4. Dietary protein restriction, following the RDA of 0.8 g/kg based on a normal BMI

5. Guidance and support from a nutrition professional to prevent malnutrition 6. Multidisciplinary support Nutrition intervention is a formidable ally in each stage of CKD. Contact with an RD who is competent in MNT for both diabetes and CKD and involved in the care and management of these patients as part of a multidisciplinary health care team can greatly enhance the opportunity to delay progression of the disease. The complicated nature of nutritional guidelines for renal disease and diabetes necessitates a multidisciplinary educational effort.

Gastric emptying and blood glucose

An individuals blood glucose levels after eating are influenced by a number of factors but it is now recognized that gastric emptying accounts for at least 35 percent of the variance in peak postprandial glucose levels after oral glucose (75 grams) in both healthy individuals and patients with Type 2 diabetes. Controlling gastric emptying by dietary and pharmacological means in order to minimize postprandial glucose represents a new approach to glycemic control. Studies in rodents have established the importance of early insulin release in the control of postprandial glucose excursions in that a small, early increase in blood/portal insulin levels is more effective than a larger, later increase in reducing blood glucose levels. Thus, whereas slowing of nutrient absorption may benefit Type 2 diabetes patients, it is possible that modest acceleration of the initial gastric emptying rate of carbohydrates would have a beneficial effect on overall glycemia in Type 2 diabetes. This would also be true among healthy subjects because it would to an increase in early insulin release, particularly if the subsequent emptying of carbohydrates is slower. Postprandial hypotension, defined as a fall in systolic blood pressure of approximately 20 mmHg after a meal, occurs frequently in older persons and in patients with diabetes mellitus and autonomic neuropathy and is associated with a number of clinical conditions including loss of consciousness, falls, stroke, angina, and increased mortality. Ingestion of a carbohydrate, particularly large amounts, induces the greatest cardiovascular response, particularly after a meal while fat, protein, or water have relatively little effect. The mechanisms mediating the fall in postprandial blood pressure are poorly defined. It is believed that digestive blood flow, release of gut hormones, and sympathetic nervous activity are thought to play a role. Recent studies indicate

that the magnitude of the fall in blood pressure in both Type 2 diabetes and healthy older subjects is greater when gastric emptying is relatively more rapid. Furthermore, in healthy older subjects, the fall in blood pressure and increase in heart rate are greater during intraduodenal glucose infusion. These observations suggest that the postprandial fall in blood pressure and rise in heart rate may be related to the early phase of gastric emptying

The primary treatment goals for gastroparesis related to diabetes are to improve stomach emptying and regain control of blood glucose levels. Treatment includes dietary changes, insulin, oral medications, and, in severe cases, a feeding tube and parenteral nutrition. Dietary Changes The doctor will suggest dietary changes such as six smaller meals to help restore your blood glucose to more normal levels before testing you for gastroparesis. In some cases, the doctor or dietitian may suggest you try eating several liquid or pureed meals a day until your blood glucose levels are stable and the symptoms improve. Liquid meals provide all the nutrients found in solid foods, but can pass through the stomach more easily and quickly. Insulin for Blood Glucose Control If you have gastroparesis, food is being absorbed more slowly and at unpredictable times. To control blood glucose, you may need to

take insulin more often or change the type of insulin you take take your insulin after you eat instead of before check your blood glucose levels frequently after you eat and administer insulin

Canabenoid receptors
The discovery of the first cannabinoid receptors in the 1980s helped to resolve this debate. These receptors are common in animals, and have been found in mammals, birds, fish, and reptiles. At present, there are two known types of cannabinoid receptors, termed CB1 and CB2, with mounting evidence of more. Cannabinoid receptor type 1 CB1 receptors are found primarily in the brain, to be specific in the basal ganglia and in the limbic system, including the hippocampus. They are also found in the cerebellum and in both male and female reproductive systems. CB1 receptors are absent in the medulla oblongata, the part of the brain stem responsible for respiratory and cardiovascular functions. Thus, there is not a risk of respiratory or cardiovascular failure as there is with many other drugs. CB1 receptors appear to be responsible for the euphoric and anticonvulsive effects of cannabis. Cannabinoid receptor type 2 CB2 receptors are almost exclusively found in the immune system, with the greatest density in the spleen. While found only in the peripheral nervous system, a report does indicate that CB2 is expressed by a subpopulation of microglia in the human cerebellum. CB2 receptors appear to be responsible for the anti-inflammatory and possibly other therapeutic effects of cannabis.

Enteral nutrition use of diabetic specific formulas

The majority of enteral nutrition products for diabetes mellitus have a carbohydrate content of 3045% and fat between 4049%, mainly monounsaturated fat, with a mix of soluble and insoluble fibre (total of 1424 g/l). Does this have short- and long-term benefits and which component(s) is/are crucial for the outcome or is it the combination that counts? Both manipulations of DM specific enteral formulae, i.e. addition of fibre and altered carbohydrate to fat percentage seem to be effective for short-term glucose control, but do not show convincing evidence regarding lipid management. In terms of gastro-intestinal function, there seems to be adequate evidence that fibre plays an important role for the management of diarrhoea and constipation. The implications of high fat intake on the longer-term, especially in patients suffering from gastroparesis, are less clear. The goals of nutritional therapy for DM include the maintenance of as nearnormal blood glucose levels as possible, the achievement of optimal blood lipid levels, the prevention and treatment of acute and chronic complications of diabetes; while concurrently maintaining fluid balance in a patient receiving nutritional support.1,2 Another important factor in the nutritional management of a diabetic patient is glycaemic control during enteral feeding since hyperglycaemia has been associated with an increased risk for infection in patients with DM and in ICU patients in general.2,3 Current guidelines for blood glucose control in critically ill patients with and without DM, recommend keeping glucose values in the range of 6,18,3 mmol/L. Do we really need specialised formulae for diabetes patients or can the patients be treated just as effectively with a standard polymeric formula with or without fibre? According to the ADA,3 various studies have attempted to identify the ideal mix of macronutrients for patients with DM. It is unlikely that one such combination of macronutrients exists and therefore emphasis should be placed

in individualized approaches.1,3 The majority of diabetes-specific enteral formulae on the market in South Africa contain a combination of different fibres, with an altered carbohydrate to fat ratio with emphasis on MUFA. The question can thus be asked which of these two main alterations i.e. addition of fibre or carbohydrate to fat manipulation is the most important and successful, or is it the combination of the two that is of the essence? In all patients, fermentable fibres are effective for glucose control.8,9 Since the dyslipidaemia of diabetes (type 2), especially hypertriglyceridaemia, is often disproportionate to the degree of hyperglycaemia, the latter needs to be monitored and treated individually.2 Both manipulations of DM-specific enteral formula, i.e. addition of fibre and altered carbohydrate to fat percentage does not show convincing evidence regarding lipid management.2,19 In the critically ill patient in an ICU setting, the tolerance of fibre sources is dependent on the function of the gastrointestinal tract and the use of fibre (quantity and type) should be reconsidered based on the given clinical setting. Patients at high risk of bowe dysmotility and hypotensive patients at risk of developing bowel ischaemia should not receive any fibre, especially insoluble fibre.4,16 Since bowel dysmotility is present in a great number of ICU patients, the use of most fibre-containing feeds would not be indicated. In the non-ICU patient population in a general ward or in the longterm home enterally supported patient the scenario can be totally different. Diarrhoea and/or constipation are probably the most commonly encountered complications in these cases. Fibre containing feeds have been shown to be effective in the management of both extremes of stool adaptations and therefore have a definite role to play.8 To prevent and manage diarrhoea, soluble fibre should be administered and to prevent and manage constipation, a mixture of soluble and insoluble fibre is recommended.8,9 In the DM patient with gastroparesis, fibre blends, especially insoluble fibre, is not very practical and a high fat intake which normally may have beneficial outcomes on glucose management due to slowing down of gastric emptying, will also worsen the gastroparesis

MNT and hypertension(MEDICAL NUTRITION THERAPY)

Lifestyle modifications have been shown to lower blood pressure, enhance effectiveness of antihypertensive drug therapy, and reduce overall cardiovascular risk.3,4 However, few studies have been carried out exclusively in people with diabetes.Therefore, lifestyle recommendations for people with diabetes are by necessityextrapolated from studies in the general population. Along with the lifestyle modifications discussed below, interventions to stop smoking are of primary importance.The effects of lifestyle modifications are dose and time dependent and therefore can be greater for some individuals than others and may have greater benefits when combined. It is important for clinicians to know the potential outcomes from medical nutrition therapy (MNT) in themajority of people. Lifestyle recommendations to manage hypertension and their potential to reduce blood pressure are summarized in Table 1.3 Weight Reduction In people with diabetes, there is a general association between weight reduction and a reduction in blood pressure, but there is a great deal of variability in this response. In almost all weight-reduction studies in the general population, systemic blood pressure is reduced even if the degree of weight loss is small.1 Overall, the greater the weight loss, the greater the reduction in blood pressure. In a meta-analysis5 of 11 weight-loss trials, the average systolic and diastolic blood pressure reductions per kilogram of weight loss were 2 and 1 mmHg, respectively. In the Trials of Hypertension Prevention,6 weight loss (goal of 4.5kg loss) alone or in combination with sodium restriction lowered the incidence of hypertension; however, behavior changes tended not to be sustained over time, thus diminishing the positive effects on blood pressure.

Modification Recommendations Approximate Range of Systolic Blood Pressure Reduction (mmHg) Weight reduction, if Maintain normal body weight (BMI 18.524.9 kg/m2) ===========================================520 per 10 kg Overweight or obese weight loss,Adopt DASH eating plan Consume a diet rich in fruits, vegetables, and low-fat dairy products with reduced content of saturated and total fat products with reduced content of saturated and total fat ============================================58 Reduction in dietary sodium Reduce intake to no more than 2.3 g (2,300 mg) sodium or 6 g sodium chloride ============================================28 Increase physical Engage in regular aerobic physical activity such as brisk walking activity level (at least 30 minutes/day, most days of the week) =========================================== 49 Moderation in alcohol Limit consumption to no more than 2 drinks per day in adult men consumption and to no more than 1 drink per day in adult women and lighter weight people. (1 drink = 15 g alcohol, e.g., 12 oz of beer, 5 oz of wine, or 1 1/2 oz of 80-proof distilled spirits) ============================================= 24 Comprehensive lifestyle Combination of lifestyle modifications: sodium reduction, weight modifications loss, DASH diet, and regular aerobic exercise ============================================= 911 Stop smoking. Maintain a reasonable body weight; if needed and if possible, lose weight. Reduce sodium intake to 2,300 mg daily. Increase physical activity; accumulate 30 minutes of aerobic activity most days of the week. Maintain adequate potassium, magnesium, and calcium by eating a diet rich in fruits, vegetables, and low-fat dairy foods. Reduce intake of dietary saturated fat and cholesterol.

 Limit alcohol intake. TIPS TO REDUCE SALT INTAKE Read food labels and look for foods with 400 mg of sodium per serving and 800 mg of sodium per convenience dinner or entre. Add little or no salt to foods at the table. Leave the salt shaker in the cupboard and pass the pepper! Taste foods before deciding if they really need salt. Cook with little or no added salt. When cooking pastas, vegetables, and cereals, salt can be omitted without losing much flavor. In many recipes, half the salt called for can be used, and in some recipes, salt can be left out altogether. However, many baked recipes, especially those with yeast, require salt for the recipe to work. Avoid high-sodium meats, such as ham, bacon, sausage, and cold cuts. Rinse canned foods with fresh water to reduce the sodium content. Rinsing the contents of a can of tuna for 1 minute will wash away three-fourths of the sodium. Almost half the sodium can be removed from canned vegetables by rinsing for 1 minute and heating the vegetables in water instead of the canning liquid. Use herbs and spices instead of salt. Begin by using no more than one or two herbs or spices at a time. As a general rule, use one-quarter teaspoon of dried herbs or three to four teaspoons of fresh herbs for every four servings of food. Add herbs or seasonings to soups or stews during the last hour of cooking to retain flavor. In cold dressings, dips, or marinades, add herbs and spices several hours before serving to blend the flavors. Try salt-free herb blends. Limit use of salt-based condiments, such as soy sauce, steak sauce, catsup, Substitute onion and garlic powder for onion and garlic salts. Choose low-sodium or lower-salt crackers, snacks, and soups. Limit fast foods. When eating at fast-food restaurants, be careful with food choices during the rest of the day.

