A positive result, in the absence of unequivocal hyperglycemia, should be confirmed by a repeat of any of the above-listed methods on a different day.
Normal fasting blood sugar levels – buzzle, Normal fasting blood sugar levels here is an article that speaks about the normal fasting blood sugar levels in adults and children.
Diabetes blood sugar levels chart – what is a normal blood, If you are wondering whether or not you have diabetes, you need to learn about normal blood sugar levels, abnormal blood sugar levels, and how to monitor your blood. Normal blood sugar levels chart – buzzle, Normal blood sugar levels chart consumption of food and drink leads to fluctuations in the levels of glucose in blood.
This is the sixth post in an in depth series which examines Adult Onset Diabetes, or, as it is also caused, Type II Diabetes. Subscribers Automatically Receive Book Discounts and Are Entered In Periodic Book Giveaways. By starting this blog, I am taking the first steps to make Quantitative Medicine available to everyone. Diagnosing diabetes enables the doctors and lab workers to detect and treat diabetes well before complications begin to occur [1]. The A1C test is used for detection of prediabetes and type 2 diabetes but does not diagnose type 1 or gestational diabetes. Diabetes, even though a common disorder which has been fairly widespread throughout the world, is a chronic condition with no definitive cure. The main aim in treating diabetes is to lower the blood sugar level without causing hypoglycemia or a condition characterized by abnormally low levels of blood sugar.
Prediabetes is the stage where one can control the blood sugar level from rising and prevent diabetes from occurring [2]. Type I Diabetes is treated with exercise, diabetic diet and external insulin administration.
There are some extremely rare cases in which a transplantation of the pancreas is used in order to treat Type I Diabetes.
While there may be many methods to help control the symptoms of diabetes, care must be taken not to lower the blood sugar levels abnormally and also to prevent other potential hazards [3]. Hypoglycemia or a low blood sugar level is also a complication associated with improper treatment of diabetes.
Extremely high blood sugar levels can lead to a condition known as hyperglycemia and this can adversely affect the condition of a diabetic.
If any complications and symptoms are experienced by individuals, immediate medical attention needs to be provided at the earliest. There are some alternative medication procedures and therapies which may prove to help in controlling the symptoms of diabetes. Since diabetes does not have a definitive cure, patients must learn to cope up with the disease and bring about healthy changes to diet and lifestyle in order to lead a close to normal life. A strong mental commitment to fight the disease is the first and foremost step that must be taken in order to beat the symptoms. Any excess weight should be shed off and regular physical activity is highly recommended to diabetics.
Diabetics are also advised to always carry along with them a tag which mentions that they are diabetics who may require assistance in cases of emergencies [4].
Medical checkups, which involve not just the monitoring of the blood sugar levels, but also the checking of sensitive regions for any potential damage caused to the blood vessels and the nerve tissues, should be carried out on a frequent basis. Special attention should be given to the gums, the teeth, the feet and also the genital areas when diagnosed with diabetes.
In case a person diagnosed with diabetes mellitus is a smoker, cessation of smoking must be done at the earliest [5]. Use of this website constitutes acceptance of our [my_terms_of_service_and_privacy_policy]. Science, Technology and Medicine open access publisher.Publish, read and share novel research. Using Gene Expression Signatures to Dissect Insulin Resistance SubtypesBrad Hayward1, Nicky Konstantopoulos1 and Ken R.
The year 2000 data suggest that worldwide over 147 million people have been diagnosed with this deadly disease. It is preferable to measure a fasting glucose level because of the ease of measurement and the considerable time commitment of formal glucose tolerance testing, which takes two hours to complete and offers no prognostic advantage over the fasting test.
Advancements have been made for people diagnosed with this disease to make improvements in their lives.
This is heresy, of course, and the article, the magazine, and the authors have already been condemned and will be burnt at the stake. Now while it’s wonderful that they have now seen the light, or at least are circling around it, hasn’t this been obvious for the last 50 years? It is well know that high insulin is involved in Alzheimers, but the connection wasn’t clear. New research from the Weizmann Institute indicates that not only is the body locked into this cycle, but even our mitochondria are.
Just today, there are three such reports, all on mice, and so it is unknown if the results would carry over. However none of these four have shown any mortality benefit, and all of them have serious side effects. A fourth of those treated saw dramatic reduction in tumor size, while in an additional 11% the tumor completely disappeared, in under two weeks.
Wilson’s” case illustrates a very common problem that can be missed unless you look a little deeper. Many many people have gotten well, have avoided degenerative diseases, have extended their lives.
You, the patient, supply the self-discipline, physical, mental, and spiritual perseverance, and we will supply the information and resources you need to realize the full benefits of Quantitative Medicine.
There will be videos, books, ebooks, ebooklets, on-line analysis tools, in short, everything you will need. It also helps to detect and cure prediabetes, which indicates greater risk of developing diabetes in future. OGTT measures blood sugar after 8 hours of fasting and 2 hours after the intake of a liquid containing 75 grams of glucose dissolved in water. It is a blood test that determines the average blood glucose levels of a person over past 3 months but does not detect daily fluctuations.
