Bakgrund: Diabetes Mellitus typ 2 är en av vår tids största sjukdomar och ett växande folkhälsoproblem. Mer än 75 % av personer med Diabetes Mellitus typ 2 som befinner sig i övergången till insulinbehandling upplever det som en svår utmaning.Syftet: Var att beskriva upplevelser hos personer med Diabetes Mellitus typ 2 vid transition till insulinbehandlingMetod: Litteraturöversikt med kvalitativ ansats, 14 artiklar analyserades.Resultat: Presenteras under tre huvudkategorier och sju underkategorier. Vid övergång till insulinbehandling upplevdes rädsla för smärta och biverkningar. Oro i samband med injektionsgivning och okunskap gällande biverkningar och insulinets påverkan på kroppen samt skuldkänslor gällande misskötsel av sjukdomen beskrevs. Sociala och praktiska förändringar i vardagen så som oro inför egenvård och minskad flexibilitet upplevdes. Förväntad positiv effekt av insulin gällande förbättrad hälsa bidrog till att transitionen underlättades.Slutsats: För att underlätta transition krävdes individanpassad utbildning för både patienten och dennes anhörig om sjukdomens progression, behandling och påverkan på kroppen i ett tidigt skede av sjukdomen. Förhoppningsvis kan resultatet leda till en ökad förståelse hos vårdpersonal för hur personer med Diabetes Mellitus Typ 2 upplever transition till insulinbehandling, för att på så vis ge adekvat stöd till dessa personer.Nyckelord: Diabetes Mellitus typ 2, insulinbehandling, psykologisk insulinresistens,upplevelser. / Background: Diabetes type 2 is now one of the world’s diseases and an increasing public health problem. More than 75% of people with diabetes mellitus type 2 who are in transition to insulin therapy experience the transition to a difficult challenge.Aim: Was to describe how people with diabetes mellitus type 2 experience the transition to insulin therapy.Method: Literature review outgoing from articles that had a qualitative design. 14 articles were analyzed.Results: These presented in three main categories and seven subcategories. During the transition to insulin therapy patients experienced worry for potential pain and side effects. Anxiety about transition to insulin therapy because ignorance of insulin´s effect on the body and guilt about their own inability to manage the disease was described. Social and practical changes in everyday life such anxiety about self-care and reduced flexibility was experienced. Anticipated positive effects of insulin for their health contributed to make the transition easier.Conclusions: To facilitate the transition required individualized information to both the patient and his family about disease progression, treatment and the impact on the body in the early stages of the disease. The results are expected to provide greater insight into how people with type 2 diabetes experience transition to insulin therapy, to thus provide adequate support to these people.Keyword: Diabetes Mellitus type 2, insulin therapy, psychological insulin resistance, experiences

Les protéines SREBP-1, Sterol Response Element Binding Proteins, sont des régulateurs clés du métabolisme des lipides et du cholestérol. A ce titre, ils ont été largement étudiés dans le foie et le tissu adipeux. Les facteurs SREBP-1 sont également exprimés dans le muscle squelettique au sein duquel ils sont les principaux médiateurs des effets géniques de l’insuline.Les travaux de thèse présentés dans ce manuscrit ont eu pour but de définir le rôle spécifique de SREBP-1 dans le muscle squelettique. L’étude transcriptomique de cellules musculaires humaines révèle plus de1500 gènes régulés par SREBP-1 dans le muscle squelettique humain, dont la moitié est réprimée. L’analyse fonctionnelle de ces gènes révèle l’implication de SREBP-1 dans des fonctions musculaires dépassant la cadre du métabolisme glucido-lipidique. Ainsi, SREBP-1 inhibe l’expression de plusieurs gènes impliqués dans la différenciation et le maintien du phénotype musculaire. En conséquence, la sur expression de SREBP-1 bloque la différenciation myogénique in vitro et induit une atrophie marquée in vitro, sur des myotubes différenciés et in Vivo, dans le muscle squelettique de souris.En parallèle, deux répresseurs transcriptionnels : BHLHB2 et BHLHB3 apparaissent, après étude de leur promoteur, comme deux nouvelles cibles directes de SREBP-1. Ainsi, 20% des gènes inhibés par SREBP-1sont des cibles de BHLHB2 et BHLHB3, de nombreux gènes muscle-spécifiques y compris. De plus, BHLHB2 apparaît, de la même façon que SREBP-1, comme un acteur essentiel dans l’action de l’insuline sur le muscle squelettique, et dans le développement de l’insulino-résistance musculaire chez les patients diabétiques de type2.Le blocage de la différenciation myogénique et l’atrophie induite par SREBP-1 in vitro étant reversées par l’inhibition de l’expression de BHLHB2 et BHLHB3, nous concluons que BHLHB2 et BHLHB3 sont responsables de l’effet répressif de SREBP-1 sur le phénotype musculaire.Ces résultats mettent donc en évidence un nouveau rôle pour les facteurs SREBP-1 dans la régulation de la myogenèse et le maintien de la masse musculaire. SREBP-1 intègrent ainsi la régulation métabolique au contrôle du phénotype musculaire / Transcription factors SREBP-1, Sterol Response Element Binding Proteins, are key regulators of lipid and cholesterol homeostasis. Their function has been largely studied in liver and adipose tissue, but they are also well expressed in skeletal muscle where they mediate insulin transcriptional effects.This work aims to define the muscle specific role of SREBP-1. Microarray analysis of human myotubes over-expressing SREBP-1 identifies more than 1500 SREBP-1 target genes in human skeletal muscle, including number of repressed genes. Gene ontology analysis reveals the involvement of SREBP-1 in a large variety of biological functions in muscle cells. In fact, SREBP-1 represses expression of a number of muscle-specific genes and markers of muscle differentiation. As a result, SREBP-1 over-expression leads to blockage of in vitro myogenic differentiation and marked atrophy in vitro as in Vivo.In the same time, we identified the transcriptional repressors BHLHB2 and BHLHB3 as new direct target genes of SREBP-1, by promoter analysis. 