Dietary carbohydrate Investigation

The low-carbohydrate, calorie-restricted diet might help those with type 2 diabetes obtain blood glucose levels under control when common dietary alterations and medicines have failed, based on California scientists. A minimum of within the short run, the diet might help sufferers stay away from needing to get blood insulin to regulate their own disease. It is still important to take in enough calories so that protein is used for anabolic processes and not for energy needs. If protein is limited to 10% of calories, then carbohydrates and fat will make up 90% of the diet. It is established that carbohydrates are the preferred source of fuel for the brain and central nervous system, yet carbohydrates do have the greatest influence on blood glucose. An issue in nutrition that is gaining support is the use of the glycemic index (GI) or glycemic load (GL) of foods. The GI ranks foods related to their effect on postprandial glycemia but may be affected by cooking method, fiber content, or mixture with other foods in the context of a meal. The GL is the product of the GI and the number of grams of carbohydrate in a particular serving, so it may be a more useful number, but there are few well-controlled clinical trials validating this concept. The ADA revised its MNT recommendations in 2006 to state that both the amount of carbohydrate and the type of carbohydrate affect blood glucose and that attention to the GI or GL can be helpful in controlling postprandial glucose levels.7 Foods with a lower GI or GL include fruits, vegetables, and whole grains. However, these foods may be significant sources of potassium or phosphorus, so as kidney function decreases, careful manipulation of these nutrients will be necessary.

Following 8 weeks over a diet along with 25% of calories from fat from carbohydrates, type two diabetes patients were built with a substantial

development within glucose levels when compared with these observed with a diet along with 55% regarding energy from carbohydrates, the actual authors statement inside the Dec concern of the Diary of the U . s . College of Nourishment. With the twenty eight individuals inside the examine, nine were treated using a standard diet plan made up of 55% carbohydrates, and also 19 with sulfonylurea brokers, however none of the subject matter could actually accomplish target blood sugar levels along with these remedies, in accordance with Dr. Lois Jovanovic as well as co-workers from Sansum Medical research Basis in Santa Barbara, Los angeles. Right after 8 weeks on the 25% diet, the themes stood a decrease within hemoglobin A1c, the marker with regard to blood sugar levels manage. When positioned on the 55% carbohydrate diet plan for an additional twelve weeks, hemoglobin A1c elevated, any marker associated with difficult blood glucose levels handle. Sufferers which experienced earlier obtained sulfonylurea drugs also the weight they lost while on the 25% diet, but some great benefits of this diet werent depending on this damage, according to the record. The benefit of insulin shots treatment within diabetes type 2 symptoms will be controversial and the files suggest that diet remedy may well support remission for an beginning and allow the actual reintroduction of oral hypoglycemic treatment in the event that low-carbohydrate diet treatment on its own just isnt productive, the creators note.

Carotid intimal medial thickness

Intima-media thickness (IMT), also called intimal medial thickness, is a measurement of the thickness of artery walls, usually by external ultrasound, occasionally by internal, invasive ultrasound catheters, see IVUS, to both detect the presence and to track the progression of atherosclerotic disease in humans. IMT has increasingly been used in medical research since the mid-1990s to track changes in arterial walls. It is occasionally used in clinical practice. However, its role in clinical practice is not clear, as although IMT does predict cardiovascular risk, its addition to traditional risk factors in predictive risk models does not seem to improve risk classification.[1] Historically, since the 1950s, focus was initially placed on detection and progression of the atherosclerotic process by its late affects on the lumens of arterial blood vessels, either narrowing or enlargement. This led to the still widely held beliefs that if the lumen looked OK, then little to no atherosclerotic disease was presumed to be present Though it seems clear that carotid intima-media thickness is strongly associated with atherosclerosis, it is worth noting that not all the processes of thickening of the intima-media are due to atherosclerosis. Intimal thickening is in fact a complex process, depending on a variety of factors, not necessarily related to atherosclerosis. Local hemodynamics plays an important role, higher blood pressure and changes in shear stress being potential causes of intimal thickening, even differences in cholesterol homeostasis[2]. Changes in shear stress and blood pressure may cause a local delay in lumen transportation of potentially atherogenic particles, which favors the penetration of particles into the arterial wall and consequent plaque formation. However non-atherosclerotic reactions may also exist, as in intimal hyperplasia and intimal fibrocellular

hypertrophy, two different compensatory reactions of the arterial wall to changes in shear stress, which also consist in thickening of the arterial wall. In some cases, more than one of these reactions may be present, and indeed as all of these are associated to particular flow conditions, they are often found in common areas, such as the inflow side of branches, the inner curvature at bends and opposite the flow divider at bifurcations. However, changes in the IMT above thresholds of around 900 m almost certainly are indicative of an atherosclerotic pathology. Mechanisms such as these may explain, at least in part, why the carotid artery seems to be a preferential site for analyzing the relation between wall thickness and atherosclerosis. In general, wall thickening may be in the intimal layer or in the muscular, medial, layer. As the carotid artery is an elastic artery, the muscular media is relatively small. Hence, thickening of the carotid arterial wall is due essentially to intimal thickening. In muscular arteries wall thickening may imply instead (or also) a thickening of the medial wall. Whether or not wall thickening in the carotid artery and the femoral artery (or other muscular arteries) have the same meaning is as yet uncertain. Several studies seem to suggest that the mechanisms underlying their evolution may at least in part differ, with consequently possibly different clinical implications. Another issue to consider, once the choice to examine the carotid artery has been defined, is on which segment of the carotid artery to perform the measurement. Often, the measurement of the IMT is measured in three tracts: in the common carotid, at one or two cms from the flow divider, at the bifurcation and in the internal carotid artery Contents

1 IMT measurements in the carotid artery 2 Ultrasound methods 3 Radiographic methods

From an academic standpoint, the region to select for IMT measurement is still an object of study. IMT measurements of the deep wall, by ultrasound, are generally more reliable than measurements performed on the outer wall. This difference in the accuracy of near and far wall measurements may be a problem, as some studies have used both measurements to quantify the IMT. A practical approach to tracking disease presence and progression on any given individual is to select and track those regions with the greatest thickness, i.e. greatest disease burden, as opposed to arbitrarily selecting a particular segment in which the individual may not have much pathology

Coronary artery calcium scoring Biomarkers

CT scanning combines special x-ray equipment with sophisticated computers to produce multiple images or pictures of the inside of the body. These cross-sectional images of the area being studied can then be examined on a computer monitor, printed or transferred to a CD. CT scans of internal organs, bones, soft tissue and blood vessels provide greater clarity and reveal more details than regular x-ray exams. A cardiac CT scan for coronary calcium is a non-invasive way of obtaining information about the presence, location and extent of calcified plaque in the coronary arteriesthe vessels that supply oxygen-containing blood to the heart muscle. Calcified plaque results when there is a build-up of fat and other substances under the inner layer of the artery. This material can calcify which signals the presence of atherosclerosis, a disease of the vessel wall, also called coronary artery disease (CAD). People with this disease have an increased risk for heart attacks. In addition, over time, progression of plaque build up (CAD) can narrow the arteries or even close off blood flow to the heart. The result may be chest pain, sometimes called "angina," or a heart attack. Because calcium is a marker of CAD, the amount of calcium detected on a cardiac CT scan is a helpful prognostic tool. The findings on cardiac CT are expressed as a calcium score. Another name for this test is coronary artery calcium scoring. Determine if CAD is present and to what extent, even if there are no symptoms. It is a screening study that may be recommended by a physician for patients with risk factors for CAD but no clinical symptoms. The major risk factors for CAD are:

high blood cholesterol levels family history of heart attacks diabetes high blood pressure cigarette smoking overweight or obese physical inactivity

No special preparation is necessary in advance of a cardiac CT examination. You should continue to take your usual medications, but should avoid caffeine and smoking for four hours prior to the exam.

You should wear comfortable, loose-fitting clothing to your exam. You may be given a gown to wear during the procedure. Metal objects including jewelry, eyeglasses, dentures and hairpins may affect the CT images and should be left at home or removed prior to your exam. You may also be asked to remove hearing aids and removable dental work. Women should always inform their physician and the CT technologist if there is any possibility that they are pregnant. The CT scanner is typically a large, box like machine with a hole, or short tunnel, in the center. You will lie on a narrow examination table that slides into and out of this tunnel. Rotating around you, the x-ray tube and electronic x-ray detectors are located opposite each other in a ring, called a gantry. The computer workstation that processes the imaging information is located in a separate room, where the technologist operates the scanner and monitors your examination. In many ways CT scanning works very much like other x-ray examinations. X-rays are a form of radiationlike light or radio wavesthat can be directed at the body. Different body parts absorb the x-rays in varying degrees. In a conventional x-ray exam, a small burst of radiation is aimed at and passes through the body, recording an image on photographic film or a special image recording plate. Bones appear white on the x-ray; soft tissue shows up in shades of gray and air appears black. With CT scanning, numerous x-ray beams and a set of electronic x-ray detectors rotate around you, measuring the amount of radiation being absorbed throughout your body. At the same time, the examination table is moving through the scanner, so that the x-ray beam follows a spiral path. A special computer program processes this large volume of data to create two-dimensional cross-sectional images of your body, which are then displayed on a monitor. This technique is called helical or spiral CT. CT imaging is sometimes compared to looking into a loaf of bread by cutting the loaf into thin slices. When the image slices are reassembled by computer software, the result is a very detailed multidimensional view of the body's interior. Refinements in detector technology allow new CT scanners to obtain multiple slices in a single rotation. These scanners, called "multislice CT" or "multidetector CT," allow thinner slices to be obtained in a shorter period of time, resulting in more detail and additional view capabilities.

Modern CT scanners are so fast that they can scan through large sections of the body in just a few seconds. Such speed is beneficial for all patients but especially children, the elderly and critically ill. The technologist begins by positioning you on the CT examination table, usually lying flat on your back or possibly on your side or on your stomach. Straps and pillows may be used to help you maintain the correct position and to hold still during the exam. Electrodes (small, sticky discs) will be attached to your chest and to an electrocardiograph (ECG) machine that records the electrical activity of the heart. This makes it possible to record CT scans when the heart is not actively contracting. Next, the table will move quickly through the scanner to determine the correct starting position for the scans. Then, the table will move slowly through the machine as the actual CT scanning is performed. Patients are asked to hold their breath for a period of 10 to 20 seconds while images are recorded. When the examination is completed, you will be asked to wait until the technologist verifies that the images are of high enough quality for accurate interpretation. The entire procedure including the actual CT scanning is usually completed within 10 minutes. Most CT exams are painless, fast and easy. Though the scanning itself causes no pain, there may be some discomfort from having to remain still for several minutes. If you have a hard time staying still, are claustrophobic or have chronic pain, you may find a CT exam to be stressful. The technologist or nurse, under the direction of a physician, may offer you a mild sedative to help you tolerate the CT scanning procedure. When you enter the CT scanner, special lights may be used to ensure that you are properly positioned. With modern CT scanners, you will hear only slight buzzing, clicking and whirring sounds as the CT scanner revolves around you during the imaging process. You will be alone in the exam room during the CT scan. However, the technologist will be able to see, hear and speak with you at all times. After a CT exam, you can return to your normal activities. A physician, usually a radiologist with expertise in supervising and interpreting radiology examinations, will analyze the images and send a signed report to your primary care physician or the physician who referred you for the exam, who will discuss the results with you.

A negative cardiac CT scan for calcium scoring shows no calcification within the coronary arteries. This suggests that CAD is absent or so minimal it cannot be seen by this technique. The chance of having a heart attack over the next two to five years is very low under these circumstances. A positive test means that CAD is present, regardless of whether or not the patient is experiencing any symptoms. The amount of calcificationexpressed as the calcium scoremay help to predict the likelihood of a myocardial infarction (heart attack) in the coming years and helps your medical doctor or cardiologist decide whether the patient may need to take preventive medicine or undertake other measures such as diet and exercise to lower the risk for heart attack. The extent of CAD is graded according to your calcium score: Calcium Score 0 1-10 11-100 101-400 Over 400 What are the benefits vs. risks? Benefits

Presence of CAD No evidence of CAD Minimal evidence of CAD Mild evidence of CAD Moderate evidence of CAD Extensive evidence of CAD

Cardiac CT for calcium scoring is a convenient and noninvasive way of evaluating whether you may be at increased risk for a heart attack. The exam takes little time, causes no pain, and does not require injection of contrast material. No radiation remains in a patient's body after a CT examination. X-rays used in CT scans usually have no immediate side effects.

Risks

There is always a slight chance of cancer from excessive exposure to radiation. However, the benefit of an accurate diagnosis far outweighs the risk. The effective radiation dose for this procedure varies. dose. Women should always inform their physician and x-ray or CT technologist if there is any possibility that they are pregnant. CT scanning is, in general, not recommended for pregnant women unless medically necessary because of potential risk to the baby. A high calcium score may sometimes be followed by other diagnostic tests for heart disease, which may not be necessary and might cause side effects.