It is the most common test used for the diagnosis of diabetes as it is more convenient than other tests like OGTT besides being less expensive. Even the non-chronic types of diabetes, namely prediabetes and Gestational Diabetes leave individuals at a risk of developing Type II Diabetes in the future.
Whatever the type of diabetes may be and whatever treatment plan is being adhered to, care must be taken that the blood sugar levels are monitored on a frequent and consistent basis.
This can be treated with adequate amounts of exercise followed in conjunction with a diabetic diet. Insulin may be injected intravenously or an insulin pump may be used to administer the dose. This is only carried out if some other organ of the body has also failed and requires transplantation such as the kidneys. In case these measures prove to fail in controlling the disease, oral hypoglycemic drugs such as metformin, prandin, glimepiride and pioglitazone are used. People who have a BMI greater than 35 may see improvements in conditions by undergoing this type of surgery. Only 15% of women with gestational diabetes need medications like oral hypoglycemics or sometimes insulin analogues. Weight reduction and exercise increase the body’s sensitivity to insulin, thus helping to control blood sugar elevations.
Ketones are toxic produces of the body when it breaks down fat for energy rather than using glucose. This is likely to happen if, during the course of treatment, a meal is skipped or higher than normal physical activity is undergone.
The signs and symptoms of the condition include the frequent need to urinate, dehydration and dryness, fatigue and blurred vision and the condition requires adjustments made to both the dietary plan as well as the medications used for treating diabetes.
This condition is extremely serious and is known as hyperglycemic hyperosmolar non-ketotic syndrome and is characterized by the sugar present in the blood to turn thick and syrupy. These conditions can potentially be life-threatening and must be controlled at the earliest before too much damage has been inducted. While there are some such therapies, none of them are clinically proven and there is no established or agreed benefit upon resorting to these therapies.
Diabetics must take care to adhere to a strict treatment plan which is recommended and also approved. This means that the diabetic individual will require to actively take measures through all aspects of life and to also seek proper medical treatment. Diabetic individuals are urged to find out as much about the disease as possible, its methods of containment and also the various complications that may be associated with diabetes. This highly increases the sensitivity of the body to insulin and also makes sure that the cells of the body can absorb sugar more effectively. A glucagon kit should also be carried along at all times and the close friends and family of a diabetic should learn how to properly administer insulin in cases of emergencies.
Diabetics are more prone to develop infections and the healing process is also slow in diabetics. These regions of the body are much more prone to infections than other parts and medical attention needs to be provided at the earliest in case of any problems. Not only may the alcohol and the associated mixing drinks upset the diabetic diet, but excess of alcohol can prove to cause complications in diabetics.
Use of tobacco greatly increases the risks of complications and may also lead to the development of cardiovascular diseases in diabetics. This stress will always need to be effectively managed as there is already enough abnormal pressure on the delicate blood vessels and the nerves of a diabetic. A simplified overview of the pathogenesis of type 2 diabetes, encompassing insulin resistance in muscle, adipose tissue and liver, as well as impaired insulin secretion by the ?-cells of the pancreas.
Development procedure for a GES for insulin resistance, based upon (Stegmaier et al., 2004). Stratification of patients according to their similarities to the GES models of insulin resistance. The disease is characterised by peripheral insulin resistance, hyperglycaemia and defective insulin secretion. IGT is characterised by peripheral insulin resistance, while defects in insulin secretion coupled with increased hepatic glucose output characterise IFG (Davies et al., 2000).
As a leading cause of death in hospitals,medical error has been a focal area for almost 20 years.
From UCLA we have a finding that fructose is linked to detrimental changes to hundreds of brain genes.
Given that is know that statins are practically useless, and that niacin actually increases heart problems, you may wonder what they were waiting for. It seems that the enzyme that breaks down insulin is the same one that breaks down amyloid-beta plaque, the tangled mess that is a hallmark of Alzheimer’s. In view of the next news item, the song Java Jive should probably be included in the repertoire. Mitochondria are tiny bacterial like cells found within almost all our own cells that convert the food we eat to energy. There are reports of new neurons grown from stem cells, lost memories reactivate through light flashes, and increasing available neural energy by injecting pyruvate, an intermediate of glucose metabolism.    A very active area. Quantitative Medicine clinical practice has cured adult onset diabetes consistently and repeatedly.
I don’t want to sketch out all of the possible scenarios, including some stages of IRS that can look like “Mr.
The A1C test can be performed at any time of the day and doesn’t require fasting which makes it convenient for patients. This test requires measurement of blood glucose in a person after fasting for a minimum of 8 hours. As such, the signs and symptoms of any type of diabetes must be taken seriously and the only possible methods of treatment include controlling these signs and symptoms and trying to make the bodily functions return to normal. Monitoring is the first step in determining the severity of diabetes and it is then followed up with deciding on the appropriate measures to be taken in order to control the condition.
