Vivre avec une maladie chronique a des implications multiples sur une personne atteinte et ses proches. Ces implications sont majeures en cas de diabète insulino-traité comme le diabète de type 1 (DT1) et le diabète de type 2 avancé (DT2). Bien qu’un contrôle glycémique optimal soit indispensable pour prévenir et ralentir les complications micro-vasculaires chroniques, l’atteinte d’un tel objectif avec l’intensification de l’insulinothérapie se heurte à un risque important d’hypoglycémie. Les progrès technologiques : pompes à insuline, systèmes de surveillance de la glycémie interstitielle en continu (SSGC) et couplage de ces dispositifs avec un algorithme dans les systèmes de pancréas artificiel (PA) mono-hormonal avec insuline seule, ou bi-hormonal avec ajout de glucagon permettent de plus en plus de rendre le traitement plus simple (automatisation), plus efficace (moins d’hyperglycémies) et plus sûr (moins d’hypoglycémies). Cependant ces technologies apportent de nouveaux défis que nous avons explorés. À travers les projets de cette thèse : 1) Nous avons exploré la gestion de diabète avec le recours à la technologie de point de vue des utilisateurs actuels pour les pompes et les utilisateurs potentiels futurs pour les systèmes PA. Nos questionnaires ont mis l’accent sur l’enthousiasme des patients pour l’adoption de ces technologies et la perception positive de leur rôle dans le contrôle glycémique et la réduction de la glycémie; toutefois, plusieurs problèmes techniques ont été rapportés avec les pompes (nécessitant une amélioration de la technologie, un meilleur recensement ou une meilleure évaluation des effets indésirables) et une préférence d’être capable au besoin d’ignorer les recommandations du PA. 2) Nous avons testé pour la première fois le système PA développé à Montréal pour les patients vivant avec un DT2 insulino-traité et démontré son applicabilité pour cette population avec amélioration du contrôle glycémique en comparaison aux traitements conventionnels ouvrant la porte aux études plus vastes en vie réelle. 3) Trois stratégies en PA ont été aussi testé pour la première fois pour améliorer le contrôle glycémique pendant l’exercice pratiqué dans la période postprandiale (une situation d’hyperinsulinémie et variations rapides de la glycémie). Nous avons comparé : a) un contrôle glycémique exclusivement basé sur les données de la SSCG, b) une annonce avant le repas visant une glycémie plus haute et c) une annonce combinant la réduction du bolus du repas avec la cible glycémique plus haute. L’option qui consiste à annoncer l’exercice avant le repas à l’algorithme en combinant une cible glycémique plus haute avec une réduction de tiers du bolus prandial constituait l’approche la plus pratique pour éviter les hypoglycémies pendant un exercice d’intensité modérée pour 1h débuté 90 minutes post-repas. 4) Le système PA bi-hormonal est avantageux pour la réduction de l’hypoglycémie mais la formulation actuelle du glucagon présente la problématique de la stabilité avec une recommandation d’utilisation immédiate. Nous avons démontré sa stabilité pour 24 heures en contexte de PA ce qui permet de mener des études pour explorer le bénéfice du PA bi-hormonal. 5) Nous avons également exploré la question de sécurité de cette nouvelle utilisation du glucagon en mini-bolus et de façon chronique et nous avons proposé une liste de paramètres à surveiller dans les études prolongées compte tenu l’effet pléiotropique du glucagon sur la majorité des organes. 6) Nous avons démontré que le traitement des épisodes d’hypoglycémie non-sévères résiduels qui surviennent lors du traitement par PA restent difficiles à traiter avec seulement 17% des épisodes corrigés 15 min après l’ingestion des 15 grammes de glucides tel que recommandé. 7) Nous avons finalement exploré si le traitement des épisodes d’hypoglycémies non sévères pourrait être modulé en fonction du seuil glycémique atteint et de la quantité initiale des glucides consommés. Nous avons alors testé l’ingestion de 16 g de glucides (selon les recommandations) contre 32 g de glucides (plus représentatif des pratiques des patients) à deux seuils d’hypoglycémie (3,0 à 3,5 mmol/L et  3,0 mmol/L). Nos résultats confirment la difficulté de traitement de ces épisodes (lenteur de la correction et besoin fréquent de second traitement) quel que soit le seuil de traitement et/ou la dose initiale de glucides consommés. Ainsi, nous avons démontré les avantages et les limites de la technologie pour le diabète insulino-traité, y compris les systèmes PA, en allant de la préférence des patients pour la technologie, à l’utilité du PA dans le DT2 avancé, à la nécessité de annoncer l’exercice à l’algorithme avant le repas pour l'exercice postprandial, à la stabilité de la formulation