What are the limitations of Cardiac CT for Calcium Scoring? A person who is very large may not fit into the opening of a conventional CT scanner or may be over the weight limit for the moving table which is usually about 450 pounds. CAD, especially in people below 50 years of age can be present without calcium (non-calcified plaque) and may not be detected by this exam. Not all health insurance plans cover cardiac CT for calcium scoring. A high heart rate may interfere with the image quality of the test. If a patient's heart rate is 90 or more beats per minute, the exam may need to be rescheduled. Exactly how your treatment or prevention for heart attacks should be modified according to your calcium score remains uncertain.

Glucometers
This is the most useful device for self-monitoring of blood glucose (SMBG). Various types and brands of glucometers are available today based on the following two principles: 1. A chemical is present on the test strip which on contact with glucose produces a colour. The meter measures this color intensity and the level of glucose present is expressed in mg/dl. 2. The other type of glucometer measures the electric current in the blood, which depends on the amount of glucose present. When blood is put on the test strip, an enzyme transfers electrons from glucose to a chemical in the test strip and the meter measures the flow of the electrons as current. The amount of current depends on the amount of glucose present and the meter produces the reading in mg/dl. Accuracy of Glucometers: Sometimes people are worried about the accuracy of the meter readings. The values are generally quite reliable. There may be a slight inconsequential difference between the laboratory sample and glucometer reading due to the following reasons: 1. A 10-15% difference in readings - because laboratory uses plasma blood while glucometers use whole blood. 2. Meters use capillary blood while laboratory uses venous blood. Capillary

blood can give a slightly higher reading than venous blood. Advantages of glucometers There are obvious advantages It empowers diabetics to take care of themselves without the need to visit doctors and labs regularly. It promotes well-being of the patient. It helps to detect and confirm hypoglycemia. It provides better understanding of medications and also helps to alter medications. It helps in detecting infections. High blood sugars may be a sign of infection or illness that needs to be treated. Test strips Each glucometer has its own test strips and one must be sure of buying the correct strip for the glucometer. The test strip has a code and before using any test strip the glucometer must be set to the correct code. Lancets These are used to prick the finger to obtain a drop of blood to be placed on a test strip. Each pricking device has its own size of lancet. The lancets are sterile and must not be shared. It can be used for multiple pricks by the same person

HbA1c and eAG

The HbA1C or A1C (pronounced A-one-C) test, also known as glycated hemoglobin or HbA1c, measures average blood glucose control for approximately the 3 months. The results can help health care providers and their patients know if the diabetes treatment plan is working or if adjustments to treatment are needed. A1C is measured by a simple blood test performed in a laboratory. The American Diabetes Association recommends that most people with diabetes have their A1C level checked at least twice a year. The American Diabetes Association recommends that people with diabetes strive for an A1C goal of less than 7%. An A1C for a person without diabetes is approximately 4-6%. Why is understanding average blood glucose control important in the management of diabetes? In 1993, when the landmark Diabetes Control and Complications Trial (DCCT) was completed, the importance of A1C as an indicator of risks for the complications of diabetes, such as blindness, kidney disease and nerve damage was firmly established. The DCCT demonstrated that keeping A1C closer to normal reduces the risk for diabetes-related complications. As A1C increases, so does the risk of complications. In 1994, the American Diabetes Association began recommending specific A1C treatment goals based on the results of the DCCT. From that time on, the goal for most people with diabetes has been less than 7%.

What is the difference between A1C and the blood glucose measure obtained through daily self-monitoring? A1C results, which tend to be measured at least 2 times a year as part of a visit with the doctor, measure average blood glucose control over the past 2 to 3 months. Results from the A1C test are reported in percentage points (i.e., A1C of 7%). When people with diabetes test their blood glucose through daily selfmonitoring, those results are reported in different units mg/dl (i.e., 170 mg/dl). They represent the level of glucose in the blood at that moment in time, but do not give any indication of what the level is at other times of day.

Why is daily self-monitoring of blood glucose so important? Although the A1C test is an important tool, it can't replace daily selfmonitoring of blood glucose (SMBG). A1C tests don't measure a persons dayto-day control. People with diabetes can't adjust their insulin on the basis of their A1C tests. That's why blood glucose checks and log results are so important to staying in good control. The A1C test alone is not enough to measure good blood glucose control. But it is a good resource to use along with your daily blood glucose checks, to work for the best possible control.

What is the A1C-Derived Average Glucose (ADAG) Study and why was it conducted?

The A1C-Derived Average Glucose (ADAG) Study is an international study sponsored by the American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), and International Diabetes Federation (IDF). It was conducted in response to the introduction of a new worldwide method of standardization of the A1C assay that would result in values that are 1.5-2 percentage points lower than current standards. It was felt that this change would cause considerable confusion for patients and health care providers. The objective of the ADAG Study was to define the mathematical relationship between A1C and estimated average glucose (eAG) and determine if A1C could be reliably reported as eAG, which would be in the same units as daily selfmonitoring.

How was the ADAG Study conducted? Five hundred seven people, including 268 patients with type 1 diabetes, 159 with type 2 diabetes, and 80 people without diabetes were recruited from 10 international centers. A1C was measured using a combination of continuous glucose monitoring and frequent finger stick glucose measurements similar to the way in which people with diabetes check their diabetes control at home by self-monitoring of blood glucose (SMBG). By comparing the measurement of A1C with the average glucose levels, study investigators were able to derive an equation so that A1C levels can be interpreted accurately as an average glucose level or eAG.

What is estimated Average Glucose (eAG) and why is this measure important? The ADAG Study establishes what has long been assumed but never demonstrated that A1C does represent average glucose over time. With that relationship demonstrated and defined, health care providers can now report A1C results to patients in the same units that they are using for self-monitoring (i.e., mg/dl) which should benefit clinical care. Why is the chart in ADAs Standards of Care showing a correlation between A1C and mean glucose levels slightly different from the correlation published with the ADAG results (as above) The chart published in the ADAs Standards of Care is based on a study that analyzed data collected during the DCCT, which included quarterly A1C tests and 7-point glucose measurements in 1,400 type 1 diabetes patients. The International A1C-Derived Average Glucose (ADAG) Study involved people with type 1 and type 2 diabetes as well as people without diabetes, and took advantage of the development of continuous glucose monitors, as well as patients making traditional glucose checks, to generate a much larger pool of data. Both studies showed a linear relationship between A1C and average glucose; the ADAG study presents a more refined and accurate formula describing that relationship, and the ADAs Standards of Care will adopt the new correlation. The formula describing the relationship is: 28.7 times A1C minus 46.7 = eAG.

How will this new terminology, eAG, help health care providers and their patients?

Reporting glucose control as average glucose will assist health care providers and their patients in being able to better interpret the A1C value in units similar to what patients see regularly through their self-monitoring. Part of the logic for choosing the term eAG is that the medical community recently adopted another new term, eGFR, for estimated glomerular filtration rate, which was introduced as an easier to understand measure of kidney function than the established method of measuring creatinine levels to assess kidney function. The hope is that the growing acceptance of eGFR will help spur the adoption of the similar eAG. The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), and International Diabetes Federation (IDF) will be working together to conduct educational efforts to make both patients and providers aware of this new terminology, and help to understand the relationship between A1C and eAG.

Many patients who practice SMBG already see an average glucose on their blood glucose meters. Is eAG the same thing? No, an eAG value is unlikely to match the average glucose level shown on a persons meter. Because people with diabetes are more likely to test more often when their blood glucose levels are low---first thing in the morning, and before meals---the average of the readings on their meter is likely to be lower than their eAG, which represents an average of their glucose levels 24 hours a day, including post-meal periods of higher blood glucose when people are less likely to test. One advantage of using eAG as a measure of glucose control is that it will help patients more directly see the difference between their individual meter readings and how they are doing with their glucose management overall.

What are the plans to work with laboratories and manufacturers to incorporate average glucose values in their reports? The American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), and International Diabetes Federation (IDF) will be working with labs to encourage them to incorporate AG values in their reports to physicians

blood glucose how QC is done ? what is the reference value , what is the VIS value ? how to interpret the lab value ? how much correct the results are ?

Glucose Glucose Oxidase Method Introduction Glucose is a reducing monosaccharide that serves as the principal fuel of all the tissues. It enters the cell through the influence of insulin and undergoes a series of chemical reactions to produce energy. Lack of insulin or resistance to its action at the cellular level causes diabetes. Therefore, in diabetes mellitus the blood glucose levels are very high. Some patients with very high blood glucose levels may develop metabolic acidosis and ketosis caused by the increased fat metabolism, the alternate source for energy. Hyperglycaemia is also noted in gestational diabetes of pregnancy and may be found in pancreatic disease, pituitary and adrenal disorders. A decreased level of blood glucose, hypoglycaemia is often associated with starvation, hyper insulinaemia and in those who are taking high insulin dose for therapy. Principle of the method Glucose present in the plasma is oxidized by the enzyme glucose oxidase (GOD) to gluconic acid with the liberation of hydrogen peroxide, which is converted to water and oxygen by the enzyme peroxidase (POD). 4 aminophenazone, an oxygen acceptor, takes up the oxygen and together with phenol forms a pink coloured chromogen which can be measured at 515mm. Specimen type, collection and storage

Plasma is the specimen of choice for glucose estimation. Plasma glucose levels have been checked to be quite stable for 6 hours at room temperature (25 -350C) in the authors laboratory. It is important that plasma should be separated from the cells soon after collection, preferably within 1 hour. About 2 ml of the patients blood should be collected by venipuncture into a tube containing a mixture of potassium ethylene diaminetetraacetate (EDTA) sodium fluoride at a ratio 1:2 (W/W). Five mg of the mixture is adequate for 2 ml of blood. The tube should be gently but thoroughly shaken for complete mixing. Preparation of the anitcoagulant mixture: 100 g of potassium EDTA and 200 g of sodium fluoride should be mixed and ground into a fine powder using a blender. This should preferably be done in a fume cupboard. The mixture should be stored in a clean container. A thin, long spatula that can scoop 5 mg when levelled, can be used for delivering the mixture into the tube. Reagents All chemicals must be Analar grade Phosphate Buffer : 100 mmol/L. pH 7.0 To 800 ml of distilled water add the following in the order: Disodium hydrogen phosphate dihydrate [Na2HPO4 2H2O] 12.95 g Anhydrous potassium dihydrogen phosphate [KH2PO4] 4.95 g Sodium azide [NaN3] 0.5 g Add one by one, dissolve and finally make up to 1 litre with distilled water.

Stable for 3-4 months, at 2-80C. Check that the final pH is 7.0 + 0.05 with a pH meter. Colour Reagent To 100ml of the above phosphate buffer add the following in the order and then mix to dissolve: 4 amino phenazone 16 mg GOD [Sigma G 7016] 1800 units POD [Sigma P 8250 ] 100 units Phenol 105 mg Tween 20 [Sigma P 1359] 50m l Reconstitute the purchased GOD & POD powder with phosphate buffer. Dispense separately into vials so that each vial represents the requisite number of units. Store the vials frozen. Stable for 2 weeks at 2-80C. Store in a brown bottle. Benzoic acid 1g/l. Dissolve 1.0g of benzoic acid in water and make up to 1 litre with water. This solution is stable indefinitely at room temperature. Stock glucose solution, 1 g/l. Before weighing, dry the glucose at 60-800C for 4 hours. Allow to cool in a dessicator. Dissolve 1g of glucose in benzoic acid solution and make up to 100 ml in a volumetric flask. Stable for six months at room temperature (25-350C). DO NOT FREEZE THE STANDARD Working glucose standard 100 mg/dl.

Dilute 10 ml of stock glucose (use either a volumetric pipette or a burette) to 100 ml with benzoic acid in a 100 ml volumetric flask. Mix well. Stable for 6 months at room temperature (25-350C). Equipment, glassware and other accessories Refer to Section A (2), Introduction to SOP Procedure The protocol of the procedure is described below. Dilution of standards (S1-S5), Test & QC Pipette the following into appropriately labelled 13 x 100 mm tubes S1 Distilled Water (ml) 1.9 100 mg/dl glucose 0.1 (ml) Test sample /QC (ml) Mix well Colour development Pipette the following into another set of appropriately labelled tubes. Colour reagent (ml) Distilled water (ml) Blank S1 S2 1.2 1.2 1.2 0.1 S3 1.2 S4 1.2 S5 1.2 Test QC 1.2 1.2 S2 1.8 0.2 S3 1.7 0.3 S4 1.6 0.4 S5 1.5 0.5 Test 1.9 0.1 QC 1.9 0.1

Diluted Standards (ml) Diluted Test Sample/QC (ml)

0.1 0.1 -

0.1 -

0.1 -

0.1 -

0.1

0.1

Mix all tubes well. Incubate at 370C in a waterbath for 15 minutes. Remove from waterbath and cool to room temperature. Set the spectrophotometer/ filter photometer to zero using blank at 510 nm/ green filter and measure the absorbance of Standards, Test and QC. This protocol is designed for spectrophotometers / filter photometer that require a minimum volume of reaction mixture in the cuvette of 1 ml or less. Economical use of reagents is possible with this protocol, thus the cost per test can be kept to the minimum. However, if a laboratory employs a photometer requiring a large volume of the reaction mixture for measurement, viz. 5 ml, it is advisable to increase the volume of all reagents mentioned under Tabulation "(b) Colour development" proportionately. Calculation and calibration graph Since the protocol for standard tube S1 and test is identical, the standard S1 will represent a concentration of 100 mg/dl. The glucose concentrations represented by other standard tubes are S2 =200; S3 = 300; S4 =400 & S5 = 500 (mg/dl). Plot the absorbance values of standards against their respective concentrations. The measurable range with this graph is from 10 to 500 mg/dl. Plot absorbance values of Test/QC on the calibration graph and read off the concentrations.