20% of SREBP-1 repressed genes are also target genes of BHLHB2 and BHLHB3. Furthermore, BHLHB2, like SREBP-1, is involved in insulin action on skeletal muscle and muscular insulin-resistance in type 2 diabetic patients.As SREBP-1 effects on atrophy and myogenic differentiation inhibition are reversed by silencing BHLHB2 and BHLHB3 expression, we can conclude that BHLHB2 and BHLHB3 mediate negative SREBP-1action on muscular phenotype.These results confer a new role for SREBP-1 in the regulation of muscle mass and muscle cell differentiation, thus linking the control of muscle mass to metabolic pathways

L'insuline, hormone clé du contrôle de l'homéostasie métabolique, exerce également des effets trophiques sur la croissance et la prolifération cellulaire. Des études épidémiologiques ont récemment montré que les individus obèses ou diabétiques de type 2 ont un risque plus élevé de développer des cancers et elles ont également suggéré que l’insuline jouerait un rôle dans ce développement tumoral. Ainsi, une signalisation adéquate en aval du récepteur de l’insuline est indispensable pour éviter des processus physiopathologiques. La signalisation de l’insuline est contrôlée par des mécanismes de rétrocontrôle, dont l’adaptateur moléculaire Grb14 qui agit comme un inhibiteur endogène de l’activité catalytique du RI. L’objectif de ma thèse a été d’étudier les conséquences métaboliques et mitogéniques de l’inhibition de Grb14 in#vivo spécifiquement dans le foie de souris. Dans une première étude, nous montrons que sept jours après l’invalidation de Grb14, les souris présentent une activation des voies de signalisation de l’insuline, qui s’accompagne d’une amélioration de la tolérance au glucose et de la production hépatique de glucose. Cependant, de façon paradoxale, la voie de la lipogenèse est très fortement diminuée. En décryptant le mécanisme moléculaire impliqué, nous montrons que l’inhibition de Grb14 permet la libération de la protéine p62/sqstm1 qui active le facteur de transcription Nrf2, ce qui entraine une inhibition du récepteur nucléaire pro-lipogénique LXR. De façon intéressante, l’invalidation de Grb14 chez des souris ob/ob permet de restaurer la glycémie et la stéatose hépatiques à des valeurs comparables aux témoins. Cette étude a ainsi permis de mettre en évidence une nouvelle voie de régulation de la lipogenèse hépatique. Dans une deuxième étude, nous nous sommes intéressés à l'action mitogénique de l'insuline. Nous montrons que 48 heures après l'inhibition de Grb14, les hépatocytes, qui sont des cellules quiescentes, entrent massivement dans le cycle cellulaire. Ce processus est dépendant de l’expression du RI et est médié par la signalisation PI3K/Akt/mTORC1 et la voie Rb/E2F1. Ces données révèlent ainsi que l'insuline est un puissant facteur mitogène dans le foie et que son action est étroitement contrôlée par l’adaptateur Grb14. D’un point de vue physiopathologique, nous avons pu mettre en évidence une diminution de significative de 58% de l’expression de Grb14 dans une collection de 70 CHC humains, apportant ainsi une explication moléculaire à une action pro-tumorigène de l’insuline dans le foie. L’ensemble de ces deux études permet de placer Grb14 au centre de la régulation des actions métaboliques et mitogéniques de l’insuline dans le foie. / Insulin is a key hormone controling metabolic homeostasis which also exerts having trophic effects on cell growth and proliferation. Epidemiological studies have recently shown that obese and type 2 diabetes patients are at higher risk of developing cancers, suggesting that insulin could be involved in tumor development. Proper signaling downstream the insulin receptor is thus essential to prevent pathophysiological processes. Insulin signaling is controlled by feedback mechanisms including the molecular adapter Grb14 which acts as an endogenous inhibitor of the IR catalytic activity. The aim of my PhD was to investigate the metabolic and mitogenic consequences of liver specific Grb14 inhibition in mouse. In the first study, we showed that after seven days of Grb14 invalidation, liver insulin signaling is enhanced, resulting in improved glucose tolerance and diminished hepatic glucose production. However, paradoxically, lipogenesis was greatly decreased. Deciphering the molecular mechanism, we show that Grb14 inhibition leads to the release of its partner p62/SQSTM1, inducing the activation of the Nrf2 transcription factor, which ultimatly inhibited the pro-lipogenic LXR nuclear receptor. Interestingly, Grb14 invalidation in ob/ob mice can restore blood glucose and hepatic steatosis comparable to control values. The study thus highlighted a new pathway controlling lipogenesis that could be targetted to improve metabolic diseases. In the second study, we were interested in insulin mitogenic action. We showed that 48 hours after Grb14 inhibition, hepatocytes that are quiescent cells, massively go through one cell cycle. This process depend on IR expression and is mediated by the PI3K/Akt/mTORC1 pathway and the Rb/E2F1 complex. Our data thus suggest that insulin is a potent mitogenic factor in the liver whose action is closely controlled by the Grb14 adapter in physiological conditions. Importantly, Grb14 expression is significantly decreased in a collection of human HCC, hence bringing out a molecular basis for a pro-tumorigenic action of hyperinsulinemia. Together these two studies reveal that Grb14 is a crucial gatekeeper of insulin metabolic and mitogenic actions in the liver.

