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John L.

Leahy, MD

Natural History of P-Cell


Dysfunction in NIDDM

Non-insulin-dependent diabetes mellitus (NIDDM)


is characterized by insulin resistance and p-cell
dysfunction. This review focuses on the p-cell, what
defects occur when and why. Two major anatomic
observations have been made in NIDDM. The p-cell
mass is mildly reduced, especially when obesity is taken
into account. Also, amyloid deposits are frequently
observed in the islets. It is unclear whether these
changes are genetically mediated or result secondary
to the loss of glucose homeostasis. Many studies have
looked at some aspect of insulin secretion in NIDDM,
and two types of distinct abnormalities have been
described. Early on, there is a marked disruption in
pulsatile insulin delivery, which is potentially an
important contributor to the insulin resistance. It is
unclear whether the loss of pulsatile delivery is acquired
or genetically induced. Later, after glucose intolerance
has started, several other secretory abnormalities
develop coincident with loss of p-cell glucorecognition.
The net result is further deterioration in timing of
insulin delivery and postprandial hyperglycemia. A
second important consequence of the glucose blindness
is that the inherent compensatory p-cell mechanisms
that guard against hyperglycemia are bypassed. We
propose that the loss of glucose responsiveness is a
direct result of an elevated glucose concentration (socalled glucotoxicity) and have generated substantial
data in rat models that support this idea. The logical
conclusion is that P-cell function in NIDDM can be
maximized by achieving the best metabolic control
possible. Diabetes Care 13:992-1010, 1990

From the Research Division, Joslin Diabetes Center, and the Department of
Medicine, New England Deaconess Hospital and Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
Address correspondence and reprint requests to John L. Leahy, MD, Research
Division, Joslin Diabetes Center, 1 Joslin Place, Boston, MA 02215.

992

n simplest terms, glucose tolerance is normal when


insulin secretion and insulin needs perfectly balance. The relationship is a dynamic one; numerous
environmental and physiological influences at various stages of life make us less insulin sensitive (1). The
fact that only a small percentage of people become diabetic as they grow older, less active, and fatter attests
to the system's ability to compensate. The regulatory
component is the endocrine pancreas working through
a classic negative feedback loop; a rising plasma glucose level stimulates insulin secretion and, over a longer
period, promotes growth of more p-cells (2,3). Indeed,
as the complicated fluctuations in insulin release that
occur throughout the day are better appreciated, the
preciseness of the system is marvelous (4).
Non-insulin-dependent diabetes mellitus (NIDDM) is
characterized by glucose intolerance, and the debate
has raged for more than two decades whether insulinsecretory dysfunction or insulin resistance is the cause
(5,6). Current understanding is that NIDDM is a genetic
disorder, probably of a heterogenous nature, and that
insulin secretion and insulin sensitivity both must be
defective to get full phenotypic expression (7). No convincing data have yet proved whether one type of defect
predates the other, and it remains to be determined
whether both are genetically mediated or one causes
the other. The ideal approach would be to take individuals who have inherited the NIDDM gene(s) and to
study them years before the onset of glucose intolerance. However, the lack of genetic or functional markers effectively precludes this strategy. Several groups
have instead used people at increased risk for NIDDM,
e.g., children of parents with NIDDM, women in remission from gestational diabetes, and certain ethnic
populations with high incidence rates. These studies
have not settled the "which comes first" dilemma. They

DIABETES CARE, V O L . 13, N O . 9, SEPTEMBER 1990

I.L. LEAHY

have, however, contributed to the understanding of the


natural history of p-cell dysfunction and insulin resistance by providing glimpses of abnormalities in euglycemic individuals.
This review focuses on (3-cell function in NIDDM,
what defects occur and when, their possible causes, and
what implications they may hold for treatment and prevention of the disease. This article is not a comprehensive discussion of the pathogenesis of NIDDM: readers
wanting to learn more about the controversy between
(3-cell dysfunction and insulin resistance are referred to
reviews from some of the leading investigators in the
field (8-12).