Once linearity is proved, it is not necessary to prepare the standard graph every time that patients samples are analysed. It will be adequate if standard S2 is taken every time and patients results are calculated using the formula : Test absorbance ---------------------- x 200 mg/dl Standard absorbance

Analytical reliabilities Refer to pages 7-9 of section 1 (General Introduction) on the use of internal QC and interpretation of daily QC data (for releasing patients results). Since glucose is the most common analyte measured in a laboratory, it is advisable to include an internal QC (normal QC pool) with every batch of samples analysed in the day, irrespective of the number of samples in a batch. Further, even when a single sample is analysed as an "emergency" sample at any time of the day or night, it is essential to include an internal QC. From the QC results obtained for the day, mean, standard deviation and %CV can

be calculated to ensure that within-day precision is well within the acceptable limit, i.e, 5%. The mean value of internal QC for the day can be pooled with the preceding 10 or 20 mean values obtained in the previous days, and betweenday precision can be calculated and expressed as % CV. Ensure that this is well within the acceptable limit, i.e, 8%. At least once a day analyse another QC serum from either a low QC or high QC pool. "Assayed" QC sera with stated values (ranges) are available from several commercial sources, viz. Boehringer Mannheim, BioRad & Randox. If a laboratory uses QC sera from a commercial source, it is important that the company certifies that their QC materials are traceable to international reference materials. Hazardous materials This procedure uses sodium azide and phenol, which are poisonous and caustic. Do not swallow, and avoid contact with skin and mucous membranes Reference range and clinical interpretation Plasma glucose: Fasting: 70 110 mg/dl Post-prandial: 80 140 mg/dl Random: 60 140 mg/dl Elevated plasma glucose levels are expected in a variety of clinical conditions, especially diabetes mellitus, Cushings syndrome and hyperadrenalism. Decreased plasma glucose levels are observed in hyper-

insulinism, anti-diabetic treatment and hypoadrenalism. Limitations Any sample that gives aglucose value > 500 mg/dl should be diluted 1:2 with 0.9g% sodium chloride solution and the correct value obtained by multiplying the result by 3. At high plasma levels, uric acid, glutathione and bilirubin may interfere with the assay by causing a decrease in glucose values. Ascorbic acid will decrease glucose values by retarding colour development. Do not report results from specimens with suspected interference. Inform the requesting physician of the problem.

ACE gene polymorphism

The insertion/deletion (I/D) polymorphism of angiotensin converting enzyme (ACE) gene has been associated with progression of renal diseases. AIMS: We investigated its role in the rate of progression of focal segmental glomerulosclerosis (FSGS). Idiopathic focal segmental glomerulosclerosis (FSGS) is one of the most important diseases leading to progressive renal failure in adults and children. A number of observations suggest that genetic factors may play an important role in progression of FSGS. A polymorphism of the angiotensin converting enzyme (ACE) gene consisting of a 287 bp fragment within intron 16 defined by insertion (I) or deletion (D) was reported to be associated with progression of several renal diseases including IgA nephropathy, autosomal dominant polycystic kidney disease and diabetic nephropathy. A strong genetic association has also been found between a DD genotype and increased risk of atherosclerotic cardio-vascular and cerebral diseases. In African Americans (AA) endstage renal disease (ESRD) due to FSGS occurs much more frequently than in the general population AA with essential hypertension have a higher frequency of DD genotype than normotensive AA. The rate of progression of FSGS varies among different races. FSGS can be particularly aggressive in AA with the rate of progression to ESRD from the time of diagnosis is significantly less than other racial groups Losartan treatment reduced renal outcomes in proteinuric patients with type 2 diabetes in the Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan (RENAAL) study. It is unknown whether an insertion (I)/deletion (D) polymorphism in the angiotensin I-converting enzyme (ACE) gene predicts renal outcomes and death and influences the effect of losartan in these patients. Pharmacogenetic analyses were performed comparing losartan with placebo administered with conventional blood pressure-lowering therapy in 1435 (95%) of the 1513 RENAAL study patients. The primary endpoint was the composite of doubling of baseline serum creatinine concentration, end-stage renal disease (ESRD) or death. Cox regression models were stratified on baseline proteinuria and included treatment, geographic region, ACE/ID

genotype, and treatment x genotype interaction. Within the placebo group, subjects with the ID or DD genotype were more likely than those with the II genotype to reach the composite endpoint or its individual components. Within the losartan group, genotype did not correlate with reaching the composite endpoint. Compared with placebo, however, losartan reduced the risk of reaching the composite endpoint . In conclusion, proteinuric type 2 diabetic patients with the D allele of the ACE gene have an unfavorable renal prognosis, which can be mitigated and even improved by losartan. Given the enormous number of studies that support the concept that blocking ACE by ACE inhibitors is beneficial for patients with hypertension, congestive heart failure, and possibly, coronary artery disease, it is our understanding (and persuasion) that the ACE D/D polymorphism contributes to the overall risk of developing a myocardial infarction rather than trying to prove this concept. It seems naive to expect that by combining heterogeneous study populations from around the globe and calculating a meta-analysis one could identify the impact of a single polymorphism (only 260 bp in the human genome) on the risk of myocardial infarction, especially since polymorphisms are characterized by an undefined phenotype compared with gene mutations. Thus, the question remains whether or not we should believe that a single-gene polymorphism is associated with a higher risk of myocardial infarction and if so, how do we prove this concept. Coronary artery disease is a multifactorial disease. Many environmental and potentially, genetic factors contribute to the development of a clinical event, such as myocardial infarction. Each of the underlying risk factors, such as LDL cholesterol or homocysteine, is also multifactorial and polygenic. Therefore, for any individual, variations at different gene loci will interact with different environmental factors to determine their overall risk of myocardial infarction. Moreover, the age and duration of environmental influence on the individual seem to play an important role. All of the previous studies enrolled adults. Observations in large cohorts of apoE4-positive infants, however, have demonstrated that the harmful influences of environmental factors, eg, of a Western diet, start as early as 7 to 8 month postpartum. Thus, it seems odd nowadays to summarize heterogeneous populations of different ages and calculate their risk for myocardial infarction

Genetic susceptibility to microvascular disorder

Diabetic retinopathy is a sight-threatening complication of the retinal microvasculature. While important environmental factors have been clearly identified as influencing its development, increasing evidence suggests that diabetic retinopathy has a genetic component. A variety of studies have explored associations between candidate genes and frequency and severity of retinopathy. Overall, this review has found that the majority of candidate genes studied exhibit weak or no association with retinopathy status, and where associations have been detected these results have not been replicated in multiple populations. This may reflect inaccurate case definition, small subject numbers and possibly inadequate markers for genetic studies It is recognised that polymorphic variability in the genetic make-up of an individual can profoundly influence the expression of a gene and its response to environmental factors.1,2 Useful clinical markers for genetic susceptibility to a disease are either familial aggregation or a variation in disease frequency, which are not explained by environmental, biochemical, or biological risk factors. Diabetic retinopathy (DR) displays these characteristics as clinical studies on human subjects with diabetes reveal substantial variation in the onset and severity of retinopathy that are not fully explained by the known risk factors such as duration of diabetes, level of glycaemic control, or concomitant vascular disease.3,4 The risk of severe DR in the siblings of affected individuals is substantially increased,5 and the Diabetes Control & Complications Trial has shown that retinopathy tends to cluster in families.4 Furthermore, differences in the frequency of disease in ethnic populations6 also suggest that genetic

influences are operating in DR. With the complex metabolic environment of the retina, many risk factors have been proposed in the past Microvascular disease underlies the 3 most common and devastating manifestations of DM: Retinopathy Nephropathy Neuropathy Microvascular disease may also impair skin healing, so that even minor breaks in skin integrity can develop into deeper ulcers and easily become infected. Intensive control of plasma glucose can prevent many of these complications but may not reverse them once established.

Diabetic retinopathy: Diabetic retinopathy is the most common cause of adult blindness in the US (see also Retinal Disorders: Diabetic Retinopathy). It is characterized initially by retinal capillary microaneurysms and later by macular edema and neovascularization. There are no early symptoms or signs, but focal blurring, vitreous or retinal detachment, and partial or total vision loss eventually develop; rate of progression is highly variable. Diagnosis is by retinal examination. Treatment is argon laser photocoagulation or vitrectomy. Strict glycemic control and early detection and treatment are critical to preventing vision loss. Diabetic nephropathy: Diabetic nephropathy (see also Glomerular Disorders: Diabetic Nephropathy) is a leading cause of chronic renal failure in the US. It is characterized by thickening of the glomerular basement membrane, mesangial expansion, and glomerular sclerosis. These changes cause glomerular hypertension and progressive decline in GFR. Systemic hypertension may accelerate progression. The disease is usually asymptomatic until nephrotic syndrome or renal failure develops. Diagnosis is by detection of urinary

albumin. A urine dipstick positive for protein signifies albumin excretion > 300 mg/day and advanced diabetic nephropathy (or an improperly collected or stored specimen). If the dipstick is negative for protein, the albumin:creatinine ratio on a spot urine specimen or urinary albumin in a 24-h collection should be measured. A ratio > 30 mg/g or an albumin concentration 30 to 300 mg/24 h signifies microalbuminuria and early diabetic nephropathy. Treatment is rigorous glycemic control combined with BP control. An ACE inhibitor, an angiotensin II receptor blocker, or both should be used to treat hypertension at the earliest sign of microalbuminuria or even before, because these drugs lower intraglomerular BP and thus have renoprotective effects. Diabetic neuropathy: Diabetic neuropathy is the result of nerve ischemia from microvascular disease, direct effects of hyperglycemia on neurons, and intracellular metabolic changes that impair nerve function. There are multiple types, including Symmetric polyneuropathy (with small- and large-fiber variants) Autonomic neuropathy Radiculopathy Cranial neuropathy Mononeuropathy Symmetric polyneuropathy is most common and affects the distal feet and hands (stocking-glove distribution); it manifests as paresthesias, dysesthesias, or a painless loss of sense of touch, vibration, proprioception, or temperature. In the lower extremities, these symptoms can lead to blunted perception of foot trauma from ill-fitting shoes and abnormal weight bearing, which can in turn lead to foot ulceration and infection or to fractures, subluxation, and dislocation or destruction of normal foot architecture (Charcot's joint). Small-fiber neuropathy is characterized by pain, numbness, and loss of temperature sensation with preserved vibration and position sense. Patients are prone to foot ulceration and

neuropathic joint degeneration and have a high incidence of autonomic neuropathy. Predominant large-fiber neuropathy is characterized by muscle weakness, loss of vibration and position sense, and lack of deep tendon reflexes. Atrophy of intrinsic muscles of the feet and foot drop are common. Autonomic neuropathy can produce orthostatic hypotension, exercise intolerance, resting tachycardia, dysphagia, nausea and vomiting (due to gastroparesis), constipation and diarrhea (including dumping syndrome), fecal incontinence, urinary retention and incontinence, erectile dysfunction and retrograde ejaculation, and decreased vaginal lubrication.

GAD 65 antibody screening in type 2

GAD antibodies are an indicator of autoimmunity related to Type 1 diabetes, and having it positive does put you at higher risk for developing diabetes in future. Given that you also have positive thyroid antibodies, you are in general more likely to develop other autoimmune conditions in future as well. Your blood sugar levels right now are mostly within the normal range aside from some mild elevations in your fasting levels. A C-peptide level will give some indication of how much of your own insulin function remains, so this is useful to know. Checking blood sugars after meals may also offer some information in terms of how well your body is able to handle glucose loads right now and if medications is needed yet. Type 2 diabetes mellitus (DM), is characterized by disorders in insulin secretion and, in many patients, relative insulin deficiency as well as the inability to Effectively utilize insulin production (insulin resistance)[1]. Many studies have shown that type 1 DM is caused by autoimmune d e s t ruction of the panceratic -cells, which is characterized by the presence of circulating islet Autoantibodies, and has a strong association with endocrine autoimmunity[2-4]. Little is known about the risk for autoimmunity in subjects with type 2 DM. Autoantibodies to islet cell antigen Glutamic Acid Decarboxylase (GAD65) can be detected in 70- 90% of new-onset type 1 DM. It has also been detected in 10-20% of type 2 DM and this has been suggested to reflect autoimmunity as well as being the most sensitive single marker for identifying persons at risk of developing the disease. Type 2 DM with GAD65 Autoantibodies has been classified as a latent autoimmune diabetes in adults (LADA)[ 7 ] in diff e rent ethnic gro u p s Patients initially diagnosed with type 2 diabetes may, in many cases, suffer from LADA. Therefore, testing for GAD65 antibodies may be of assistance in diagnosis.