disponible du glucagon et les paramètres cliniques à surveiller dans les essais à long terme du PA. Cette thèse a finalement montré le manque d’efficacité du traitement de l'hypoglycémie non-sévère par consommation de glucides oraux même dans le cadre du PA. / Living with diabetes, a chronic disease, has multiple implications for a person and their loved ones. These implications are major in the case of insulin-treated diabetes such as type 1 diabetes (T1D) and advanced type 2 diabetes (T2D). Although optimal glycemic control is essential to prevent and slow chronic microvascular complications, achieving such a goal through intensive insulin therapy has the drawback of increased risks of hypoglycemia. Technological advances: insulin pumps, continuous glucose monitoring systems (CGMS) and coupling of these devices with an algorithm in artificial pancreas (AP) systems, mono-hormonal (insulin) or bi-hormonal (with glucagon), can make diabetes treatment simpler (automation), more effective (less hyperglycemia) and safer (less hypoglycemia). However, these technologies bring up new challenges that we have explored through the projects of this thesis: 1) We have examined the use of technology in diabetes management from the perspective of current users for insulin pumps and potential future users for AP systems. Our online surveys highlighted the enthusiasm of patients for technology adoption and the positive perception they hold about its role in glycemic management; nevertheless, several technical problems have been reported with insulin pumps (hence the need to improve the identification of adverse events) and a preference to ignore AP recommendations if necessary. 2) We have tested for the first time the mono-hormonal AP system developed in Montreal for patients living with insulin-treated T2D and demonstrated its applicability for this population with improved glucose management in comparison to conventional treatments opening the door to larger studies in real life settings. 3) Three strategies in AP were also tested for the first time to improve glucose management during exercise practiced in the postprandial period (a situation of hyperinsulinemia and rapid changes in blood sugar). We compared: a) glycemic control based exclusively on CGMS data, b) a pre-meal announcement of exercise to the algorithm that increases target glucose levels, and c) a combination of exercise announcement with meal bolus reduction. The last strategy offered the most practical approach to avoid hypoglycemia during moderate-intensity aerobic exercise of one hour duration that is practiced 90 minutes post-meal. 4) The bi-hormonal AP system is advantageous for the reduction of hypoglycemia but the current commercial glucagon formulation (lyophilized powder) is not stable in liquid form and is only approved for immediate use post reconstitution in an acid solution. We have however demonstrated its stability for 24 hours in the context of AP use (mini-boluses through pumps), which makes it possible to conduct studies to explore the benefit of bi-hormonal AP until new stable formulations are approved. 5) We have also explored the question of the safety of this new use of glucagon in mini-bolus and in chronic way. We have proposed a list of parameters to be monitored in prolonged bi-hormonal AP studies given the pleiotropic effect of glucagon on the majority of organs. 6) We have demonstrated that during AP control (mono-or bi-hormonal), residual non-severe hypoglycaemic episodes remain difficult to treat with a resolution of only 17% of these episodes 15 min after ingestion of the recommended 15 grams of carbohydrates (CHO). 7) We have finally investigated whether non-severe hypoglycaemia treatment with oral CHO could be modulated according to the hypoglycemia threshold reached and the initial amount of CHO consumed. We have thus tested 16 g CHO (recommended by guidelines) versus 32 g CHO (closer to patients’ practices) at two hypoglycemia thresholds (3.0- 3.5 mmol/L and  3.0 mmol/L). Our results confirm the difficulty of treating these episodes (slow correction and frequent need for a second treatment) regardless of the treatment threshold and/or initial CHO dose consumed. Therefore, we have demonstrated the advantages and limits of technology in insulin-treated diabetes including AP systems, by revealing the preferences of patients for technology use, the usefulness of AP in insulin treated T2D, the need of pre-meal announcement to the algorithm during postprandial exercise, the stability of commercial glucagon formulation and the clinical parameters to be monitored in long-term trials. This thesis finally showed the compromised efficacy of non-severe hypoglycaemia treatment with recommended oral CHO even in the context of AP.