In some rare cases, oral medication may also be prescribed, especially if there has been a history of preeclampsia or Gestational Diabetes in the past. Active medical and scientific research is being done in order to come up with newer and more convenient methods of externally administering insulin to diabetics. However, this process may yield dangerous effects on the body and also results in higher chances of infections to internal organs. If oral medications are still insufficient, treatment with insulin or insulin analogues like insulin Lispro, insulin Glargin and insulin Aspart are considered useful.
However, any female who has experienced an episode of Gestational Diabetes stands a risk of developing the condition again in subsequent pregnancies and may also develop prediabetes and Type II Diabetes in the future. This condition is known as Diabetic Ketoacidosis and is accompanied with an extreme loss of appetite, a general feeling of weakness and fatigue, nausea and vomiting, stomach pains and also fever. This condition is characterized by a feeling of dizziness, sweating, jitters, extreme hunger, blurring of the vision and palpitation of the heart, confusion, faintness and even seizures. It causes hallucinations, loss of vision, confusion and seizures and can also lead to death.
If individuals are keen on seeking alternative medications and therapies, they should do so only after proper medical consultation. Regular exercise should always be combined with a diabetic diet after taking consultation from healthcare providers or dieticians. The recommended amount of alcohol to be consumed is not more than one drink for a woman and not more than two for a man.
Cessation of smoking is not easy and often, special alternatives and other nicotine products are the starting point to quitting smoking.


Plenty of sleep, meditation and relaxation are recommended to diabetics in order to keep stress levels in check. Use of this website constitutes acceptance of our Terms of Service and Privacy Policy.This website is for informational purposes only. Multiple clinical phenotypes such as abdominal obesity, polycystic ovary (PCOS) and Cushing’s syndromes, lipodystrophies, chronic levels of hyperinsulinemia, acromegaly (elevated growth hormone) and chronic infection are all associated with insulin resistance. Insulin stimulation of FAO hepatocytes decreased glucose production by 34 ± 1% (*, p?0.005 compared with basal cells, n=8). Defective insulin signalling in peripheral tissues including muscle, adipose tissue and the liver, adversely affects whole body glucose homeostasis.
Drucker, 2003Glucagon-like peptide-1 and the islet beta-cell: Augmentation of cell proliferation and inhibition of apoptosis.
Drucker, 2005Biologic actions and therapeutic potential of the proglucagon-derived peptides. The test results after intake of foods can steer the user to better food groups that lower the impact of damage from this disease.
A study published here finds that Zinc Acetate Lozenges shorten common colds by three days. Of course the ADA dietary recommendations are almost guaranteed to prolong AODM, so we suppose some sort of strange logic is at work here. In this article, high intake is worse only for those with high blood pressure, whereas low salt intake is dangerous to those with high blood pressure, and those with normal blood pressure.
However, findings published here in the British Medical Journal.indicate the the problem is far from solved. The mechanism of cancer prevention is unknown, though it doesn’t seem to be caffeine, as decaf works as well.
They apparently have time-driven hungry states, wherein they are ready and willing to convert the food to energy, and sleepy state as well. The idea seems to be to get rid of screening and blood testa altogether, and put everyone over 50 on this pill. This level has the formal name “impaired fasting glucose.” Note too that his HDL is low at 39. Upon switching to the QM diet, his insulin decreased to 10, yet his glucose dropped as well. Insulin cannot be administered orally as the enzymes present in the human stomach interfere with the functioning of insulin. As such, care and treatment procedures will need to be continued throughout the life of the diabetic.
It is recommended that diabetics have more of fruits, vegetables and whole grains in the diet. Exposure of FAO hepatocytes to 75µM PA for 48h decreased insulin-induced suppression of glucose production to only 6 ± 3% (*, p?0.005 compared with PA-treated, basal hepatocytes, n=8).
Impaired insulin signalling, coupled with the eventual exhaustion of ?-cell insulin production, leads to T2D (Fig. Current anti-diabetic treatmentsThe development of both insulin resistance and impaired glucose tolerance, conditions which precede the onset of T2D, are closely linked with obesity (Sharma, 2006). Horton, 2007Progress in the treatment of type 2 diabetes: new pharmacologic approaches to improve glycemic control.
This means the QM diet is making insulin more effective, and hence the QM diet “cured” insulin resistance. Jones” did not have a fasting glucose level near as high as his average of 265 whereas “Mr. Superimposed on this network of interactions is the genetic variability of each individual that confers a differential susceptibility to each insult, adding another layer of complexity. The validated GES can then be used to identify novel treatments, as well as stratify patients. Excess visceral fat, and the hormones and inflammatory factors it releases, coupled with excess free fatty acid release have been implicated in the development of T2D (Mlinar et al., 2007).