In conclusion, there is a significant prevalence of anti-GAD65 antibody among type 2 diabetic patients studied, in particular among females over 40 years of age. Omani type 2 diabetic patients show similar prevalence of GAD65 autoimmunity and LADAas in other population groups.They also express thyroid autoimmunity. The significance of GAD65 and thyroid autoimunity among these patient and the role of early insulin therapy needs to be evaluated.

Rennin angiotensin system- clinical utility

The pathological mechanisms of out-of-office hypertension (e.g., masked hypertension and workplace hypertension) have been remained unclear, but several mechanisms for this unique phenomenon have been proposed. Altered neurohumoral regulations, increased activity of sympathetic nerve and reninangiotensin-system (RAS), and reduced baroreflex gain, coupled to a prolonged endothelial dysfunction, play an important role in out-of-office hypertension. Previous studies showed that angiotensin receptor blocker (ARB) reduced not only RAS but also sympathetic activity, and improved baroreflex as well asendothelial function, which suggested that ARB may be suitable for treating subjects with out-of-office hypertension. In the TROPHY (TRial Of Preventing HYpertension) study, it has been demonstrated that treatment with ARB reduced the risk of development of true hypertension from a pre-hypertensive state. Because there were close associations between pre-hypertension and out-ofoffice hypertension, especially in those with obesity and metabolic syndrome, this study may also provide an important information about the treatment strategy of out-of-office hypertension. Elevated peripheral vascular tone has been proposed as one of the detrimental factors causing increased cardiac after load and reduced exercise capacity in patients with congestive heart failure (CHF). A number of studies have shown impaired endothelium-dependent vasodilation in limb resistance and conduit vessels in CHF, suggesting that this is one of the important etiologies of vascular dysfunction. Several clinical trials have shown that pharmacological inhibition of the renin-angiotensin-aldosterone system by angiotensin converting enzyme inhibitors, angiotensin II receptor antagonists, or aldosterone receptor antagonists, significantly improves prognosis in this disorder. However, the

relationship between the clinical utility of this type of drug and its pharmacological effects on the peripheral vasculature has not been extensively assessed in patients with CHF. The present review summarizes recent reports including our own observations on the pharmacological effects and mechanisms of this type of drug on vascular endothelial function in the peripheral vasculature in human CHF The Renin Angiotensin system (RAS) has been implicated in the mediation of the cytokine storm, suggesting a potential benefit for Angiotensin Converting Enzyme (ACE) inhibitors and Angiotensin II Receptor Blockers (ARBs), and ACE has been implicated in inflammatory lung pathologies. Shigehara et al. published research confirming that serum angiotensin-converting enzyme (ACE) is a useful marker for disease activity in cytokine-mediated inflammatory lung disease. Marshall and co-workers also found that angiotensin II was associated with cytokine-mediated lung injury and suggested a role for ACE inhibitors. Wang and co-workers published data that cytokine-mediated pulmonary damage (apoptosis of lung epithelial cells) in response to the pro-inflammatory cytokine TNF-alpha (implicated in the cytokine storm) requires the presence of angiotensin II, suggesting that ARBs might have clinical utility in this setting. Das published a review of ACE inhibitor and angiotensin-II receptor blocker use in a number of cytokine-mediated inflammatory pathologies and suggested that ACE inhibitors and Angiotensin receptor blockers have theoretical benefit in downregulation of the cytokine storm The reninangiotensin system participates significantly in the pathophysiology of hypertension, congestive heart failure, myocardial infarction, and diabetic nephropathy. This realization has led to a thorough exploration of the renin

angiotensin system and the development of new approaches for inhibiting its actions. This chapter discusses the biochemistry, molecular and cellular biology, and physiology of the reninangiotensin system; the pharmacology of drugs that interrupt the reninangiotensin system; and the clinical utility of inhibitors of the reninangiotensin system The combination of a diuretic with an agent that inhibits the RAS is a logical one Thiazide diuretics lower BP via sodium excretion and volume reduction, making thiazides most effective in patients with salt- or volume-sensitive hypertension. Thiazide-induced volume reduction may activate the RAS as a compensatory mechanism and, in turn, promote renin release and formation of angiotensin II; thus, RAS activation in response to diuretic therapy may limit the hypotensive action of the diuretic. ACE inhibitors and ARBs counteract angiotensin II-mediated activation of the RAS and sympathetic nervous system, and provide BP control via their powerful vasodilatory effects. The combination of a RAS inhibitor and a thiazide diuretic effectively lowers BP in patients with renin- or salt-sensitive hypertension; among those with salt-sensitive hypertension, the BP-lowering effects of an ARB are enhanced when it is combined with even minimally natriuretic doses of hydrochlorothiazide. RAS inhibition normalizes the pressure-natriuresis gradient and allows sodium balance to be maintained at lower arterial pressures ACE inhibitors and ARBs reduce urinary protein excretion and slow the progression of chronic kidney disease. This beneficial effect on renal disease progression is greater in patients with higher urinary protein excretion at the onset of treatment. The amount of proteinuria remaining during therapy is proportional to the subsequent rate of renal function loss, suggesting that interventions designed to further lower urinary protein excretion will enhance renal outcomes. Restricting dietary salt intake and using effective diuretic therapy have been shown to augment the antiproteinuric effect of RAS

blockade, which provides additional rationale for the use of these two drug classes together. Thiazide diuretics can be used for this purpose when the estimated glomerular filtration rate is >30 mL/minute; however, loop diuretics should be utilized in patients with more severe renal insufficiency. ARBs offer utility in combination regimens due to the low rate of adverse events associated with this class compared with other antihypertensive classes; for example, ARBs demonstrate a lower incidence of cough and angioedema than ACE inhibitors. Because of their complementary mechanisms of action, the combination of an ARB with hydrochlorothiazide provides significantly greater BP reductions than either component as monotherapy. Furthermore, a dosedependent effect of ARB/hydrochlorothiazide has been observed through the approved dose range with losartan (up to 100 mg), valsartan (up to 320 mg),and olmesartan (up to 40 mg) in combination with hydrochlorothiazide 12.5-25 mg, without a substantial increase in adverse events. In the recently reported ValMARC (Valsartan-Managing Blood Pressure Aggressively and Evaluating Reductions in hs-CRP) trial, the median change in SBP with the combination valsartan/hydrochlorothiazide (320/12.5 mg/day) was -25 mmHg versus -18 mmHg with valsartan monotherapy (320 mg/day) at 6 weeks (p < 0.001); median change in DBP was -14 mmHg versus -9 mmHg, respectively (p < 0.001). The greater reduction observed with combination therapy was statistically significant as early as the second week.In addition to increased BPlowering efficacy with the combination of a diuretic and an agent that blocks the RAS, evidence suggests that combination therapy mitigates some of the adverse events associated with these drug classes when given as monotherapy. STUDIES suggesting a potential mechanism for the increased incidence of newonset diabetes mellitus observed with diuretics. RAS blockade inhibits urinary potassium secretion and thereby counteracts potassium wasting as well as aldosterone secretion associated with diuretic monotherapy. Hyperkalemia remains a common concern voiced by clinicians regarding the use of agents that

block the RAS in patients with or at risk for chronic kidney disease; however, the risk of hyperkalemia can be minimized with the addition of a low-dose diuretic. Despite the evidence for a beneficial effect of RAS blockade on the kidney, some clinicians remain concerned by the observed changes in markers of renal function with these agents. A small, nonprogressive increase in serum creatinine may be observed with any antihypertensive therapy as a result of BP lowering, and this effect may be more pronounced with ACE inhibitors or ARBs. However, because of changes in renal autoregulation that occur in chronic kidney disease, this increase, rather than signaling structural injury, reflects a favorable hemodynamic effect of antihypertensive agents in the kidney. A slight rise in serum creatinine concentrations in patients with well controlled BP is an indicator that intraglomerular pressure has been reduced. Thiazide diuretics will not cause the degree of volume contraction seen with more potent loop diuretics and therefore are less likely to be associated with an increased serum creatinine concentration when combined with RAS blockade. The long-term renoprotective effects of RAS inhibitors are maintained when used in combination with thiazide diuretics and may be possibly enhanced through better BP control and further reductions in urinary protein excretion.

Mealtime stimulated insulin secretion Improving Mealtime Glucose Control by Restoring Early Insulin Secretion in Type 2 Diabetes Whereas sulfonylureas or insulin may adequately control fasting blood glucose levels, it is usually more challenging to modulate postprandial glucose excursions. Because neither sulfonylureas nor regular insulin appropriately simulate the postprandial insulin response to a meal, they are not ideal for managing postprandial hyperglycemia. Furthermore, because these agents produce increases in insulin levels that extend beyond the postprandial period, they may predispose the patient to hypoglycemia. The rationale for tailoring pharmacologic therapy to mealtimes is based on the importance of restoring the mealtime insulin secretion profiles of patients with type 2 diabetes to reestablish the tight control of blood glucose levels during the postprandial period. Furthermore, this approach also takes into account that most people with type 2 diabetes are overweight and are advised to reduce calorie consumption, but the risk of hypoglycemia does not allow them to be flexible about their day-to-day calorie intake. Dietary modifications may somewhat diminish postprandial hyperglycemia, but they often do not produce a satisfactory response, and therefore pharmacologic intervention is usually undertaken. Several classes of pharmacologic agents are either currently available or in clinical development for managing postprandial glucose excursions. These include alpha-glucosidase inhibitors, short-acting insulinotropic agents, rapid-acting insulin analogues, and amylin analogues.

Alpha-glucosidase Inhibitors Alpha-glucosidase inhibitors, such as acarbose, miglitol, and voglibose, delay the digestion of complex carbohydrates by competitively inhibiting intestinal

alpha-glucosidases that hydrolyze oligosaccharides into monosaccharides. By delaying the digestion and prolonging the intestinal absorption of dietary carbohydrates, these agents diminish postprandial hyperglycemia. However, because the total amount of carbohydrate absorbed is not reduced, there are no net energy losses. Clinical studies have shown that alpha-glucosidase inhibitors reduce postprandial glucose levels and improve overall glycemic control as indicated by HbA1c. In addition, some studies suggest that acarbose reduces the postprandial increase in triglycerides and may have beneficial effects on lipoproteins. Compared with sulfonylureas, they are not associated with postprandial hypoglycemia.[ In a comparative study of miglitol and acarbose, both agents produced comparable reductions in HbA1c concentrations.[ When used as monotherapy, these agents may not achieve overall glycemic control in all patients, especially in those with elevated FPG levels. Patients should be instructed to take their dose of alpha-glucosidase inhibitor with the first bite of each meal. The principal side effects of alpha-glucosidase inhibitors are related to their effect on the gastrointestinal tract and are primarily manifested as flatulence and loose stools. They do not appear to affect the rate of gastric emptying. Tolerance to these side effects usually occurs with continued administration.

Short-acting Insulinotropic Agents Because these agents more rapidly stimulate insulin secretion compared with sulfonylureas, they simulate a more physiologic increase in mealtime insulin levels. Thus, they are primarily used for reducing postprandial hyperglycemia. Repaglinide, a carbamoylmethyl benzoic acid derivative structurally related to meglitinide, is the first short-acting insulinotropic agent approved in the United

States for the treatment of type 2 diabetes. Repaglinide augments glucosestimulated insulin secretion by closing ATP-sensitive potassium [K+(ATP)] channels on beta cells. This causes depolarization of the beta cell and the opening of voltage-sensitive calcium channels allowing the influx of extracellular calcium ions, which in turn, stimulates insulin release. Repaglinide more effectively increases insulin release from islet cells incubated in vitro in the presence of D-glucose or other nutrients than in their absence. Repaglinide significantly increases postprandial insulin levels and also decreases mean FPG, postprandial PG levels, and HbA1c. It is more effective than glipizide and similar to glibeclamide and gliclazide in maintaining overall glycemic control as measured by HbA1c. Patients should be instructed to take repaglinide within 15 minutes of a meal, but this time may vary from immediately preceding the meal to as long as 30 minutes before. Patients who skip a meal should be instructed to skip the dose for that meal. Conversely, if a meal is added, then patients should be instructed to add a dose. Nateglinide, another short-acting insulinotropic agent, is an amino acid derivative that stimulates insulin secretion from pancreatic beta cells by closing K+(ATP) channels. In vitro studies using rat cardiac myocytes and vascular smooth muscle cells suggest that nateglinide is more selective for beta-cell K+(ATP) channels than repaglinide and glyburide. Nateglinide blunts mealtime glucose excursions, returning glucose levels to predose values 4 hours after a meal.