INTERPRETATION OF INSULIN-SECRETION STUDIES


Many studies have examined some aspect of insulin secretion in NIDDM. Usually, fasting insulin values or
stimulated responses are compared directly with those
of nondiabetic control subjects. This approach is not
unreasonable when the aim is to determine, under basal
conditions, whether tissues are exposed to subnormal
concentrations of insulin. Studies that try to prove or
disprove that (3-cell function is normal are faced with a
much more difficult challenge. The complex nature of
p-cell secretory responses makes it nearly impossible to
control for all of the variables that affect insulin output.
Some of the better-known examples follow.
Ambient plasma glucose concentration. The insulinotropic effect of most secretagogues varies with the
plasma glucose concentration. Increasing the glucose
level in healthy subjects from basal to 10 mM causes
insulin responses to standardized challenges to rise as
much as 5-to 10-fold (13-15). It follows that studies on
NIDDM and nondiabetic control subjects should be
conducted at the same glucose value. Some authors
have even argued that matching glucose values is not
enough but that responses should be mapped out over
a wide range of glycemia (16).
Mass of functional p-cells. The quantity of p-cells determines how much insulin is released to a particular
stimulus (17). Although there is some disagreement,
studies that used modern techniques generally found
that the (3-cell mass in NIDDM is reduced (18,19). Reversal studies where insulin responses are compared before and after treatment routinely underestimate benefits
by failing to consider the smaller |3-cell mass.
Degree of insulin resistance. Plasma insulin levels
(fasting and stimulated responses to standardized challenges) vary in an inverse fashion with insulin sensitivity
(20-23). In other words, insensitive people put out
more insulin than sensitive individuals to the same stimulus. To negate this effect, insulin-secretion studies in
nondiabetic subjects are routinely performed in age- and
weight-matched subjects. The practice has carried over
to studies between NIDDM and nondiabetic control
subjects, which defeats the original purpose because of
the diabetes-associated insulin resistance (11).

DIABETES CARE, VOL. 13, N O . 9, SEPTEMBER 1990

Factors that preclude direct comparison of plasma


insulin values in diabetic and nondiabetic subjects.
The last few years have seen the emergence of techniques to directly measure the insulin secretion rate in
humans (24-26). Few studies have used this technology, so that much current knowledge is based on the
assumption that plasma insulin levels (basal and stimulated responses) are reasonable indicators of insulin
output. The presumption is that two people with the
same values have the same output, whereas a difference
indicates dissimilar output. Recently, several factors
have been identified that raise serious doubts about the
validity of directly comparing insulin values in diabetic
and nondiabetic subjects. First, after being released into
the portal vein, 50% of secreted insulin is degraded during its first pass through the liver (27). It has been suggested, based on insulin-C-peptide ratios, that a smaller
percentage is lost in NIDDM (28,29). Second, all insulin
assays cross-react to some degree with proinsulin.
Therefore, insulin measurements are a mixture of insulin
and its inactive precursor (30). In NIDDM, proinsulin is
present in unusually large amounts, artifactually raising
insulin values (31,32). Finally, insulin is released as a
complicated series of oscillations and postprandial
spikes (4). In NIDDM, this pulsatility is profoundly disrupted (33,34), but there is no indication of this fact in
either fasting or stimulated plasma insulin values. Both
are indistinguishable from those of nondiabetic control
subjects (34).
In summary, we have learned a great deal about insulin secretion in NIDDM without having taken into account the factors listed above. They are most important
when trying to interpret quantitative insulin output.
Missing responses and aberrant patterns of release are
still identifiable. In contrast, the literature is replete with
statements about normal versus abnormal (3-cell function based on quantitative data when many or all of the
relevant variables have been ignored. When viewing
these data, readers should use caution and follow the
dictum that appropriate insulin secretion will continue
to be a difficult concept until all of the factors that affect
the secretion rate are defined and routinely controlled.

P-CELL MASS AND MORPHOLOGY IN NIDDM

When studying (3-cell function in NIDDM, a key question becomes: Are p-cells present in normal amounts,
and are they structurally intact? No single large study
has quantified p-cell mass in NIDDM, but there are several small studies that together comprise a sizable number of patients. Studies combining quantitative
morphometry with either histochemical (35,36) or immunocytochemical (18,19) techniques generally have
agreed that p-cell mass is modestly reduced compared
with that of age-matched control subjects. Stefan et al.
(37) reported no overall difference in 3 NIDDM subjects
and 13 nondiabetic subjects. However, their data also
show a decrease when the diabetic subjects are com-