Vasopressin är ett viktigt hormon som har många fysiologiska funktioner, däribland upprätthållandet av vätskebalansen i kroppen. Mätning av detta hormon är dock komplicerat och därför används ”skuggfragmentet” copeptin, som härstammar från samma prekursor. Genom användandet av metoden B·R·A·H·M·S KRYPTOR compact PLUS mäts copeptin. Studiens syfte är att beräkna variations-koefficienten och därmed undersöka de uppmätta värdenas reproducerbarhet. Vidare blir syftet att använda EpiHealth-kohortstudien för att validera den redan kända kopplingen mellan copeptin och förhöjt blodsocker genom en multivariant linjär regression. Vi kan i arbetet konstatera att copeptin metoden har en god reproducerbarhet, där majoriteten av de multipelt uppmätta copeptin-värdena har en inter-assay CV <8%. Vid undersökning av EpiHealth-kohorten fann vi att en ökning av copeptin var kross-sektionellt associerad med ett flertal metabola riskmarkörer, däribland fastande plasma-glukos, efter multivariant justering. Att copeptin var signifikant relaterat till denna potenta metabola riskmarkör kan tyda på att det finns ett orsakssamband mellan förhöjt vasopressin och förhöjt blodsocker, något som även tidigare studier har pekat på. Detta i sin tur visar att vasopressin kan spela en roll i utvecklandet av typ 2-diabetes. Om ett orsaks-samband föreligger undersöks nu i en stor randomiserad klinisk studie där vasopressin-nivåerna hos hälften av deltagarna sänks med hjälp av ökat vatten-intag (H2O-metab-studien). Det finns förhoppningar om att användandet av copeptin skall kunna användas i klinisk verksamhet för att riskbedöma individer avseende kardiometabola sjukdomar (däribland typ 2-diabetes). / Vasopressin is an important hormone that has many physiological functions, including the maintenance of fluid balance in the body. Measurement of this hormone is however complicated and therefore the "shadow fragment" copeptin is used, which is derived from the same precursor. Using the BRAHMS copeptin proAVP KRYPTOR method, copeptin was measured in this study. The purpose of the study is to calculate the coefficient of variation, and thus examine the reproducibility of the measured values ​. Furthermore, the aim will be to use the EpiHealth cohort study was used to validate the link between copeptin and elevated blood sugar through a multivariate linear regression. The majority of the multiple measurements of copeptin values had an inter-assay CV <8%, which indicates that the method has a good reproducibility. Examination of the EpiHealth cohort revealed that elevated copeptin was cross-sectionally associated with a number of metabolic risk markers, including fasting plasma glucose, after multivariate adjustment, a finding that is in line with previous findings from epidemiological studies. The fact that copeptin was significantly related to this potent metabolic risk marker may indicate a causal role of the vasopressin system in elevated blood glucose and may play a role in the development of type 2 diabetes metillus. Previous experimental and genetical studies have indicated a causal association between elevated vasopressin and diabetes development. Currently, a randomized clinical trial is ongoing (the H2O-metab-study) in order to investigate a possible causal association between elevated vasopressin and glucose. In the study, increased water intake is used to lower plasma vasopressin (measured as copeptin), and the glucose-lowering potential of this water treatment is tested. There are hopes that copeptin can in the future be used in clinical practice for risk assessment with respect to cardiometabolic diseases (including type 2 diabetes).