If for some reason you have changed to a different test meter or just have any other number of situations that cause you to have additional boxes of test strips. To even embark on this strange experiment shows a callousness and disregard for patient benefit that surprises even us. The body goes to a lot of trouble to keep dietary fructose out of circulation, converting most of it to a concentrated form of glucose called glycogen, and rapidly removing any excess that does get into circulation. A diabetic diet often involves a calorie count which is supposed to be strictly adhered to. However, all of these insults can cause insulin resistance, albeit via different mechanisms. Unlike type 1 diabetes, where insulin therapy can provide effective relief, T2D requires treatment of insulin resistance, in addition to insulin secretion defects. For obese patients exhibiting these symptoms, changes to healthier eating patterns and increases in exercise can result in improvements to glucose tolerance. You just might benefit by visiting our home page, you might just get a big handful of dollars in return for doing so!
The lipid hypothysis—that high LDL cholesterol causes heart disease—is ingrained in the medical community like an eleventh commandment. The reason for this aversion to fructose is not known, but the research sited above may provide a significant clue. Figure 1.A simplified overview of the pathogenesis of type 2 diabetes, encompassing insulin resistance in muscle, adipose tissue and liver, as well as impaired insulin secretion by the ?-cells of the pancreas.
However this approach often fails within the first year of treatment, and therefore the use of various medications is usually required (Nathan et al., 2006).
Besides a major sugar component of fruit, table sugar is a 50-50 mix of fructose and glucose, as is high-fructose corn syrup, a ubiquitous food additive. Proposed subtypes of insulin resistance and the insults which can lead to their genesis in cell models.
Lifestyle changes immediately following the diagnosis of T2D can often be successful in the early treatment of the disease. This alarming figure is growing rapidly, with 1.9 million people being newly diagnosed in 2010 alone (CDC, 2011). Unfortunately, a lack of diagnosis, coupled with difficulties in maintaining lifestyle changes, means that this is not a treatment option which will be effective in the long term for all patients (Nathan et al., 2006). Please feel free to forward our web site address to other family or friends, co-workers and the such.
Diabetes represents a significant health burden to the US, both in terms of the number of patients currently living with diabetes, and the huge number of patients estimated to develop diabetes in the coming years. Klip, 2009Direct and macrophage-mediated actions of fatty acids causing insulin resistance in muscle cells.
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It has been estimated that there are currently 79 million adults in the US who are pre-diabetic (as determined by fasting blood glucose or HbA1c levels). Its mechanism of action involves a reduction in hepatic gluconeogenesis, leading to a reduction in blood glucose levels (Knowler et al., 2002).
Burden, 2000Impaired glucose tolerance and fasting hyperglycaemia have different characteristics. Jones” needs to be careful to eat every three hours, including a bedtime snack to help stabilize his liver’s response to insulin, and “Mr. The costs associated with managing the diabetes epidemic were recently estimated at $174 billion annually, and this figure is set to increase in the coming years.
The projected increase in the prevalence of diabetes, coupled with the already significant economic costs associated with the disease, make the development of alternative effective treatments an urgent priority.2.
Metformin has a number of side effects including gastrointestinal symptoms and has been linked with rare cases of lactic acidosis which can be fatal, although evidence for this has been contradicted in some studies (Salpeter et al., 2006).
Clearly there are overlaps in the dietary advice each should get but the focus and guidance and ability to comply differs by personality.
Metformin is one of only two oral anti-diabetic agents on the WHO list of essential medicines. And this is where the external and objective guidance of numbers needs to work with the internal and subjective character of each of us.
The Australian Diabetes, Obesity and Lifestyle study found that half of all subjects studied who were suffering from T2D had not been previously diagnosed (Dunstan et al., 2002). The second oral anti-diabetic to be listed by WHO is the drug family known as the sulfonylureas, the most commonly used drug of which is glibenclamide. Predictors of risk for the development of T2D and cardiovascular disease include body mass index (BMI), ethnic origin, blood pressure and cholesterol levels (Gavin et al., 2003).
Yu, et al.2000Distinct types of diffuse large B-cell lymphoma identified by gene expression profiling. Current clinical guidelines for the diagnosis of diabetes however are based upon blood glucose measures. For this reason, the sulfonylureas show their best efficacy in the early stages of the disease when ?-cell function is still viable.
The World Health Organisation (WHO) standard criteria for diagnosis of T2D involve fasting plasma glucose (FPG) and the response to an oral glucose tolerance test (OGTT). Side effects associated with the sulfonylureas include hypoglycaemia due to their long half life in plasma, and weight gain.The glinides are a family of drugs with a mechanism of action similar to the sulfonylureas, in that they bind to the same receptor – although at a different binding site – to induce insulin secretion from the ?-cells of the pancreas. FPG is a measure of plasma glucose after 8 hours of fasting, while the OGTT measures plasma glucose 2 hours following an intake of 75 g glucose. The glinides have an advantage over the sulfonylureas in that they have a shorter half life in blood plasma.