L'insuline, hormone clé du contrôle de l'homéostasie métabolique, exerce également des effets trophiques sur la croissance et la prolifération cellulaire. Des études épidémiologiques ont récemment montré que les individus obèses ou diabétiques de type 2 ont un risque plus élevé de développer des cancers et elles ont également suggéré que l’insuline jouerait un rôle dans ce développement tumoral. Ainsi, une signalisation adéquate en aval du récepteur de l’insuline est indispensable pour éviter des processus physiopathologiques. La signalisation de l’insuline est contrôlée par des mécanismes de rétrocontrôle, dont l’adaptateur moléculaire Grb14 qui agit comme un inhibiteur endogène de l’activité catalytique du RI. L’objectif de ma thèse a été d’étudier les conséquences métaboliques et mitogéniques de l’inhibition de Grb14 in#vivo spécifiquement dans le foie de souris. Dans une première étude, nous montrons que sept jours après l’invalidation de Grb14, les souris présentent une activation des voies de signalisation de l’insuline, qui s’accompagne d’une amélioration de la tolérance au glucose et de la production hépatique de glucose. Cependant, de façon paradoxale, la voie de la lipogenèse est très fortement diminuée. En décryptant le mécanisme moléculaire impliqué, nous montrons que l’inhibition de Grb14 permet la libération de la protéine p62/sqstm1 qui active le facteur de transcription Nrf2, ce qui entraine une inhibition du récepteur nucléaire pro-lipogénique LXR. De façon intéressante, l’invalidation de Grb14 chez des souris ob/ob permet de restaurer la glycémie et la stéatose hépatiques à des valeurs comparables aux témoins. Cette étude a ainsi permis de mettre en évidence une nouvelle voie de régulation de la lipogenèse hépatique. Dans une deuxième étude, nous nous sommes intéressés à l'action mitogénique de l'insuline. Nous montrons que 48 heures après l'inhibition de Grb14, les hépatocytes, qui sont des cellules quiescentes, entrent massivement dans le cycle cellulaire. Ce processus est dépendant de l’expression du RI et est médié par la signalisation PI3K/Akt/mTORC1 et la voie Rb/E2F1. Ces données révèlent ainsi que l'insuline est un puissant facteur mitogène dans le foie et que son action est étroitement contrôlée par l’adaptateur Grb14. D’un point de vue physiopathologique, nous avons pu mettre en évidence une diminution de significative de 58% de l’expression de Grb14 dans une collection de 70 CHC humains, apportant ainsi une explication moléculaire à une action pro-tumorigène de l’insuline dans le foie. L’ensemble de ces deux études permet de placer Grb14 au centre de la régulation des actions métaboliques et mitogéniques de l’insuline dans le foie. / Insulin is a key hormone controling metabolic homeostasis which also exerts having trophic effects on cell growth and proliferation. Epidemiological studies have recently shown that obese and type 2 diabetes patients are at higher risk of developing cancers, suggesting that insulin could be involved in tumor development. Proper signaling downstream the insulin receptor is thus essential to prevent pathophysiological processes. Insulin signaling is controlled by feedback mechanisms including the molecular adapter Grb14 which acts as an endogenous inhibitor of the IR catalytic activity. The aim of my PhD was to investigate the metabolic and mitogenic consequences of liver specific Grb14 inhibition in mouse. In the first study, we showed that after seven days of Grb14 invalidation, liver insulin signaling is enhanced, resulting in improved glucose tolerance and diminished hepatic glucose production. However, paradoxically, lipogenesis was greatly decreased. Deciphering the molecular mechanism, we show that Grb14 inhibition leads to the release of its partner p62/SQSTM1, inducing the activation of the Nrf2 transcription factor, which ultimatly inhibited the pro-lipogenic LXR nuclear receptor. Interestingly, Grb14 invalidation in ob/ob mice can restore blood glucose and hepatic steatosis comparable to control values. The study thus highlighted a new pathway controlling lipogenesis that could be targetted to improve metabolic diseases. In the second study, we were interested in insulin mitogenic action. We showed that 48 hours after Grb14 inhibition, hepatocytes that are quiescent cells, massively go through one cell cycle. This process depend on IR expression and is mediated by the PI3K/Akt/mTORC1 pathway and the Rb/E2F1 complex. Our data thus suggest that insulin is a potent mitogenic factor in the liver whose action is closely controlled by the Grb14 adapter in physiological conditions. Importantly, Grb14 expression is significantly decreased in a collection of human HCC, hence bringing out a molecular basis for a pro-tumorigenic action of hyperinsulinemia. Together these two studies reveal that Grb14 is a crucial gatekeeper of insulin metabolic and mitogenic actions in the liver.