Rapid-acting Insulin Analogues The tendency of human insulin to self-associate under normal physiologic conditions results in a slow and prolonged absorption from the subcutaneous site of injection. This requires that regular human insulin be injected approximately

30 to 60 minutes before a meal, as administration immediately before a meal produces less than optimal insulin levels during the early phase of glucose absorption and hyperinsulinemia by the time meal absorption is complete. Structural modifications of the insulin molecule have produced insulin analogues that have a weaker tendency to self-associate and, as a result, are more rapidly and reliably absorbed from the injection site. The short-acting analogues of insulin, insulin lispro and insulin aspart, were developed to provide a more physiologic insulin response to food intake. These insulin analogues are usually administered within 10 to 20 minutes of a meal, allowing more flexibility in insulin dosing. Clinical trials in patients with both type 1 and type 2 diabetes have shown that insulin lispro reduces postprandial glucose excursions. A large, multinational study compared the effect of lispro injected immediately before a meal with regular human insulin, which was injected 30 to 45 minutes before eating. Postprandial glucose levels were lower in patients in the insulin lispro group.[ When the early rise in plasma insulin was restored by the lispro analogue, postprandial glucose levels were reduced and subsequent hyperglycemia and hyperinsulinemia were prevented after an oral glucose load was compared with regular human insulin.[21] This improvement in glucose tolerance was associated with a prompter, short-lived suppression of endogenous glucose production. The degree of self-association of insulin aspart is similar to that of insulin lispro. Insulin aspart is absorbed twice as fast and it produces maximum insulin leves that are approximately twice as high compared with human insulin. In patients with type 1 diabetes, insulin aspart significantly improved postprandial blood glucose control after lunch and dinner and significantly reduced the occurrence of hypoglycemic episodes requiring third-party intervention.[ Amylin Analogues

Amylin is a pancreatic hormone produced by the beta cell and cosecreted with insulin in response to various secretagogues. Amylin delays gastric emptying and inhibits postprandial glucagon secretion. In individuals with type 2 diabetes, the decline in amylin secretory response correlates with reduced pancreatic betacell activity. However, the short half-life limits the use of amylin. These limitations have been overcome by the advent of pramlintide, an analogue of amylin. Recent clinical studies in patients with type 1 diabetes indicate that pramlintide produces a significant decrease in mean PG and postprandial glucose concentration despite comparable insulin level. In patients with type 2 diabetes, pramlintide produced a decrease in HbA1c. However, the clinical usefulness of pramlintide in type 2 diabetes remains to be defined.

B cell response to glucose stimulus. Delayed response in type 2 , clinical application. Beta cells in the islets of Langerhans release insulin in two phases. The first phase insulin release is rapidly triggered in response to increased blood glucose levels. The second phase is a sustained, slow release of newly formed vesicles that are triggered independently of sugar. The description of first phase release is as follows:

Glucose enters the beta cells through the glucose transporter GLUT2 Glucose goes into glycolysis and the respiratory cycle where multiple high-energy ATP molecules are produced by oxidation Dependent on the ATP:ADP ratio, and hence blood glucose levels, the ATPdependent potassium channels (K+) close and the cell membrane depolarizes On depolarization, voltage controlled calcium channels (Ca2+) open and calcium flows into the cells An increased calcium level causes activation of phospholipase C, which cleaves the membrane phospholipid phosphatidyl inositol 4,5-bisphosphate into inositol 1,4,5triphosphate and diacylglycerol [citation needed]. Inositol 1,4,5-triphosphate (IP3) binds to receptor proteins in the membrane of endoplasmic reticulum (ER). This allows the release of Ca2+ from the ER via IP3 gated channels, and further raises the cell concentration of calcium. Significantly increased amounts of calcium in the cells causes release of previously synthesized insulin, which has been stored in secretory vesicles

This is the main mechanism for release of insulin. In addition some insulin release takes place generally with food intake, not just glucose or carbohydrate intake, and the beta cells are also somewhat influenced by the autonomic nervous system. The signaling mechanisms controlling these linkages are not fully understood. Other substances known to stimulate insulin release include amino acids from ingested proteins, acetylcholine released from vagus nerve endings (parasympathetic nervous system), gastrointestinal hormones released by enteroendocrine cells of intestinal mucosa and glucose-dependent insulinotropic peptide (GIP). Three amino acids (alanine, glycine and arginine) act similarly to glucose by altering the beta cell's membrane potential.

Acetylcholine triggers insulin release through phospholipase C, while the last acts through the mechanism of adenylate cyclase. The sympathetic nervous system (via 2-adrenergic stimulation as demonstrated by the agonists clonidine or methyldopa) inhibit the release of insulin. However, it is worth noting that circulating adrenaline will activate 2-Receptors on the Beta cells in the pancreatic Islets to promote insulin release. This is important since muscle cannot benefit from the raised blood sugar resulting from adrenergic stimulation (increased gluconeogenesis and glycogenolysis from the low blood insulin: glucagon state) unless insulin is present to allow for GLUT-4 translocation in the tissue. Therefore, beginning with direct innervation, norepinephrine inhibits insulin release via 2-receptors, then subsequently, circulating adrenaline from the adrenal medulla will stimulate 2-receptors thereby promoting insulin release. When the glucose level comes down to the usual physiologic value, insulin release from the beta cells slows or stops. If blood glucose levels drop lower than this, especially to dangerously low levels, release of hyperglycemic hormones (most prominently glucagon from Islet of Langerhans' alpha cells) forces release of glucose into the blood from cellular stores, primarily liver cell stores of glycogen. By increasing blood glucose, the hyperglycemic hormones prevent or correct life-threatening hypoglycemia. Release of insulin is strongly inhibited by the stress hormone norepinephrine (noradrenaline), which leads to increased blood glucose levels during stress. Evidence of impaired first phase insulin release can be seen in the glucose tolerance test, demonstrated by a substantially elevated blood glucose level at 30 minutes, a marked drop by 60 minutes, and a steady climb back to baseline levels over the following hourly time points. Insulin release from pancreas oscillates with a period of 36 minutes. Even during digestion, generally one or two hours following a meal, insulin release from pancreas is not continuous, but oscillates with a period of 36 minutes, changing from generating a blood insulin concentration more than ~800 pmol/l to less than 100 pmol/l. This is thought to avoid downregulation of insulin receptors in target cells and to assist the

liver in extracting insulin from the blood. This oscillation is important to consider when administering insulin-stimulating medication, since it is the oscillating blood concentration of insulin release, which should, ideally, be achieved, not a constant high concentration. This may be achieved by delivering insulin rhythmically to the portal vein or by islet cell transplantation to the liver. Future insulin pumps hope to address this characteristic. (See also Pulsatile Insulin.) Signal transduction There are special transporter proteins in cell membranes through which glucose from the blood can enter a cell. These transporters are, indirectly, under blood insulin's control in certain body cell types (e.g., muscle cells). Low levels of circulating insulin, or its absence, will prevent glucose from entering those cells (e.g., in Type 1 diabetes). However, more commonly there is a decrease in the sensitivity of cells to insulin (e.g., the reduced insulin sensitivity characteristic of Type 2 diabetes), resulting in decreased glucose absorption. In either case, there is 'cell starvation', weight loss, sometimes extreme. In a few cases, there is a defect in the release of insulin from the pancreas. Either way, the effect is, characteristically, the same: elevated blood glucose levels. Activation of insulin receptors leads to internal cellular mechanisms that directly affect glucose uptake by regulating the number and operation of protein molecules in the cell membrane that transport glucose into the cell. The genes that specify the proteins that make up the insulin receptor in cell membranes have been identified and the structures of the interior, transmembrane section, and the extra-membrane section of receptor have been solved. Two types of tissues are most strongly influenced by insulin, as far as the stimulation of glucose uptake is concerned: muscle cells (myocytes) and fat cells (adipocytes). The former are important because of their central role in movement, breathing, circulation, etc., and the latter because they accumulate excess food energy against future needs. Together, they account for about two-thirds of all cells in a typical human body. Insulin binds to the extracellular portion of the alpha subunits of the insulin receptor. This in turn causes an conformational change in the insulin receptor that activates the kinase domain that resides on the intracellular portion of the beta subunits. The activated kinase

domain autophosphorylates tyrosine residues on the C-terminus of the receptor as well as tyrosine residues in the IRS-1 protein. 1. phosphorylated IRS-1 in turn binds to and activates phosphoinositol 3 kinase (PI3K) 2. PI3K catalyzes the reaction PIP2 + ATP PIP3 3. PIP3 activates protein kinase B (PKB) 4. PKB phosphorylates glycogen synthase kinase (GSK) and thereby inactivates GSK[15] 5. GSK can no longer phosphorylate glycogen synthase (GS) There is a progressive deterioration in -cell function and mass in type 2 diabetics. It was found that islet function was about 50% of normal at the time of diagnosis, and a reduction in -cell mass of about 60% was shown at necropsy. The reduction of -cell mass is attributable to accelerated apoptosis. The major factors for progressive loss of -cell function and mass are glucotoxicity, lipotoxicity, proinflammatory cytokines, leptin, and islet cell amyloid. Impaired -cell function and possibly -cell mass appear to be reversible, particularly at early stages of the disease where the limiting threshold for reversibility of decreased -cell mass has probably not been passed. Among the interventions to preserve or "rejuvenate" -cells, short-term intensive insulin therapy of newly diagnosed type 2 diabetes will improve -cell function, usually leading to a temporary remission time. Another intervention is the induction of -cell "rest" by selective activation of ATP-sensitive K+ (KATP) channels, using drugs such as diazoxide. A third type of intervention is the use of antiapoptotic drugs, such as the thiazolidinediones (TZDs), and incretin mimetics and enhancers, which have demonstrated significant clinical evidence of effects on human -cell function. The TZDs improve insulin secretory capacity, decrease -cell apoptosis, and reduce islet cell amyloid with maintenance of neogenesis. The TZDs have indirect effects on -cells by being insulin sensitizers. The direct effects are via peroxisome proliferator-activated receptor activation in pancreatic islets, with TZDs consistently improving basal -cell function. These beneficial effects are sustained in some individuals with time. There are several trials on prevention of diabetes with TZDs.

Incretin hormones, which are released from the gastrointestinal tract in response to nutrient ingestion to enhance glucose-dependent insulin secretion from the pancreas, aid the overall maintenance of glucose homeostasis through slowing of gastric emptying, inhibition of glucagon secretion, and control of body weight. From the two major incretins, glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), only the first one or its mimetics or enhancers can be used for treatment because the diabetic -cell is resistant to GIP action. Because of the rapid inactivation of GLP-1 by dipeptidyl peptidase (DPP)-IV, several incretin analogs were developed: GLP-1 receptor agonists (incretin mimetics) exenatide (synthetic exendin-4) and liraglutide, by conjugation of GLP-1 to circulating albumin. The acute effect of GLP-1 and GLP-1 receptor agonists on -cells is stimulation of glucose-dependent insulin release, followed by enhancement of insulin biosynthesis and stimulation of insulin gene transcription. The chronic action is stimulating -cell proliferation, induction of islet neogenesis, and inhibition of -cell apoptosis, thus promoting expansion of -cell mass, as observed in rodent diabetes and in cultured -cells. Exenatide and liraglutide enhanced postprandial cell function. The inhibition of the activity of the DPP-IV enzyme enhances endogenous GLP-1 action in vivo, mediated not only by GLP-1 but also by other mediators. In preclinical studies, oral active DPP-IV inhibitors (sitagliptin and vildagliptin) also promoted -cell proliferation, neogenesis, and inhibition of apoptosis in rodents. Meal tolerance tests showed improvement in postprandial -cell function.