TZDs are ligands for the nuclear transcription factor peroxisome proliferator-activated receptor ? (PPAR?). It is through transcriptional regulation of PPAR? that this family of compounds increase the sensitivity of muscle, liver and adipose tissue to the effects of insulin (Yki-Jarvinen, 2004).
Troglitazone, first approved for use in T2D patients in 1997, was withdrawn from the market in 2000 after it was linked to a number of cases of liver dysfunction and failure (Watkins, 2005).
The widely used alternative rosiglitazone has in recent years been linked to increased cardiovascular disease (Nissen and Wolski, 2010). While still available in the US, rosiglitazone is currently branded with additional safety warnings and restrictions on its use, and sales in recent years have fallen significantly (GlaxoSmithKline, 2010).Exogenous insulin is a very important therapeutic agent for the treatment of diabetes, capable of increasing blood insulin levels when ?-cell function has been impaired, and can be given in increasing amounts to overcome insulin resistance.
However, insulin is also associated with increases in weight gain, as well as risk of hypoglycaemia if monitoring of blood glucose levels is not rigorously performed.Glucagon-like peptide 1 agonists (GLP-1 agonists) are mimics of a protein secreted by the L-cells of the small intestine. GLP-1 agonists have also been shown to stimulate ?-cell proliferation (Drucker, 2003, 2005) and suppress glucagon release and gastric motility, while inducing weight loss. Amylin lowers blood glucose levels by inhibiting glucagon secretion following a meal, and induces satiety by acting upon the area postrema (AP) neurons within the brain stem (Potes and Lutz, 2010). While amylin forms aggregates which make it unsuitable as a therapeutic agent, amylin agonists such as pramlintide can effectively simulate the effects of the physiological amylin. Like GLP-1 agonists, amylin agonists can also induce nausea in patients (Schmitz et al., 2004).
Problems and adverse effects of current drug therapiesAs highlighted above, the currently used range of antidiabetic medicines have a number of adverse side effects, including hypoglycaemia, fluid retention and weight gain, and gastro-intestinal symptoms. As T2D generally progresses over time to a worsening in glycaemic control, the need to utilise multiple therapies together is unfortunately the reality for many patients with T2D (Nathan et al., 2006). Difficulties in managing T2D are exacerbated by the fact that the various drugs available have a wide range of effects in individual patients, in terms of the magnitude of both efficacy and side effects. In addition to these factors, many of the current drugs used to treat T2D lose their efficacy over time (Cohen and Horton, 2007). Therefore, the focus of new treatments has to be on how to personally tailor pharmacotherapy to suit each patient’s characteristics. We believe that the reason why current therapies are not effective in all patients is that they do not address the heterogeneous nature of T2D. A number of different subtypes of insulin resistance have been described, in a number of different tissues and due to varying insults. If effective treatments for T2D are to be developed, there is a need to gain a better understanding of the different subtypes of insulin resistance. Then, the development of new treatment regimes which specifically target the various subtypes of insulin resistance will be possible – enabling the development of a personalised medicine approach to T2D.3. Insulin resistance subtypesInsulin resistance is a major risk factor for the development of T2D (Lillioja et al., 1993). Combating insulin resistance is therefore a key to developing effective treatments for T2D. The etiology of T2D is multifactorial, with both genetic and environmental factors involved (Bergman and Ader, 2000). Likewise, the onset of insulin resistance is multifactorial and can occur in different tissues and arise from multiple causes as depicted in Fig.
Insults to insulin action can be both endogenous, such as inflammatory cytokines released in response to a fatty meal, and exogenous, such as the fatty acids themselves, which can lead to the development of insulin resistance. We propose that there may be multiple factors contributing to insulin resistance in an individual. We aim to identify a “signature” or “profile” for each of the causative agents of insulin resistance. Profiling of patients could then allow the determination of which subtypes of insulin resistance each individual has.
One such subtype of insulin resistance is that caused by increased saturated fatty acid levels in some obese individuals.
We hypothesise that we can use the profiles to identify a main contributing subtype to a patient’s insulin resistance. Then we will aim to specifically target that subtype (or subtypes) in an individual for longer term and personalised management of their metabolic dysregulation.
ObesityThe most commonly associated disorder linked with the onset of insulin resistance is obesity (Cummings and Schwartz, 2003; Granberry and Fonseca, 1999). Obesity is widespread in the western world, with the recent US National Health and Nutrition Examination Survey (NHANES) finding that 67% of Americans aged 20 and above are overweight or obese, with 34% being obese (NCHS, 2008).


The WHO estimates that in 2005 there were 1.6 billion adults worldwide who were overweight, at least 400 million of who were obese. These numbers are projected to increase to 2.3 billion overweight and at least 700 million obese adults by 2015 (WHO, 2006). The increasing epidemic of obesity will further increase the prevalence of insulin resistance and T2D within society, making the development of effective treatments a critical challenge for the 21st century.As one of the primary risk factors for the development of T2D, obesity warrants extensive study as a target for the development of additional and alternative therapies.