Parmi l’ensemble des désordres métaboliques retrouvés en insuffisance rénale chronique (IRC), la résistance à l’insuline demeure l’un des plus importantes à considérer en raison des risques de morbidité et de mortalité qu’elle engendre via les complications cardiovasculaires. Peu d’études ont considéré la modulation de transporteurs de glucose comme mécanisme sous-jacent à l’apparition et à la progression de la résistance à l’insuline en IRC. Nous avons exploré cette hypothèse en étudiant l’expression de transporteurs de glucose issus d’organes impliqués dans son homéostasie (muscles, tissus adipeux, foie et reins) via l’utilisation d’un modèle animal d’IRC (néphrectomie 5/6e). La sensibilité à l’insuline a été déterminée par un test de tolérance au glucose (GTT), où les résultats reflètent une intolérance au glucose et une hyperinsulinémie, et par les études de transport au niveau musculaire qui témoignent d’une diminution du métabolisme du glucose en IRC (~31%; p<0,05). La diminution significative du GLUT4 dans les tissus périphériques (~40%; p<0,001) peut être à l’origine de la résistance à l’insuline en IRC. De plus, l’augmentation de l’expression protéique de la majorité des transporteurs de glucose (SGLT1, SGLT2, GLUT1; p<0,05) au niveau rénal en IRC engendre une plus grande réabsorption de glucose dont l’hyperglycémie subséquente favorise une diminution du GLUT4 exacerbant ainsi la résistance à l’insuline. L’élévation des niveaux protéiques de GLUT1 et GLUT2 au niveau hépatique témoigne d’un défaut homéostatique du glucose en IRC. Les résultats jusqu’ici démontrent que la modulation de l’expression des transporteurs de glucose peut être à l’origine de la résistance à l’insuline en IRC. L’impact de la parathyroïdectomie (PTX) sur l’expression du GLUT4 a été étudié étant donné que la PTX pourrait corriger l’intolérance au glucose en IRC. Nos résultats démontrent une amélioration de l’intolérance au glucose pouvant être attribuable à la moins grande réduction de l’expression protéique du GLUT4 dans les tissus périphériques et ce malgré la présence d’IRC. L’excès de PTH, secondaire à l’hyperparathyroïdie, pourrait alors être à l’origine de la résistance à l’insuline en IRC en affectant l’expression du GLUT4. L’IRC partage de nombreuses similitudes avec le prédiabète quant aux défaillances du métabolisme du glucose tout comme l’hyperinsulinémie et l’intolérance au glucose. Aucune étude n’a tenté d’évaluer si l’IRC pouvait ultimement mener au diabète. Nos résultats ont par ailleurs démontré que l’induction d’une IRC sur un modèle animal prédisposé (rats Zucker) engendrait une accentuation de leur intolérance au glucose tel que constaté par les plus hautes glycémies atteintes lors du GTT. De plus, certains d’entre eux avaient des glycémies à jeun dont les valeurs surpassent les 25 mmol/L. Il est alors possible que l’IRC puisse mener au diabète via l’évolution de la résistance à l’insuline par l’aggravation de l’intolérance au glucose. / Of all metabolic disorders found in chronic renal failure (CRF), insulin resistance remains one of the most important to consider because of the risk of morbidity and mortality it causes via cardiovascular complications. Few studies have considered the modulation of glucose transporters as the mechanism underlying the emergence and progression of insulin resistance in CRF. We explored this hypothesis by studying the expression of glucose transporters from organs involved in its homeostasis (muscle , fat , liver and kidneys) through the use of an animal model reflecting CRF (5/6th nephrectomy). The insulin sensitivity was determined by a glucose tolerance test (GTT), where the results reflect glucose intolerance and hyperinsulinemia , and transport studies in muscle show a decrease in glucose uptake in CRF ratss (~31% , p<0.05). The significant decrease in GLUT4 in peripheral tissues (~40%, p<0.001) may be the cause of insulin resistance in CRF. Furthermore, increased protein expression of the majority of glucose transporters (SGLT1, SGLT2, GLUT1, p<0.05) within the kidney in CRF causes greater glucose reabsorption in which consequential hyperglycemia promotes a decrease in GLUT4 thus exacerbating insulin resistance. Elevated protein levels of GLUT1 and GLUT2 in the liver reflects an impaired glucose homeostasis in CRF. The results show that the modulation of the expression of glucose transporters may be responsible for insulin resistance in CRF. The impact of parathyroidectomy (PTX) on the expression of GLUT4 was studied since PTX is known to correct glucose intolerance in CRF. Our results show an improvement in glucose intolerance which may be due to less reduction of GLUT4 protein expression in peripheral tissues despite the presence of CRF. The excess of PTH, linked to secondary hyperparathyroidism, could be held responsible to the presence of insulin resistance in CRF by affectant GLUT4 expression. CRF shares many similarities with prediabetes in regards to impaired glucose metabolism such as hyperinsulinemia and glucose intolerance. No studies have attempted to assess whether CRF could lead to diabetes. Our results demonstrated that the induction of CRF in a predisposed animal model (Zucker rats) provoked greater glucose intolerance as evidenced by the highest blood glucose levels reached in the GTT. In addition, some of them had fasting blood glucose levels whose values exceeded 25 mmol/L. It is therefore possible that CRF can lead to diabetes through the evolution of insulin resistance by the worsening of glucose intolerance.