Grading the severity of diabetes

Table 1. International Clinical Diabetic Retinopathy (DR) Disease Severity Scale Proposed Disease Severity Level No apparent DR Mild nonproliferative DR Moderate nonproliferative DR Findings Observable With Dilated Ophthalmoscopy No abnormalities Microaneurysms only More than "mild" but less than "severe" Any of the following: 20 or more intraretinal hemorrhages in 4 quadrants Definite venous beading in 2 or more quadrants Prominent IRMA in 1 or more quadrants and no neovascularization 1 or more of the following: Definite neovascularization Preretinal or vitreous hemorrhage

Severe nonproliferative DR

Proliferative DR

IRMA = intraretinal microvascular abnormalities

Grading DKA
The severity of DKA is categorized by the degree of acidosis (18): Mild: venous pH <7.3 or bicarbonate <15 mmol/L Moderate: pH <7.2, bicarbonate <10 mmol/L Severe: pH <7.1, bicarbonate <5 mmol/L
Mild Arterial pH Arterial HCO3 Level of consciousness Moderate 7.25 - 7.30 15 18 Alert Severe 7.00-7.24 10-14 Alert drowsy <7.0 <10 Drowsy coma

Grading CKD
NKF Classification of Chronic Kidney Disease*
U.S. prevalence, number of affected patients (%)

Stage Description At increased risk for chronic kidney disease 1 Kidney damage with normal or elevated GFR 2 Kidney damage with mildly decreased GFR 3 4 5 Moderately decreased GFR Severely decreased GFR Kidney failure

GFR (mL per minute per 1.73 m ) > 60 (with risk

2

Action plan Screening, reduction of risk factors for chronic kidney disease

factors for chronic kidney disease) 90 5.9 million (3.3)

Diagnosis and treatment, treatment of comorbid conditions, interventions to slow disease progression, reduction of risk factors for cardiovascular disease

60 to 89

5.3 million (3.0)

Estimation of disease progression

30 to 59 15 to 29 < 15 (or dialysis)

7.6 million (4.3) 400,000 (0.2) 300,000 (0.1)

Evaluation and treatment of disease complications Preparation for kidney replacement therapy (dialysis, transplantation) Kidney replacement therapy if uremia is present

NKF = National Kidney Foundation; GFR = glomerular filtration rate.

Hypoglycemia or hypoglycmia is the medical term for a state produced by

a lower than normal level of blood glucose. The term literally means "under-sweet blood" .It can produce a variety of symptoms and effects but the principal problems arise from an inadequate supply of glucose to the brain, resulting in impairment of function (neuroglycopenia). Effects can range from mild dysphoria to more serious issues such as seizures, unconsciousness, and (rarely) permanent brain damage or death. The most common forms of hypoglycemia occur as a complication of treatment of diabetes mellitus with insulin or oral medications. Hypoglycemia is less common in nondiabetic persons, but can occur at any age, from many causes. Among the causes are excessive insulin produced in the body (hyperinsulinemia), inborn errors of metabolism, medications and poisons, alcohol, hormone deficiencies, prolonged starvation, alterations of metabolism associated with infection, and organ failure. Hypoglycemia is treated by restoring the blood glucose level to normal by the ingestion or administration of dextrose or carbohydrate foods. In some circumstances it is treated by injection or infusion of glucagon. Recurrent hypoglycemia may be prevented by reversing or removing the underlying cause, by increasing the frequency of meals, with medications like diazoxide, octreotide, or glucocorticoids, or by surgical removal of much of the pancreas. The level of blood glucose low enough to define hypoglycemia may be different for different people, in different circumstances, and for different purposes, and occasionally has been a matter of controversy. Most healthy adults maintain fasting glucose levels above 4.0 mmol/L), and develop symptoms of hypoglycemia when the glucose falls below 4 mmol/L. It can sometimes be difficult to determine whether a person's symptoms are due to hypoglycemia. Criteria referred to as Whipple's triad are used to determine a diagnosis of hypoglycemia: 1. Symptoms known to be caused by hypoglycemia 2. Low glucose at the time the symptoms occur 3. Reversal or improvement of symptoms or problems when the glucose is restored to normal

Hypoglycemia (common usage) is also a term in popular culture and alternative medicine for a common, often self-diagnosed, condition characterized by shakiness and altered mood and thinking, but without measured low glucose or risk of severe harm. It is treated by changing eating patterns.

Exercise physiology
Exercise physiology is the study of the acute responses and chronic adaptations to a widerange of physical exercise conditions. In addition, many exercise physiologists study the effect of exercise on pathology, and the mechanisms by which exercise can reduce or reverse disease progression. There is no licensing body for exercise physiologists, and therefore the scope of exercise physiology is diffuse. An exercise physiologist's area of study may include but is not limited to biochemistry, bioenergetics, cardiopulmonary function, hematology, biomechanics, skeletal muscle physiology, neuroendocrine function, and central and perpheral nervous system function. Furthermore, exercise physiologists range from basic scientists, to clinical researchers, to clinicians, to sports trainers.

Energy Humans have a high capacity to expend energy for many hours doing sustained exercise. For example, one individual cycling at a speed of 26.4 km/h (16.4 mph) across 8,204 km (5,098 mi) on 50 consecutive days may expended a total of 1,145 MJ (273,850 kcal) with an average power output of 182.5 W. Skeletal muscle burns 90 mg (0.5 mmol) of glucose each minute in continuous activity (such as when repetitively extending the human knee), ] generating 24 W of mechanical energy, and since muscle energy conversion is only 22-

26% efficient,[] 76 W of heat energy. Resting skeletal muscle has a basal metabolic rate (resting energy consumption) of 0.63 W/kg[] making a 160 fold difference between the energy consumption of inactive and active muscles. For short muscular exertion, energy expenditure can be far greater: an adult human male when jumping up from a squat mechanically generates 314 W/kg, and such rapid movement can generate twice this power in nonhuman animals such as bonobos, and in some small lizards. This energy expenditure is very large compared to the resting metabolism basal metabolic rate of the adult human body. This varies somewhat with size, gender and age but is typically between 45 W and 85 W.[7] [8] Total energy expenditure (TEE) due to muscular expended energy is very much higher and depends upon the average level of physical work and exercise done during a day.[9] Thus exercise, particularly if sustained for very long periods, dominates the energy metabolism of the body. Metabolic changes Rapid Energy Sources Energy needed to perform short lasting, high intensity bursts of activity is derived from anaerobic sources within the cytosol of muscle cells, as opposed to aerobic respiration which utilizes oxygen, is sustainable, and occurs in the mitochondria. The quick energy sources consist of the phosphocreatine (PCr) system, fast glycolysis, and adenylate kinase. All of these systems re-synthesize adenosine triphosphate (ATP), which is the universal energy source in all cells. The most rapid source, but the most readily depleted of the above sources is the PCr system which utilizes the enzyme creatine kinase. This enzyme catalyzes a reaction that combines phosphocreatine and adenosine diphosphate (ADP) into ATP and creatine. This resource is short lasting because oxygen is required for the resynthesis of phosphocreatine via mitochondrial creatine kinase. Therefore, under anaerobic conditions, this substrate is finite and only lasts between approximately 10 to 30 seconds of high intensity work. Fast glycolysis, however, can function for approximately 2 minutes prior to fatigue, and predominately uses intracellular glycogen as a substrate. Glycogen is broken down rapidly via glycogen phosphorylase into individual glucose units during intense exercise. Glucose is then oxidized to pyruvate and under anaerobic condition is reduced to lactic acid. This reaction oxidizes NADH to NAD, thereby releasing a hydrogen ion, promoting acidosis. For this reason, fast glycolysis can not be

sustained for long periods of time. Lastly, adenylate kinase catalyzes a reaction by which 2 ADP are combined to form ATP and adenosine monophosphate. This reaction takes place during low energy situations such as extreme exercise or conditions of hypoxia, but is not a significant source of energy. The creation of AMP resulting from this reaction stimulates AMP activated protein kinase (AMP kinase) which is the energy sensor of the cell. After sensing low energy conditions, AMP kinase stimulates various other intracellular enzymes geared towards increasing energy supply and decreasing all anabolic, or energy requiring, cell functions. Plasma glucose Plasma glucose is maintained by an equal rate of glucose appearance (entry into the blood) and glucose disposal (removal from the blood). In the healthy individual, rate of appearance and disposal are essentially equal during exercise of moderate intensity and duration; however, prolonged exercise or sufficiently intense exercise can result in an imbalance leaning towards a higher rate of disposal than appearance, at which point glucose levels fall along with the onset of fatigue. Rate of glucose appearance is dictated by the amount of glucose being absorbed at the gut as well as hepatic glucose output. Although glucose absorption from the gut is not typically a source of glucose appearance during exercise, the liver is capable of catabalizing stored glycogen (glycogenolysis) as well as synthesizing new glucose from specific reduced carbon molecules (glycerol, pyruvate, and lactate) in a process called gluconeogenesis. The ability of the liver to release glucose into the blood from glycogenolysis is unique, since skeletal muscle, the other major glycogen reservoir, is incapable of doing so. Unlike skeletal muscle, hepatocytes contain the enzyme glycogen phosphatase, which removes a phosphate group from glucose-6-P to release free glucose. In order for glucose to exit a cell membrane, the removal of this phosphate group is essential. Although gluconeogenesis is an important component of hepatic glucose output, it alone can not sustain exercise. For this reason, when glycogen stores are depleted during exercise, glucose levels fall and fatigue sets in. Glucose disposal, the other side of the equation, is controlled by uptake of glucose at the working skeletal muscles. During exercise, despite decreased insulin concentrations, muscle increases GLUT4 translocation and therefore glucose uptake. The mechanism for increased GLUT4 translocation is an area of ongoing research; however, the most wellstudied mechanism involves activation of AMP activated protein kinase. Other possible

mechanisms involve signaling via nitric oxide, reactive oxygen species, as well as a physical mechanism caused by the contraction itself. glucose control: As mentioned above, insulin secretion is reduced during exercise, and does not play a major role in euglycemia during exercise. Insulin's counter-regulatory hormones, however, appear in increasing concentrations during exercise. Principle among these are glucagon, epinephrine, and growth hormone. All of these hormones stimulate hepatic glucose output, among other functions. For instance, both epinephrine and growth hormone also stimulate adipocyte lipase, which increases non-esterified fatty acid (NEFA) release. By oxidizing fatty acids, this spares glucose utilization and helps to maintain euglycemia during exercise. Exercise for diabetes: Exercise is a particularly potent tool for glucose control in those who have diabetes mellitus. In a situation of elevated plasma glucose, or hyperglycemia, moderate exercise can induce greater glucose disposal than appearance, thereby decreasing total plasma glucose concentrations. As stated above, the mechanism for this glucose disposal is independent of insulin, which makes it particularly well-suited for people with diabetes. In addition, there appears to be an increase in sensitivity to insulin for approximately 12-24 hours post-exercise. This is particularly useful for those who have type II diabetes and are producing sufficient insulin but demonstrate peripheral resistance to insulin signaling. However, during extreme hyperglycemic episodes, people with diabetes should avoid exercise due to potential complications associated with ketoacidosis. Exercise could exacerbate ketoacidosis by increasing ketone synthesis in response to increased circulating NEFA's. Type II diabetes is also intricately linked to obesity, and there may be a connection between type II diabetes and how fat is stored within pancreatic, muscle, and liver cells. Likely due to this connection, weight loss from both exercise and diet tends to increase insulin sensitivity in the majority of people. In some people, this effect can be particularly potent and can result in normal glucose control. Although nobody is technically cured of diabetes, individuals can live normal lives without the fear of diabetic complications; however, regain of weight would assuredly result in diabetes signs and symptoms.

Oxygen Oxygen consumption (VO2) during exercise is best described by the Fick Equation: VO2=Q x (a-vO2diff), which states that the amount of oxygen consumed is equal to cardiac output (Q) multiplied by the difference between arterial and venous oxygen concentrations. More simply put, oxygen consumption is dictated by the quantity of blood distributed by the heart as well as the working muscle's ability to take up the oxygen within that blood; however, this is a bit of an oversimplification. Although cardiac output is thought to be the limiting factor of this relationship in healthy individuals, the ability of the lung to oxygenate the blood must also be considered. Various pathologies and anomalies cause conditions such as diffusion limitation, ventilation/perfusion mismatch, and pulmonary shunts that can limit oxygenation of the blood and therefore oxygen distribution. In addition, the oxygen carrying capacity of the blood is also an important determinant of the equation. Oxygen carrying capacity is often the target of ergogenic aids used in endurance sports to increase hematocrit, such as through blood doping or the use of erythropoietin (EPO). Furthermore, peripheral oxygen uptake is reliant on a rerouting of blood flow from relatively inactive viscera to the working skeletal muscles, and within the skeletal muscle, capillary to muscle fiber ratio influences oxygen extraction. Dehydration Intense prolonged exercise produces metabolic waste heat, and this is removed by sweatbased thermoregulation. A male marathon runner loses each hour around 0.83 L in cool weather and 1.2 L in warm (losses in females are about 68 to 73% lower). People doing heavy exercise may lose two and half times as much fluid in sweat as urine. This can have profound physiological effects. Cycling for 2 hours in the heat (35 C) with minimal fluid intake causes body mass decline by 3 to 5%, blood volume likewise by 3 to 6%, body temperature to rise constantly, and in comparison with proper fluid intake, higher heart rates, lower stroke volumes and cardiac outputs, reduced skin blood flow, and higher systemic vascular resistance. These effects are largely eliminated by replacing 50 to 80% of the fluid lost in sweat.