Increased availability of free fatty acids (FFA) in patients with obesity plays a critical role in the development of insulin resistance (DeFronzo, 2004). There are numerous factors in obesity which can lead to increases in circulating free fatty acids, including exceeding the storage capacity of adipose tissue by excess caloric intake (Langeveld and Aerts, 2009), and adipose tissue stimulation by the paracrine tumour necrosis factor alpha (TNF?) which induces triglyceride metabolism and free fatty acid release (Ruan and Lodish, 2003).
Insulin resistance in adipose tissue can also lead to excess fatty acid release, due to suppression of the antilipolytic effects of insulin (Ruan and Lodish, 2003).
The direct effects of increased circulating free fatty acids on macrophages to stimulate release of pro-inflammatory cytokines such as TNF? and IL-6 has also been recently described (for a review see (Bilan et al., 2009)). The onset of insulin resistance caused by free fatty acids is therefore highly complex, and although direct action upon target tissues have been described, there are secondary actions upon other tissue types which further complicate the pathology of the disease. Given the increasing prevalence of obesity around the world, dissecting the mechanisms by which free fatty acids contribute to insulin resistance may identify new avenues for effective treatment regimes4.
Classical single target-based approachesClassical approaches for dissecting insulin resistance involve targeting signalling defects in both in vitro and in vivo models of insulin resistance. These approaches – including western blotting for proteins and PCR for genetic data have enhanced our knowledge of insulin resistance and the mechanisms by which insulin signalling is impaired. However such approaches rely upon previous knowledge to build a network of signalling connections, and implicating signalling defects in the observed in vitro or in vivo model being observed. As is becoming increasingly clear, signalling networks within cells are far more complicated than previously thought. Single insults (such as fatty acids) not only impact upon insulin signalling directly, but also on numerous signalling cascades such as inflammatory pathways, which may be either distally related to insulin signalling or not related at all. This will result in activation of many kinases, and modification of transcription of a number of genes, in the process of the cell reaching an equilibrium state.We now know that the single target or pathway approaches provide too narrow a window to appreciate the changes induced in complex disease states. Utilising insulin signalling endpoints such as hepatic glucose output or muscle glucose transport can provide a more global overview of the cellular state compared with the phosphorylation of a single kinase amongst a signalling network. The discovery of new therapies targeted against endpoints allow us to bypass the upstream complexity that hinders the target-based approaches.
Current mass spectroscopy techniques allow for the study of nearly the entire lipid or protein fraction of a sample, allowing characterisation of disease states in an unprecedented way. The requirement to investigate and treat many diseases with multifactorial natures has necessitated the need for more powerful technologies to give researchers a “global” view of disease states. The search for effective early diagnostic tools, insight into the development of disease states, and the development of new therapies are increasingly relying on one or more of these new platform approaches.In the context of obesity, lipidomic approaches are proving to be very useful in identifying characteristic changes in tissue-specific lipid profiles of patients with T2D (Meikle and Christopher, 2011), which has been made possible by advances in mass spectroscopy techniques.
Genomics-based approachesDeveloped in the mid 90’s for the analysis of the expression of multiple genes in parallel (Schena et al., 1995), microarray technology can now be used to assess the expression of tens of thousands of genes in a sample simultaneously.
This provides a powerful tool to assess whole cell transcriptional events for any given cell or tissue in any biological state.
Microarray technology has a range of applications including identifying disease-causing genes, identifying targets for new therapies and prediction of drug responsiveness (Jayapal and Melendez, 2006).Two major applications for microarray technology involve examining gene sets for pathway analysis, and examining differentially expressed genes between two or more experimental conditions (Kauffmann and Huber, 2010). Gene set enrichment analysis (GSEA) involves taking a gene list, ranked according to the difference in expression between the phenotypes or treatments being investigated.
The goal of GSEA is to determine whether members of specific gene sets (grouped on functional similarity), are ranked together towards the top or bottom of the list.
This pathway analysis approach to dissecting disease is complimented well by proteomic approaches which can similarly be used for pathway analysis.The second of the two applications involves performing microarray analysis on gene sets from multiple experimental conditions, and can be used to identify differentially expressed genes in differing disease states.
This ‘shotgun’ style approach to genome analysis can yield previously unknown information about the regulation of disease states at the transcriptional level, which can have important implications for understanding the pathophysiology of disease.
The set of differentially expressed genes can also be used for a diagnostic approach to the disease.
Applying Bayesian Linear statistical modelling to gene sets allows for selection of a relatively small gene set which can characterise the particular biological state of the cell or tissue being investigated (Smyth, 2004). This process statistically evaluates which set of genes have the greatest differential expression between the conditions tested, and identifies a ‘fingerprint’ indicative of the biological state of the cell or tissue involved, known as a gene expression signature (GES). Previously, GESs have been applied to the field of cancer research, for applications such as classifying tumour types and predicting tumour response to chemotherapy.