Insulin resistance and chronic hyperglycemia promote vascular damage, increase circulating levels of inflammatory cytokines and lead to increased morbidity and mortality. MicroRNAs (miRs) -103/107 have been shown to negatively regulate insulin sensitivity and glucose homeostasis. Based on complimentary binding profiles, the downstream target gene of miR-103/107 is caveolin-1 (Cav-1). We hypothesized that daily administration of the phosphodiesterase-5 inhibitor tadalafil (TAD) ± the curcumin analogue (HO-3867) will attenuate inflammation, improve metabolic parameters and reduce infarct size after ischemia/reperfusion injury (IRI). Furthermore, we propose that TAD therapy will reduce myocardial expression of miR-103/107 and increase mRNA and protein levels of its target gene, Cav-1. Leptin receptor null mice were randomized to receive daily injections of TAD (1mg/kg), HO-3867 (25mg/Kg), combination therapy, or control for 12weeks with weight and fasting glucose monitored weekly. Upon completion, cardiomyocytes were isolated from each group and were subjected to simulated ischemia and reoxygenation (SI/RO) for cell viability and reactive oxygen species (ROS) measurement. Another set were subjected to IRI in a Langendorff model. Plasma samples were taken to measure plasma concentrations of cytokines. For miR expression, total RNA was isolated from TAD and DMSO treated mice and was subjected to reverse transcription and real time PCR using miR assay probes to determine expression. TAD, HO-3867 and the combination of both attenuated fasting glucose levels, reduced myocardial infarct size after IRI and inflammatory cytokines when compared to control (p<0.05 for each vs. control). Cardiomyocytes isolated from each treatment groups and subjected to SI/RO demonstrated reduced necrosis as shown by trypan blue exclusion assay, ROS generation, and improved mitochondrial membrane potential as compared to DMSO (control). Likewise, both mRNA and protein expression of Cav-1 were reduced in diabetic hearts but were significantly increased in TAD treated diabetic mice, which may be a mechanism to improve insulin signaling through downregulation of miR-103/107 and upregulation of Cav-1. These studies suggest that TAD alone or in combination may be a unique strategy to improve metabolic parameters and precondition diabetic hearts against IRI.

M.Tech. / Impaired glucose tolerance, as determined by an oral glucose tolerance test, is the inability of the blood glucose regulatory mechanisms in the body to return the blood glucose levels to normal physiological levels after the ingestion of a meal (Guyton and Hall, 2006). Mollentze and Levitt (2006) report on various studies that were conducted in South Africa on the prevalence of impaired glucose tolerance and diabetes mellitus and they illustrate that there is an incidence of impaired glucose tolerance as high as 10.2% in certain communities and that impaired glucose tolerance may result in diabetes mellitus. A study has shown that cinnamon controls blood sugar levels by increasing insulin sensitivity resulting in better blood sugar level control (Jarvill-Taylor et al, 2001). The above research was done on cinnamon in the crude form but there is no research on Cinnamomum verum in a homoeopathic potency. The aim of the research was to evaluate the effect of Cinnamomum verum 1X on glucose tolerance in non-diabetic males after an oral glucose tolerance test. A double-blind pre-test post-test placebo controlled study on thirty healthy adult males between the ages of eighteen and forty years was conducted. The participants were recruited by means of an advertisement at the University of Johannesburg Health Clinic. Inclusion criteria comprised: no medication for one month prior to the study with a normal fasting blood sugar level of more than 3.0 but less than 6.0 mmol/l (Oussama, 2006); systolic blood pressure between 100 and 140 mmHg and diastolic blood pressure between 70 and 90 mmHg. At the first consultation the participant data was obtained and an oral glucose tolerance test was performed. The participants were issued with 100 ml of either Cinnamomum verum 1X or a placebo and a weekly checklist to complete. After two weeks the participant data was recorded again and the oral glucose tolerance test was repeated. The Mann-Whitney U-test was used to analyse between the group data statistically and the Wilcoxon Signed-Rank test was used to perform the within-group analysis. The mean fasting blood glucose level of the experiment group changed from 4.71 mmol/l to 4.49 mmol/l. This was a statistically significant reduction, p = 0.025 (< 0.05). The reduction in the blood glucose level after the oral glucose tolerance test of the experiment group was also found to be statistically significant, p = 0.001 (< 0.05) with the mean value changing from 5.86 mmol/l to 5.40 mmol/l. It was concluded that the homoeopathic remedy, Cinnamomum verum 1X taken orally twice daily, was more effective than the placebo in reducing the fasting blood glucose level and the blood glucose level after an oral glucose tolerance test in non-diabetic males between the ages of eighteen and forty years with normal initial fasting blood glucose levels within a time period of two weeks.