Background: African-Americans are a vulnerable population group with disproportionately elevated rates of type 2 Diabetes Mellitus (DM). Resistant starch is a promising food ingredient that has the potential to reduce the risk factors involved in the development of type 2 DM. To date, there is a dearth of published research studies on the effect of resistant starch on African-Americans who are at increased risk for type 2 DM. Objective: The major objective of this study was to determine if daily consumption of approximately twelve grams of high-maize™ 260 resistant starch (RS) added to bread improved glucose homeostasis by monitoring changes in fasting plasma glucose, fructosamine, hemoglobin A1c, insulin, glucagon-like peptide-1, C-reactive protein, homeostasis model assessment insulin resistant (HOMA- IR) and beta-cell function (HOMA-Beta), serum acetate, propionate, and butyrate levels. Design: A fourteen-week, randomized, double-blind, within-subject crossover design feeding study was carried out in African-American males (n=8) and females (n=7) at increased risk for type 2 DM who resided in Southwest Virginia. All participants consumed bread containing added RS or control bread (no added RS) for six-weeks. RS and control bread feedings were separated by a two-week washout period. Results: Fasting Plasma Glucose (FPG) levels were significantly lower (P = 0.0179) after six-week control bread feedings compared to baseline. FPG levels were also significantly lower (P < 0.0001) after two-week washout period than at baseline. FPG levels were significantly higher (P < 0.0001) after six-week resistant starch bread feeding than at washout. FPG levels due to consumption of resistant starch versus control bread approached significance (P = 0.0574). Fructosamine levels were significantly lower (P = 0.0054) after control bread and resistant starch bread (P < 0.0012) consumption compared to baseline. No significant differences were found in fructosamine levels due to resistant bread intake versus control (P = 0.9692). Mean baseline HbA1c levels were 6.9% (n=15). This value was slightly lowered to 6.79% (n=14) at the end of the fourteen-week study, although statistical significance was not found. Mean ± standard errors for HbA1c values were 6.9% ± 0.18% and 6.9% ± 0.14% at baseline for the sequence groups, resistant starch first (n=7) and control treatment first (n=8) groups, respectively. Mean± standard error HbA1c values were 6.7%± 0.27% and 6.9% ± 0.27% at the conclusion of fourteen-week study for sequence groups, resistant starch first group (n=7) and control treatment first group, respectively. Baseline mean and standard errors C-reactive Protein (CRP) levels for male and female combined results were 0.62 ± 0.16 mg/dL (n=15). Mean CRP levels were 0.53 ± 0.12 mg/dL for resistant starch bread and 0.64 ± 0.21 mg/dL for control bread feeding periods. No significant differences were found for treatment, gender, or sequence effects for C-reactive protein levels during the fourteen-week study (P > 0.05). Mean HOMA-IR levels following six-week resistant starch and control bread consumption decreased to normal values (> 2.5), although no significant differences were found for treatment (P = 0.5923). Conclusions: Eighty-seven grams of Hi- maize™ 260 Resistant Starch added to baked loaves of bread consumed by a free-living African-American population at increased risk for type 2 diabetes did not consistently show significance in all clinical indicators and biochemical markers assessed. On the basis of the evidence in this study we do not have evidence that this amount of resistant starch in this population's diet will prevent the onset of diabetes. However, results are suggestive that higher levels of resistant starch in a more controlled experiment could reduce clinical risk factors for type 2 diabetes. / Ph. D.

La première cause de maigreur chez les femmes dans les pays occidentaux est l’anorexie mentale (AM). La maigreur constitutionnelle (MC) regroupe des femmes d’Indice de masse corporelle identique aux AM mais sans les anomalies psychologiques, biologiques ou hormonales (pas d’aménorrhée) rencontrées dans l’AM. Les troubles du comportement alimentaire (TCA) comprennent l’AM restrictive pure (AM-R), l’AM avec crises boulimiques (AM-BP) et la boulimie nerveuse (BN). Notre travail explore ces troubles à la lumière de la régulation de l’appétit dont le centre organique (noyau arqué) reçoit des afférences de peptides périphériques tels que la leptine, le PYY, le GLP1 , la ghréline et l’obéstatine. Nous montrons un profil orexigène dans l’AM-R, témoignant d’une intégrité du système de régulation de la prise alimentaire et adaptatif, luttant contre la restriction alimentaire. Nous avançons le concept de ghrélino-résistance dans l’AM-R dont le substratum biologique est peut-être l’obéstatine. Nous montrons une ghréline basse chez les AM-BP comme chez les BN permettant un diagnostic différentiel précis et rapide. A l’inverse, nous montrons un profil anorexigène constitutif chez les MC participant au maintien du poids bas, proposant la MC comme un modèle humain de résistance à la prise de poids. Ces hormones peuvent agir comme arbitre organique objectif entre des entités cliniques parfois à tort confondues. Une leptine basse chez une jeune fille maigre signe une AM, une ghréline basse chez une AM signe la présence de crises boulimiques. Ces éléments forts nous poussent à continuer