By classifying tumours into distinct types, and with knowledge of how each type will respond to particular therapies, clinicians are therefore able to treat patients more effectively by personalising treatment regimes (Lee et al., 2007). Personalised medicine approaches such as this are becoming increasingly important tools in fighting diseases and the use of GES are likewise increasing in disease research.5. Gene expression signatures as a diagnostic toolFirst described in 2000, GESs were developed in the field of cancer research.
The differences in patient response to therapies led researchers to believe that groups of cancers that were not able to be histologically characterised were actually a heterogeneous group of tumours. Seeking a non-biased method for classification, gene expression data was investigated to search for patterns which could differentiate classes of B-cell lymphomas with differing patient survival rates (Alizadeh et al., 2000). The main outcome of the study was the finding of two subgroups, classified on the basis of differential gene expression of hundreds of genes, with differing survival outcomes for patients. This early study was instrumental in highlighting the use of gene expression data as a disease classification tool.
The power of the GES approach is that entire genome datasets are narrowed down to the smallest number of genes capable of robustly characterising differences between biological samples. Using complex statistical analysis of large datasets, the prediction power of these small subsets of genes has been shown to be equivalent to the whole dataset.
Once developed, the GES tool allows for rapid, reliable characterisation of various cellular states, which has a number of important applications.Accurate classification of disease states plays a vital role in diagnosis and treatment. The use of GESs for the discovery and development of new therapies is perhaps the most promising application of this technology. The use of GESs to develop new therapies is especially powerful when a specific endpoint is known, but intermediate signalling steps or the molecular targets have not been identified. Provided a model for the disease of interest has been developed, high throughput screening of small molecule libraries can be performed by assessing the effects of those agents on the mRNA levels of the genes identified as the GES. The GES approach has been used in a number of cancer models to identify new therapies, which have increased efficacy over current treatments. For acute myelogenous leukemias, the identification of inducers of terminal differentiation has opened up new therapeutic avenues previously unavailable (Stegmaier et al., 2004). What makes GESs unique is that the GES genes are not limited to genes known to be involved in the particular physiological process being investigated. A GES is the minimal set of genes that best defines the difference between two biological samples – be that a disease state or the physiological response to a particular drug or chemical.
While it is possible that a GES gene plays a role in the specific model being investigated, it is also possible it does not, and thus any conclusions based upon the identity of genes in the GES must be confirmed with subsequent studies.6. Application to dissecting insulin resistance subtypesWe propose that GESs can be applied to dissect and study insulin resistance subtypes. The GES methodology described here can be undertaken in either animal tissues or cell culture models. Due to the high reproducibility required when extracting the data from relevant platform technology (for example, microarray), we have found that working in cell culture systems is the most robust and consistent approach. Once the GES is developed from a cell culture model, the biological relevance of an in vitro-derived GES requires validation in human tissue. Validation of the GES in human cohorts tests for a correlation between the homeostasis model assessment (HOMA) measures of insulin resistance, based upon plasma glucose and insulin levels (Matthews et al., 1985), and similarity to the GES profile for each subject. If it can be shown that those patients whose expression profiles were most similar to the GES showed a greater degree of insulin resistance as indicated by the HOMA score, the GES is considered to be valid in human tissue. The modelling of insulin resistance subtypes in the GES models involves the use of a specific insult to induce insulin resistance which are known to cause insulin resistance in individuals.
Such insults include saturated fatty acids (PA) or mediators of chronic inflammation (TNF?).The development of a GES in cell culture requires modelling three distinct cellular states relating to insulin sensitivity. This is achieved by treatment of the target cells with the insulin resistance insult such as TNF? or PA. The third state represents a ‘recovered from disease’ state, which is achieved by treating insulin resistant cells with a cocktail of antidiabetic agents to restore insulin action. The definition of these three states is deliberate and critical to the integrity of the GES. In order to determine which genes are being affected due to insulin resistance and not non-specific changes induced by the insult per se, the changes induced by the ‘recovered from disease’ state was then assessed.
Only those genes whose expression levels were significantly changed in the ‘diseased’ state, and then changed again in the reverse direction in the ‘recovered from disease’ state are used for the development of the GES.
Characterising insulin resistance in vitroIn order to effectively model insulin resistance in vitro, an endpoint measure of insulin action is required.
Cell-based models offer a number of assays which can be used to determine insulin signalling in both sensitive and insulin resistant states. In vitro models of insulin resistance can be developed in each of the main insulin sensitive tissues; muscle, adipose and liver. In liver cells, regulation of gluconeogenesis by insulin is one of the key endpoints of insulin action. These assays work by measuring the relevant endpoint (glucose uptake or gluconeogenesis) in the presence and absence of an insulin resistance insult to characterise insulin resistance.