Um dos principais fatores patogênicos do quadro de resistência à insulina é a deficiência na expressão de Slc2a4/GLUT4 que, ao longo prazo, causa perda da homeostasia glicêmica. Além disso, a hiperglicemia constante leva a uma glicotoxicidade que também contribui para a patogênese desse quadro. O aumento da glicose circulante leva à formação de produtos finais de glicação avançada (AGEs) que, ao interagem com seu receptor RAGE, desencadeiam processos inflamatórios e estresse oxidativo e de retículo na célula, culminando na ativação da via do NFKB, fator transcricional conhecido por ser repressor da expressão do gene Slc2a4. Nesse sentido, o objetivo do presente estudo visou investigar os efeitos dos AGEs na expressão de Slc2a4/GLUT4 e se esse efeito é mediado pela ativação da via do NFKB. Para isso, utilizamos adipócitos da linhagem 3T3-L1 tratados com albumina sérica bovina sem modificações ou conjugada com glicolaldeído e verificamos a expressão dos genes Slc2a4, Nfkb1 e Rela, a abundância das proteínas GLUT4, p65 e p50, o grau de fosforilação das proteínas IKK alfa e IKK beta e a atividade de ligação da subunidade p65 no promotor do gene Slc2a4. Os resultados indicaram que a albumina glicada é capaz de modular a expressão de Slc2a4/GLUT4 de maneira hormética, isto é, em concentração baixa (0,4 mg/mL) e tempo curto (24 horas), houve um aumento na expressão do gene e da proteína, porém, há uma redução da expressão do gene e da proteína quando em concentração alta (5,4 mg/mL) e tempo prolongado (72 horas). Além disso, a albumina glicada induz atividade pró-inflamatória no adipócito e aumento da quantidade de p65 e p50 no núcleo em concentração alta e tempo prolongado. No entanto, a ativação da via do NFKB não se dá pela via canônica, pois não foi observado ativação de IKK. Por fim, apesar de ser um dado preliminar, a albumina glicada induz aumento de ligação do NFKB na região promotora do gene Slc2a4. Em suma, o presente estudo demonstra que os AGEs participam não só da gênese das complicações degenerativas presentes no diabetes mellitus, como também, contribui ativamente para a perda da homeostasia glicêmica. / One of the main pathogenic factors of the insulin resistance is the deficiency in the expression of Slc2a4/GLUT4, which in the long term causes impaired glucose homeostasis. In addition, constant hyperglycemia leads to a glycotoxicity that also contributes to the pathogenesis of this condition. Increased circulating glucose leads to the formation of advanced glycated end products (AGEs) which, when interacting with RAGE receptor, trigger inflammatory processes and oxidative and reticulum stress in the cell, culminating in the activation of the NFKB pathway. This transcriptional factor is a known repressor of the Slc2a4 gene. In this sense, the objective of the present study was to investigate the effects of AGEs on the expression of Slc2a4/GLUT4 and whether this effect is mediated by the activation of the NFKB pathway. For this, we used 3T3-L1 adipocytes treated with bovine serum albumin without modification or conjugated with glycolaldehyde and verified the expression of the genes Slc2a4, Nfkb1 and Rela, abundance of GLUT4, p65 and p50 proteins, the degree of phosphorylation of IKK alpha and IKK beta proteins and p65 subunit binding activity in the Slc2a4 gene promoter. The results indicated that glycated albumin is able to modulate the expression of Slc2a4/GLUT4 in a hormetic manner, i.e. at low concentration (0.4 mg/mL) and short time (24 hours), there was an increase in gene expression and protein. However, there is a reduction of the gene and the protein expression when in high concentration (5.4 mg/mL) and prolonged time (72 hours). In addition, glycated albumin induces proinflammatory activity in the adipocyte and increases the amount of p65 and p50 in the nucleus in high concentration and prolonged time. Nonetheless, the activation of the NFKB pathway does not occur through canonical pathway, since no IKK activation was observed. Finally, despite being a preliminary finding, glycated albumin induces increased NFKB binding in the promoter region of the Slc2a4 gene. In summary, the present study demonstrates that AGEs participate not only in the genesis of the degenerative complications present in diabetes mellitus, but also contributes actively to the loss of glycemic homeostasis.

O indivíduo com diabetes mellitus tipo 2 apresenta um risco de 2 a 4 vezes maior de desenvolver doença cardiovascular (DCV) quando comparado ao não-diabético, sendo que este aumento do risco para o desenvolvimento da DCV também é observado quando na intolerância à glicose (IG) que ocorre em fases mais precoces da história natural do diabetes. Atribui-se ser a presença da síndrome metabólica (SM), que ocorre na maioria dos pacientes com DM2 e IG, um fator importante para o desenvolvimento da DCV nestes indivíduos. Dos componentes da SM, inúmeros estudos destacam a dislipidemia como um dos principais fatores para este risco. A dislipidemia comumente encontrada na IG é caracterizada por hipertrigliceridemia, baixo HDL-C e presença de LDL pequena e densa. Entretanto, como a elevação dos níveis séricos do LDL-C associada ao surgimento de aterosclerose prematura em indivíduos não diabéticos na maioria das vezes não é observada em pacientes com IG, questiona-se se outras alterações do metabolismo lipídico, tais como alterações da cinética do colesterol ou a transferência de lípides das lipoproteínas para a HDL, poderiam estar relacionadas ao maior risco cardiovascular nestes pacientes. Estudo prévio, utilizando uma nanoemulsão lipídica artificial de LDL, verificou uma remoção mais rápida do colesterol na forma livre em pacientes normolipidêmicos com doença arterial coronária (DAC) quando comparada com controles. No presente estudo, utilizou-se a nanoemulsão lipídica artificial para avaliar se esses dois processos envolvidos no metabolismo da LDL e da HDL estão alterados em pacientes com intolerância à glicose que os predispõem à DAC, relacionando estes