notre travail de précision et de phénotypage de ces entités pour mieux en comprendre la physiopathologie / The commonest group of underweight young women in the developed world is restrictive anorexia nervosa (AN). However, constitutional thinness (CT) is a condition described in the same low weight range as AN. CT women display normal menstruation an do not present with psychological or hormonal features of AN. Eating disorders (EA) displays Anorexia Nervosa with restrictive food behaviour (AN-R), Anorexia Nervosa with binge purge associated (AN-BP) and bulimia Nervosa (BN ). Food intake is controlled by the arcuate nucleus through integration of peripheral hormonal signals such as leptin, ghrelin, peptide YY (PYY) and glucagon like peptide 1 (GLP-1). Our objective was to understand thinness and EA through those hormonal signals. AN-R presents an orexigenic adaptative profile contrasting with the anorexigenic constitutive one in CT, proving the integrity of the appetite regulation system. We propose the ghrelin resistance concept with the putative obestatin. AN-BP presents a very different profile of appetite regulatory peptides when compared with AN-R, with low ghrelin levels. The hormones appear to be valuable biomarkers to distinguish AN and CT in severe underweight patients and to diagnose binge purge in AN. The assessment of ghrelin (and eventually obestatin) could be of particular interest for differential diagnosis between AN-R and AN-BP. The assessment of leptin could also be useful for differential diagnosis between AN and CT

Bypass or resection of the stomach and oesophagus, has long been recognised to result in profound changes in the handling of ingested nutrients. This results in significant morbidity after radical surgery for oesophago-gastric cancer, in particular post-prandial hypoglycaemia, altered appetite, early satiety and noxious post-prandial symptoms. By profiling and challenging the gut hormone axis in healthy volunteers and patients who had undergone total or subtotal gastrectomy, or oesophagectomy, this thesis explores the possible causative mechanisms for the challenges faced by this patient population. In the surgical groups, an oral glucose tolerance test (OGTT) resulted in enhanced secretion of satiety and incretin gut hormones (GLP-1, GIP, PYY) and insulin, followed by hypoglycaemia in a cohort of patients. Continuous glucose monitoring of gastrectomy participants over two weeks of normal lifestyle identified an increased incidence of day and night time hypoglycaemia. RNAseq and mass spectrometry based peptidomics of human and murine enteroendocrine cells in the pre- and post-operative populations revealed no significant change in the underlying cellular pathways for nutrient sensing and gut hormone secretion, indicating that the altered hormone secretion is primarily driven by accelerated nutrient transit, rather than adaptive changes in the gut. Finally, specific blockade of the GLP-1 receptor in post-gastrectomy patients using Exendin 9-39 normalised insulin secretion and prevented reactive hypoglycaemia after an OGTT. In conclusion, profound changes in gut hormone secretion as a result of enhanced nutrient transit after foregut surgery likely underlie the early and late post-prandial symptoms seen in this group, and therapies specifically targeting the gut hormone axis, and GLP-1 in particular, could be the first targeted treatments for post-gastrectomy syndromes.

Dans la perspective de trouver de nouvelles thérapies dans le traitement du diabète de type II, non insulino-dépendant, le Glucagon-Like Peptide-1 (GLP-1) constitue un excellent candidat. Si son mécanisme d'action est bien connu, il reste toutefois à résoudre de grands problèmes fondamentaux, avant de le substituer aux molécules utilisées pour une telle pathologie. En particulier, la compréhension de la liaison du GLP-1 à son récepteur demeure un point crucial. Une meilleure connaissance des structures du ligand et du récepteur sont nécessaires. De plus, ce peptide ne peut être utilisé dans sa forme native, dû à une inactivation rapide par les protéases.<br /><br />Pour essayer d'augmenter la stabilité du peptide, et en tenant compte des positions clés définies dans la littérature, plusieurs analogues du GLP-1-(7-37) sont conçus, et synthétisés. Ils possèdent principalement des pharmacomodulations au niveau de la partie N-terminale. Des substitutions sont également réalisées dans la partie centrale du peptide, permettant de vérifier certaines hypothèses concernant sa conformation. Considérant les résultats de liaison et d'efficacité in vitro, certains analogues sont sélectionnés pour des études in vivo d'activité et de stabilité métabolique. Le [a8,desR36]GLP-1-(7-37) se distingue des autres tant par sa grande stabilité que son efficacité, supérieure à la molécule native. Ce composé est en phase de développement pré-clinique.<br /><br />Parallèlement, la conformation de chaque analogue est étudiée (CD, IR) et ainsi, confrontée aux résultats in vitro, il est possible de proposer une conformation bioactive.<br /><br />Enfin, pour appréhender plus en avant les mécanismes de liaison du peptide avec son récepteur spécifique, la modélisation moléculaire du récepteur fait ressortir quelques hypothèses quant à la localisation probable de l'interaction hormone-récepteur. Des analyses biophysiques et la synthèse de fragments du récepteur, ont permis d'étayer de telles hypothèses.