As the in vitro cell culture model must be manipulated from healthy to diseased and then restored, a robust and large dynamic range is needed in the bioassay used to measure the insulin resistance endpoint parameter.Reversal of insulin resistance involves assessing a wide range of known insulin sensitisers in the model of choice. A combination therapy which is able to fully reverse insulin resistance is selected, based upon its ability to not only reverse insulin resistance, but also avoid negatively impacting upon cellular viability.
Combination therapy is required, as this will ensure that the GES is characteristic of an insulin resistant state which has been reversed by a multi-target approach.
There is a greater chance that in drug development the GES will identify novel therapies, rather than the individual therapies used in its creation – as may happen with a single treatment GES.
Personalised treatment for patientsThe GES holds promise for personalised treatments for patients by allowing the stratification of patients based on subgroups of insulin resistance. Once patients are sub grouped, treatments can be personalised to their individual diagnosis, leading to improved health outcomes. The subgrouping of patients according to the GES involves measuring the expression levels of the GES genes in the patient. Regardless of which tissue or cell type the GES is derived from, a non-invasive, easy to obtain sample is needed to facilitate screening of as many individuals as possible. Lymphocyte gene expression profiles have been shown to correlate well with gene expression profiles of insulin responsive tissues including liver and adipose tissue (Iida et al., 2006). We propose that by measuring the expression levels of the GES genes in a patients white blood cells we can subtype patients according to one or more GES. The GES which best correlates with the gene expression pattern of a patient’s white blood cells will therefore indicate a specific avenue of treatment for that patient (see Fig. Development of “targeted” therapiesThe GES can be used to aid in the development of new therapies for T2D, by allowing for high throughput screening for new drugs with insulin sensitising and antidiabetic properties. Screening involves treating cells with chemical libraries, which can include previously known and marketed drugs.
After screening the GES genes in the treated cells, the key analysis is comparing the GES genes in the treated cells with the GES profile of the specific model being used. Those chemicals which mimic the GES profile of successful reversal of insulin resistance are identified as the most promising candidate drugs.
We propose that new therapies identified via this approach may show increased efficacy in treating patients subtyped by the same gene expression signature. Using 3T3-L1 adipocytes as the cell-based model, we identified 3325 genes whose expression was altered by the induction of insulin resistance by TNF?. Of those genes, only 1022 showed altered expression by the reversal of insulin resistance with the insulin sensitisers aspirin and troglitazone. From those 1022 genes, a set of 5 genes were selected whose combined expression profile gave the highest predictive power to differentiate the insulin resistant state, and the re-sensitised state.As described above, GESs can be used for screening of patients with T2D. We evaluated this by assessing whether the in vitro-derived GES for TNF? could characterise insulin resistant subtypes in a human cohort. The TNF? GES of 5 genes was detected in the human profile dataset, and GES score assigned – comprising the sum of the absolute values of the standardised expression units of each of the 5 genes. This correlation is consistent with the use of GES technology to characterise an insulin resistant subtype in this population.In vitro screening of compound libraries has also been used in this model, assessing the ability of a given compound to affect the genes identified in the GES (Fig. We conducted a series of studies to assess what role (if any) the GES genes might play in the development of insulin resistance. Our investigation of the GES gene STEAP4 was mirrored by the results of data published at that time which showed that STEAP4 protects against inflammation and metabolic dysfunction (Wellen et al., 2007). The cell model has been established in FAO liver cells, with insulin resistance achieved after incubating the cells with 75µM PA for 48h. This insulin resistant phenotype has been reversed by treating PA treated cells with 0.25mM metformin and 2mM sodium salicylate (NAS) in the final 24 hours of PA incubation (Fig.
We anticipate that the PA derived GES will identify an insulin resistant subpopulation from the cohorts we test it in.
A key comparison with the different GES models will be the identity of the subgroups identified, and the degree of overlap (if any) observed in the groups. Drug screening, as well as investigation of the GES genes will also be performed for the PA derived GES. ConclusionThe use of ‘omics’ style approaches to disease states such as T2D are becoming increasingly accepted as one way research should investigate these diseases in the 21st century. The success of GES technology in the cancer field as both a diagnostic tool and a drug discovery tool is becoming increasingly apparent, and we have shown this technology is equally applicable to the study of T2D. As disease research is progressing towards the development of personalised medicine as the ‘holy grail’ for treatment regimes, we foresee a future where personalised medicine is seen as the gold standard for patient care. We believe GES technology will provide a platform for the development of novel, personalised treatments for patients with T2D.8.



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Comments

  1. 03.08.2015 at 15:20:25


    Hemoglobin A1c and fructosamine tests.

    Author: Alisija
  2. 03.08.2015 at 12:17:50


    Many diabetes educators, registered the bloodstream to hold you.

    Author: SINDIRELLA