resultados com fatores de risco cardiovasculares, tais como a resistência à insulina, a obesidade e a dislipidemia. Para tanto, foram estudados 14 pacientes com IG e 15 controles, sem manifestação clínica de DCV, que não utilizam antidiabéticos orais e hipolipemiantes, comparados com controles pareados para idade, sexo, raça, IMC, tabagismo, consumo de álcool, prática de atividade física e doenças associadas. Para o estudo cinético, a nanoemulsão marcada foi injetada endovenosamente e amostras de sangue coletadas ao longo de 24h para a determinação da radioatividade, das curvas de decaimento plasmático e da taxa fracional de remoção (TFR) dos lípides marcados a partir de um modelo de análise compartimental. Foi medida a taxa de esterificação do 3Hcolesterol livre da nanoemulsão no plasma e avaliada a transferência in vitro de lípides da nanoemulsão para a fração HDL. A resistência à insulina foi estimada pelo modelo matemático de homeostase glicêmica (HOMA) e a adiposidade abdominal por tomografia computadorizada de abdômen. A concentração plasmática de colesterol total, LDL-C, HDL-C, triglicérides e de apolipoproteínas não diferiu entre os grupos. O perfil antropométrico relacionado ao peso, IMC e circunferência abdominal foi semelhante entre os grupos. O grupo IG apresentou maior concentração de insulina de jejum (p=0,01), menor sensibilidade à insulina (p<0,01) e maior índice de resistência à insulina (p<0,01). A TFR 14C-EC foi similar nos dois grupos, porém a TFR 3H-CL foi mais rápida no grupo IG comparado com controle (p=0,04). A porcentagem de esterificação do 3H-colesterol da nanoemulsão bem como a transferência de lípides da nanoemulsão para a fração HDL foram semelhantes entre os grupos. A remoção mais rápida do 3H-colesterol livre mostra que ocorreu uma dissociação das partículas de colesterol da nanoemulsão lipídica nos pacientes com intolerância à glicose. Essa dissociação do colesterol pode refletir alterações no metabolismo intravascular da lipoproteína LDL, as quais podem favorecer a aterogênese nesses pacientes / Individuals with diabetes mellitus type 2 are 2 to 4 times more susceptible to cardiovascular disease (CVD) than non-diabetic individuals. This increased risk is also observed for glucose intolerance (GI) which appears in the initial stages of diabetes. The presence of the metabolic syndrome (MS), present in most DM2 and GI patients, is also an important factor contributing to the development of CVD in these individuals. Various MS component studies emphasize dyslipidemia as one of the main contributors for this risk factor. The dyslipidemia commonly associated to GI is characterized by hypertriglyciridemia, low HDL-C and the presence of a small and dense LDL. However, since associated LDL-C levels with the development of premature atherosclerosis in non diabetic individuals is for the most part not observed in GI patients, it is questioned whether other lipid metabolism alterations such as cholesterol kinetics or the lipid transfer to HDL could be related to a greater CVD risk in these individuals. A previous study using an artificial LDL nanoemulsion showed a faster removal rate of the free cholesterol in normolipidemic with coronary artery disease (CAD) patients when compared to control individuals. In this study an artificial lipid nanoemulsion was used to evaluate both these processes involved in the metabolism of LDL and HDL which are both altered in patients with GI that expose them to CAD, and relating the results to CVD factors such as insulin resistance, obesity and dyslipidemia. 14 GI and 15 control individuals participated in this study. All without manifestations of CVD, none using any oral antidiabetic medication or hypolipimeants, paired for age, sex, race, BMI, smoking, alcoholic consumption, physical activity and comorbidities. For the kinetic study, a labeled nanoemulsion was interveneously injected and blood samples collected at determined intervals over a 24 hour period to determine the radiactive plasma decay curves and fractional clearance rate (FCR) of the labeled nanoemulsion lipids through a compartmental analysis model. Plasma esterification rate of the 3H-free cholesterol of the nanoemulsion was measured as was the in vitro transfer from the nanoemulsion to HDL fraction. Insulin resistance was obtained by the glycemic homeostasis mathematical model (HOMA) and abdominal adipose by a computerized tomography of the abdomen. No differences were observed for total cholesterol plasmatic concentrations, LDL-C, HDL-C, triglycerides or apolipoproteins between the two groups. The anthropometric profile related to weight, BMI and abdominal circumference was similar for both groups. The GI group presented higher fasting insulin concentration (p=0.01), less insulin sensitivity (p=0.01) and a greater insulin resistance (p=0.01). The TFR 14C-CE was similar in both groups, although the TFR 3H-CL was faster in the GI group compared to the control group (p=0.04). The esterification percentage of the nanoemulsions 3H-colesterol, as well as the lipid transfer from the nanoemulsion to HDL fraction were similar for both groups. The faster 3H-free cholesterol removal shows that a dissociation of the cholesterol particles of the lipidic nanoemulsion occurred in those patients with GI. This dissociation could possibly reflect alterations in the intravascular LDL lipoprotein metabolism which in turn, may favor atherogenesis in these patients