Type 2 diabetes is still rapidly on the rise today, affecting 10.5% of individuals in the United States between the ages 45 to 64 and 18.4% of those between the ages of 65 to 74. In the past two decades, type 2 diabetes has doubled in all age groups. Many adults with type 2 diabetes experience difficulty managing their blood sugars, which can result in a range of further complications. One of the newest treatment options on the market today is a glucagon-like peptide-1 (GLP-1) receptor agonist, Bydureon. Similar to Byetta, Bydureon has a main ingredient of exenatide. It offers once a week dosing as opposed to twice-a-day, which may be more appealing to patients. The purpose of this study was to examine the efficacy of a newly FDA released medication, Bydureon, once weekly dosage in adults with type 2 diabetes. A descriptive, comparative, retrospective study of 35 patients evaluated efficacy by examining Hgb A1C and body mass index in adults with type 2 diabetes at baseline and 3 months after Bydureon was prescribed. Data were collected by a chart review of records in a primary care practice. Results demonstrated a statistically significant difference between baseline to 3 month means in both Hgb A1C (t (34)= -3.05, p=.0044) and BMI (t (34) = -2.86, p = .0072) for patients using Bydureon. Health care providers need to individualize the patients’ plans of care to address multifactorial areas of their diabetes care and provide them with an opportunity to successfully meet their goals. Practitioners must be knowledgeable about the treatment options available, including the newer GLP-1 receptor agonist, Bydureon and its efficacy for adults with type 2 diabetes.

Indiana University-Purdue University Indianapolis (IUPUI) / Recent advancements in the management of systemic glucose regulation in obesity/T2DM include drug therapies designed to utilize components of the incretin system specifically related to glucagon-like peptide 1 (GLP-1). More recently, GLP-1 has been investigated for potential cardioprotective effects. Several investigations have revealed that acute/sub-acute intravenous administration of GLP-1 significantly reduces myocardial infarct size following ischemia/reperfusion injury and improves cardiac contractile function in the settings of coronary artery disease, myocardial ischemia/reperfusion injury, and heart failure. Despite an abundance of data indicating that intravenous infusion of GLP-1 is cardioprotective, information has been lacking on the cardiac effects of iv GLP-1 in the MetS or T2DM population. Some important questions this study aimed to address are 1) what are the direct, dose-dependent cardiac effects of GLP-1 in-vivo 2) are the cardiac effects influenced by cardiac demand (MVO2) and/or ischemia, 3) does GLP-1 effect myocardial blood flow, glucose uptake or total oxidative metabolism in human subjects, and 4) are the cardiac effects of GLP-1 treatment impaired in the settings of obesity/MetS and T2DM. Initial studies conducted in canines demonstrated that GLP-1 had no direct effect on coronary blood flow in-vivo or vasomotor tone in-vitro, but preferentially increased myocardial glucose uptake in ischemic myocardium independent of effects on cardiac contractile function or coronary blood flow. Parallel translational studies conducted in the humans and Ossabaw swine demonstrate that iv GLP-1 significantly increases myocardial glucose uptake at rest and in response to increases in cardiac demand (MVO2) in lean subjects, but not in the settings of obesity/MetS and T2DM. Further investigation in isolated cardiac tissue from lean and obese/MetS swine indicate that this impairment in GLP-1 responsiveness is related to attenuated activation of p38-MAPK, independent of alterations in GLP-1 receptor expression or PKA-dependent signaling. Our results indicate that the affects of GLP-1 to reduce cardiac damage and increase left ventricular performance may be impaired by obesity/MetS and T2DM.