Other

Plasma catecholamine concentrations increase 10 fold in whole body exercise. Ammonia is produced by exercised skeletal muscles from ADP (the precursor of ATP) by purine nucleotide deamination and amino acid catabolism of myofibrils. interleukin-6 (IL-6) increases in blood circulation due to its release from working skeletal muscles.[15] This release is reduced if glucose is taken, suggesting it links to energy related stresses.[16] Sodium absorption is affected by the release of interleukin-6 as this can cause the secretion of arginine vasopressin which, in turn, can led to exercise-associated hyponatremia (dangerously low sodium levels). This loss of sodium in blood plasma can result in encephalopathy (caused by swelling of the brain). This can be prevented by awareness of the risk of drinking excessive amounts of fluids during prolonged exercise.[17][18]

Brain At rest, the human brain receives 15% of total cardiac output, and uses 20% of the body's energy consumption. The brain is normally dependent for its high energy expenditure upon aerobic metabolism. The brain as a result is highly sensitive to failure of its oxygen supply with loss of consciousness occurring within six to seven seconds, with its EEG going flat in 23 seconds.[] If it affected the oxygen and glucose supply to the brain, the metabolic demands of exercise could therefore quickly disrupt its functioning. Protecting the brain from even minor disruption is important since exercise depends upon motor control, and particularly, because humans are bipeds, the motor control needed for keeping balance. Indeed, for this reason, brain energy consumption is increased during intense physical exercise due to the demands in the motor cognition needed to control the body.[22] Cerebral oxygen Cerebral autoregulation usually ensures the brain has priority to cardiac output, though this is impaired slightly by exhaustive exercise. During submaximal exercise, cardiac output increases and cerebral blood flow increases beyond the brains oxygen

needs.However, this is not the case for continuous maximal exertion: Maximal exercise is, despite the increase in capillary oxygenation [in the brain], associated with a reduced mitochondrial O2 content during whole body exercise The autoregulation of the brains blood supply is impaired particularly in warm environments Glucose In adults, exercise depletes the plasma glucose available to the brain: short intense exercise (35 min ergometer cycling) can reduce brain glucose uptake by 32%.At rest, energy for the adult brain is normally provided by glucose but the brain has a compensatory capacity to replace some of this with lactate. Research suggests that this can be raised, when a person rests in a brain scanner, to about 17%, with a higher percentage of 25% occurring during hypoglycemia. In intense exercise, lactate has been estimated to provide a third of the brains energy needs. There is evidence that the brain might, however, in spite of these alternative sources of energy, still suffer an energy crisis since IL-6 (a sign of metabolic stress) is released during exercise from the brain. Hyperthermia Humans use sweat thermoregulation for body heat clearance, particularly to remove the heat produced during exercise. Mild dehydration as a consequence of exercise and heat is reported to impair cognition. These impairments can start after body mass lost that is greater than 1%.Cognitive impairment, particularly due to heat and exercise is likely to be due to loss of integrity to the blood brain barrier. Hyperthermia also can lower cerebral blood flow, and raise brain temperature. Ammonia Exercised skeletal muscles produces ammonia. This ammonia is taken up by the brain in proportion to its arterial concentration. Since perceived effort links to such ammonia accumulation, this could be a factor in the sensation of fatigue.

Combinational exacerbation These metabolic consequences of exercise can exacerbate each others negative neurological effects. For example, the uptake of ammonia by the brain is greater with glucose depletion (CSF ammonia levels: rest, below 2 mol min1 detection level; following 3 hours exercise with glucose supplementation, 5.3 mol min1, without glucose supplementation, 16.1 mol min1 The effects of dehydration are greater and happen at a lower threshold in hot environments. Fatigue Intense activity Researchers once attributed fatigue to a build-up of lactic acid in muscles. However, this is no longer believed. Indeed, lactate may stop muscle fatigue by keeping muscles fully responding to nerve signals. Instead, providing available oxygen and energy supply and disturbances of muscle ion homeostasis are the main factor determining exercise performance, at least during brief very intense exercise. Each muscle contraction involves an action potential that activates voltage sensors, and so releases Ca2+ ions from the muscle fibres sarcoplasmic reticulum. The action potentials causing this require also ion changes: Na influxes during the depolarization phase and K effluxes for the repolarization phase. Cl- ions also diffuse into the sarcoplasm to aid the repolarization phase. During intense muscle contraction the ion pumps that maintain homeostasis of these ions are inactivated and this (with other ion related disruption) causes ionic disturbances. This causes cellular membrane depolarization, inexcitability, and so muscle weakness. Ca2+ leakage from type 1 ryanodine receptor) channels has also been identified with fatigue.

Endurance failure After intense prolonged exercise, there can be a collapse in body homeostasis. Some famous examples include: Other factors The exercise fatigue has also been suggested to be effected by:

brain hyperthermia[53] glycogen depletion in brain cells[30][54] reactive oxygen species impairing skeletal muscle function[55] reduced level of glutamate secondary to uptake of ammonia in the brain[38] Fatigue in diaphragm and abdominal respiratory muscles limiting breathing[56] Impaired oxygen supply to muscles[57] Ammonia effects upon the brain[38] Serotonin pathways in the brain[58]

Cardiac biomarkers Prolonged exercise such as marathons can increase cardiac biomarkers such as troponin, B-type natriuretic peptide (BNP), and ischemia-modified albumin. This can be misinterpreted by medical personnel as signs of myocardial ischemia, or cardiac dysfunction. In these clinical conditions, such cardiac biomarkers are produced by irreversible injury of muscles. In contrast, the processes that create them after strenuous exertion in endurance sports are reversible, with their levels returning to normal within 24hours (further research, however, is still needed). Human evolution Humans are specifically adapted to engage in prolonged strenuous muscular activity (such as efficient long distance bipedal running).] This capacity for endurance running evolved to allow the running down of game animals by persistent slow but constant chase over many hours. Central to the success of this is the ability of the human body, unlike that of the animals they hunt, to effectively remove muscle heat waste. In most animals, this is

stored by allowing a temporary increase in body temperature. This allows them to escape from animals that quickly speed after them for a short duration (the way nearly all predators catch their prey). Humans unlike other animals that catch prey remove heat with a specialized thermoregulation based on sweat evaporation. One gram of sweat can remove 2,598 J of heat energy. Another mechanism is increased skin blood flow during exercise that allows for greater convective heat loss that is aided by the upright posture. This skin based cooling has involved humans in acquiring an increased number of sweat glands, combined with a lack of body fur that would otherwise stop air circulation and efficient evaporation. Because humans can remove exercise heat, they can avoid the fatigue from heat exhaustion that affects animals chased in persistence hunting, and so eventually catch them when they fatigue from heat exhaustion due to being forced to move constantly. Exercise-induced muscle pain Physical exercise may cause pain both as an immediate pain effect that may result from stimulation of free nerve endings by low pH, as well as a delayed onset muscle soreness. The delayed soreness is fundamentally the result of ruptures within the muscle, although apparently not involving the rupture of whole muscle fibers.

Circadian rhythm and diabetes The circadian rhythm is a cycle, 24 hours approximately, that is a bioglogical process in plants and animals. For us, the circadian clock is found in the brain. There are a cluster of cells found in the suprachiasmatic nucleus in a part of the brain. These cells are found in the hypothalamus section of the brain which controls sleeping, eating, heart rate, blood pressure, the body temperature, and levels of hormones, as well as our immune system. Insulin levels and the counterregulatory hormones, that work against the actions of insulin are in turn, influenced by the circadian rhythm. These hormones which include glucagon, epinephrine, (adrenaline), cortisol, and growth hormones raise blood sugar levels when they need to be raised. During the middle of the nighttime hours, there is a surge in the amount of growth hormone the body will release, that is followed by a surge in cortisol. This increases blood glucose production by the liver. In a nondiabetic person, these processes are offset by the increase in insulin secretion by the pancreas. Blood glucose then, remains stable. In type 1 diabetics who don't make insulin at all, and in type 2 diabetics where the liver may not respond to insulin very well to stop glucose production, changes in blood sugar levels during rest can have a large effect on morning glucose levels. The dawn phenomenon occurs, and this is where sugar levels rise between 4 AM and 8AM. Disordered sleeping in diabetics cause blood glucose to go out of control. If you are having type of sleep problems at all, it is best to see your doctor and work out the problems. Some conditions can interfere with a person's waking and sleeping cycles. Jet lag syndrome is the more common of these disorders, which means lack of daytime alertness and sleepiness when travelers cross time zones. There is also shift-work sleep disorder in people that work night shifts or shifts that rotate.

Etanercept in type 1

--In this small pilot study, treatment of pediatric patients newly diagnosed with type 1 diabetes with etanercept resulted in lower A1C and increased endogenous insulin production, suggesting preservation of [beta]-cell function. A larger study is needed to further explore safety and efficacy. Type I diabetes is a T-cell-mediated autoimmune disease characterized by selective destruction of insulin-producing [beta]-cells within the pancreatic islet. This chronic disease affects 1 in 400-600 youth and poses a significant medical and psychological burden on patients and their families. In most patients, diagnosis and treatment are followed by a "partial remission period" (honeymoon period) during which transient partial recovery of endogenous insulin production occurs. Eventually, there is progressive, irreversible [beta]-cell demise, leaving the patient totally dependent on exogenous insulin administered via multiple daily injections or continuous subcutaneous insulin infusion. Thus, the partial remission period represents a window of opportunity to halt the progression of the disease. Several clinical studies are currently conducted to test agents that may alter the natural history of type 1 diabetes. Tumor necrosis factor-or (TNF-[alpha]) and other cytokines play a role in the autoimmune process leading to pancreatic destruction). Evidence suggesting that TNF-[alpha] plays an active role in the pathogenesis of type 1 diabetes is derived from in vitro studies and animal models. In the nonobese diabetic mouse, TNF-[alpha] mRNA is produced by [CD4.sup.+] T-cells within inflamed islets during the development of diabetes. In vitro models show that TNF-[alpha] potentiates the direct functional inactivation and destruction of [beta]-cells by other cytokines such as interleukin-1[beta] and interferon[lgamma]. Transgenic mice with increased [beta]-cell expression of TNF-[alpha] have significant lymphocytic insulinitis, which is abrogated in TNF receptor-null mice. These findings support the role of TNF-[alpha] in signaling lymphocytic invasion, promoting local inflammation within pancreatic islets and contributing to cytokine-induced [beta]cell destruction. Etanercept is a recombinant soluble TNF-[alpha] receptor fusion protein that binds to TNF-[alpha]. It acts by clearing TNF-[alpha] from the circulation, thereby blocking the biological activity of this inflammatory cytokine. Although etanercept is used in the treatment of many autoimmune diseases including ankylosing

HDL 1, HDL 2, HDL 3 physiology and clinical relevance The effectiveness of lifestyle intervention strategies to improve blood lipids in women may be dependent on preexisting cholesterol concentrations. We characterized the effects of cholesterol status on blood lipid, lipoprotein lipid, and lipid regulatory enzyme responses to a single session of aerobic exercise in physically active, postmenopausal women. In this study, blood samples were obtained from 12 women with high cholesterol (HC; 200 mg/dl) and 13 women with normal cholesterol (NC; <200 mg/dl), 24 h before (Pre), immediately after (IPE), and 24 and 48 h after an exercise session (treadmill walking at 70% peak oxygen consumption, 400 kcal). We found that repeated-measures analysis revealed the following: 1) preexercise cholesterol differences did not influence the lipid or lipoprotein lipid responses to exercise; 2) for both groups, triglyceride was significantly reduced (8.5%) after exercise; 3) the concentration profile over time for high-density lipoprotein cholesterol was significant for both groups, first falling at IPE then rising back to Pre levels by 24 h after exercise; 4) the lecithin-cholesterol acyltransferase activity (LCATA) exercise response was group dependent, increasing modestly in the NC group at 24 and 48 h; 5) lipoprotein lipase activity (LPLA) increased at IPE (by 17%) in the HC group only and then fell at 24 and 48 h (by 21%) compared with Pre; and 6) cholesterol ester transfer protein activity was unchanged by exercise. From these findings, we conclude that in postmenopausal women, a single session of endurance exercise elicited a short-term, favorable decrease in triglycerides independent of initial blood cholesterol concentrations. However, LCATA and LPLA postexercise changes were influenced by preexercise cholesterol status. cholesterol ester transfer protein; high-density lipoprotein cholesterol; lecithin-cholesterol acyltransferase; lipase; triglycerides