Introdução: A Síndrome Metabólica (SM) é uma condição clínica caracterizada pela agregação de fatores de risco cardiovascular em um mesmo indivíduo. No entanto, a definição da SM é heterogênea e baseada em opiniões de especialistas de diferentes Organizações Médicas. Além disto, não está claro o papel relativo de cada componente da SM ou se existe um componente de maior importância. A maior parte da literatura tem focado no papel da gordura abdominal como eixo principal da SM. No entanto, o potencial papel de um outro componente da SM - o aumento da pressão arterial (PA) - ainda é pouco estudado. O aumento da PA está frequentemente associado com um aumento da atividade simpática que por sua vez pode contribuir para a alterações cardiovasculares na SM. Avaliamos essa hipótese estudando indivíduos com SM de acordo com a presença (MS+PA) ou ausência (MS-PA) do critério de aumento da PA. Métodos: Estudamos 75 pacientes consecutivos com diagnóstico recente de SM (critérios da ATPIII). Foram excluídos pacientes com obesidade mórbida, hipertensão arterial grave, formas secundárias de hipertensão arterial, diabetes em tratamento, fumantes, doença crônica e uso regular de medicamentos (inclusive para hipertensão arterial e diabetes). Dividimos em 2 grupos de acordo com critério do aumento da PA. Exames de sangue em jejum foram colhidos para testes bioquímicos e para níveis de citocinas. Parâmetros antropométricos, avaliação hemodinâmica não invasiva (volume sistólico, debito cardíaco, resistência vascular sistêmica e distensibilidade das artérias) pelo Hypertension Diagnostics Incorporation (HDI), análise espectral derivada da medida da PA batimento-batimento (Finometer) e sensibilidade barorreflexa (BRS) foram medidas em todos os indivíduos. Resultados: Pacientes com SM+PA (N=30) tenderam a ser mais velhos (38±11 vs 45±9 anos; p=0.061) do que os com SM-PA (N=45). Não houve diferenças em relação ao sexo, raça e dados antropométricos inclusive índice de massa corpórea, medida da cintura e relação cintura quadril. Em relação aos pacientes com SM-PA, os pacientes com SM+PA tiveram níveis mais elevados de glicose (97±8 vs. 102±7 mg/dL, p=0,013), insulina (10±4 vs. 21±20.0 U/mL, p=0.007), índice de HOMAir (2,5±1.0 vs. 5,4±5,2, p=0.006), colesterol total (194±33 vs. 221±43mg/dL, p=0.001), LDL-c (119±27 vs. 145±39 mg/dL, p=0.002), triglicérides (130±51 vs. 176±65 mg/dL, p=0.005), acido úrico (4,6±1,2 vs. 5,6±1,3 mg/dL, p=0.001), HDL-c nas mulheres (51±10,6 vs. 43±7,6 mg/dL, p=0,002). Os indivíduos com SM+PA também tiveram os níveis mais elevados de RBP 4, PAI-1, interleucina 6, MCP-1 e os níveis de adiponectina foram mais baixos do que pacientes com SM-PA. Além disto, pacientes com SM+PA apresentaram maior resistência vascular, aumento da rigidez de grandes e pequenas artérias, aumento da atividade simpática e diminuição da sensibilidade barorreflexa do que aqueles com SM-PA. Vários destes parâmetros permaneceram independentemente associados com a presença de SM+PA na análise de regressão logística. Conclusões: Pacientes com SM+PA tiveram piores alterações metabólicas, pró-inflamatórias, pró-trombóticas, vasculares, hemodinâmicas e o controle autonômico quando comparados aos pacientes com SM-PA. Estes achados não foram influenciados por diferenças na composição corporal e reforçam não só a heterogeneidade da SM mas a importância relativa do aumento da PA neste contexto / Introduction: Metabolic syndrome (MS) is a clinical condition characterized by the aggregation of cardiovascular risk factors in the same individual. However, the definition of MS is heterogeneous and based on expert opinions from different Medical Organizations. Furthermore, it is unclear the relative role of each component of the SM or if there is a component of most importance. Most of the literature has focused on the role of abdominal fat as the main component of the MS. However, the potential role of another component of MS - increased blood pressure (BP) - is still poorly studied. The increase in BP is often associated with increased sympathetic activity which in turn may contribute to cardiovascular changes in MS. Evaluate this hypothesis by studying subjects with MS in according with the presence ( MS+ BP) or absence (MS-BP) of increased blood pressure criteria. Methods: We studied 75 consecutive patients with newly diagnosed MS (ATPIII criteria). Patients with morbid obesity, severe hypertension, secondary forms of hypertension, under diabetes treatment, smoking, chronic disease, regular use of medications (including hypertension and diabetes) were excluded. We divided into 2 groups according to criteria of increased BP. Fasting blood examinations were collected for biochemical tests and cytokine levels. Anthropometric, hemodynamic variables (stroke volume, cardiac output, systemic vascular resistance and elasticity of the arteries) by Hypertension Diagnostics Incorporation (HDI), analysis of BP (Finometer) and baroreflex sensitivity (BRS) were measured in all subjects. Results: Patients with MS - BP (N = 30) tended to be older (38 ± 11 vs 45 ± 9 years; p = 0.061) than those with MS-BP (N = 45). There were no differences with regard to sex, race, and anthropometric data including body mass index, waist circumference and waist-hip ratio. Compared to patients with SM-PA, patients with MS + BP had higher glucose levels (97 ± 8 vs. 102 ± 7 mg / dL, p = 0.013), insulin (10 ± 4 vs. 21 ± 20.0 U / ml, p = 0.007), homair index (2.5 ± 1.0 vs. 5.4 ± 5.2, p = 0.006), total cholesterol (194 ± 33 vs. 221 ± 43 mg / dl, p = 0.001) , LDL-c (119 ± 27 vs. 145 ± 39 mg / dl, p = 0.002), triglycerides (130 ± 51 vs. 176 ± 65 mg / dl, p = 0.005), urc acid (4.6 ± 1 2 vs. 5.6 ± 1.3 mg / dL, p = 0.001) and HDL-c in females (51 ± 43 vs. 10.6 ± 7.6 mg / dl, p = 0.002). Individuals with MS + BP also had the highest levels of RBP 4, PAI-1, interleukin-6, MCP-1 and adiponectin levels were lower than patients with MS-BP. Furthermore, patients with MS + BP had higher vascular resistance, increased stiffness of large and small asrteries, increased sympathetic activity and decreased baroreflex sensitivity than those with MS-BP. Several of these parameters remained independently associated with the presence of MS + BP in logistic regression analysis. Conclusions: Patients with MS + BP had worse metabolic, inflammatory pro, pro-thrombotic, vascular, hemodynamic and autonomic control compared with patients with MS-BP. These findings were not influenced by differences in body composition and reinforce not only the heterogeneity of MS but the relative importance of increased BP in this context