993

P-CELL DYSFUNCTION IN NIDDM

pared to the control subjects closest in age. The study


by Kloppel et al. (18) is particularly noteworthy, not
only because it is one of the largest, but because it controlled for the presence of obesity. The major findings
are shown in Table 1. In control subjects, obesity caused
a doubling of @-cell mass, which points out how important weight matching is in this kind of study. Furthermore, both groups of diabetic subjects had clearly
reduced |3-cell masses. The only dissenting article found
complete overlap between 8 NIDDM patients and 8
age-matched control subjects (38). Of interest, most
other studies have used patients with long-standing diabetes, and 4 of their patients were of recent onset. Also,
no indication is given about how the groups matched
for obesity.
The finding of a modestly reduced (3-cell mass is made
even more impressive by the understanding that insulin
resistance, unassociated with glucose intolerance from
obesity, Cushing's disease, and acromegaly (18,39,40),
and sustained hyperglycemia (3,41,42) are both potent
stimulants for compensatory p-cell growth. Taken together, the (3-cell mass in NIDDM is clearly far below
what would be expected given the metabolic demands.
Is the decrease specific for (3-cells? The data concerning
the other islet cells (non-P-cells) are not definitive: normal (19,37,38) and reduced (18,36) non-p-cell masses
have both been reported.
Morphologically, the islets appear normal. Insulitis is
never present (43). Also missing is evidence for the hyperactivity that might be expected in response to hyperglycemia: few mitotic figures are found (3,18,43),
and overt (3-cell degranulation is unusual (44). An exciting recent development concerns amylin or islet amyloid polypeptide, the protein that makes up the amyloid
deposits that appear frequently in the islets of people
with NIDDM (45-47). Amyloid infiltration was first associated with diabetes about 90 years ago (48). Until
recently, it was thought to hold no particular significance. One reason for the lack of interest was that amyloid deposits were occasionally found in nondiabetic
elderly people (49).
Amylin has been cloned (50,51) and its biochemistry
and molecular biology studied (45-47). It is a 37-amino
acid protein that is produced normally by the (3-cell,
copackaged with insulin in secretory granules (52), and
cosecreted into the sinusoidal space (53). For unclear
reasons, in NIDDM, this material tends to accumulate

extracellularly in close contact with (3-cells and to form


fibrils (54). There is increasing interest that these fibrils
could lower functional p-cell mass either by plugging
up the sensing and/or secreting areas of the cell or
through direct cellular breakdown (45,46). The best evidence supporting a role for amylin has been obtained
in spontaneously diabetic monkeys, where the appearance of amyloid directly precedes glucose intolerance
and its extent correlates with the severity of diabetes
(55).
Recently, the amylin story has taken an unexpected
twist. In pharmacologic amounts, amylin has been reported to lower basal and insulin-stimulated glycogen
synthetase in muscle (56,57) and to inhibit glucose-stimulated insulin secretion from isolated rat islets (58).
These abnormalities are the same ones acknowledged
to be the key insulin-secretion and insulin-resistance defects in NIDDM. The question yet to be answered is
whether physiological concentrations produce the same
effects.
In summary, the major anatomical findings are a reduced p-cell mass and the occurrence of amyloid deposits. The key question is to determine when these
changes occur: Do they predate the onset of glucose
intolerance? Could a genetic defect that prevents (3-cell
mass from being maintained above a critical level, or
one that causes amyloid to accumulate, be a candidate
for what causes the susceptibility to hyperglycemia? In
humans, there is a dearth of information on (3-cell mass
and amyloid infiltration in prediabetes. Alternatively,
could these observations be secondary to glucose intolerance? In animals, it has been reported that long-term
severe hyperglycemia has a cytotoxic effect on (3-cells,
but the relevance of this observation to NIDDM is unclear (59,60).

INSULIN SECRETION IN NIDDM


Several distinct defects in insulin secretion have been
identified in NIDDM. This section describes each in detail and how they might contribute to glucose intolerance. A later section covers the time of onset.
Fasting and 24-h plasma insulin values. Thirty years
ago, Yalow and Berson (61) showed that NIDDM could
not be blamed simply on inadequate insulin delivery.
They found, with their newly developed radioimmu-

TABLE 1
Pancreatic morphometry in obese and nonobese NIDDM and control subjects

(3-Cell volume (ml)

Nonobese control (n = 7)

Nonobese NIDDM (n = 8)

Obese control (n = 4)

Obese NIDDM (n = 6)

0.21 0.10*

0.11 0.03*

0.40 0.02t

0.20 0.10t

Data are means SD. Statistical analysis was performed with Mann-Whitney U test. Morphometry was performed by point-counting method
of Weibel on whole pancreas minus pancreatic polypeptide lobe. NIDDM, non-insulin-dependent diabetes mellitus. Data taken from Kloppel
etal. (18).
*P < 0.001 nonobese control vs. nonobese NIDDM.
tP < 0.01 obese control vs. obese NIDDM.

994

DIABETES CARE, V O L . 13, N O . 9, SEPTEMBER 1990

J.L LEAHY

noassay, that insulin levels in maturity-onset patients


were at least the equal of control subjects. That study
was not matched for degree of obesity, but DeFronzo
(11) has reviewed 32 others performed in nonobese subjects, and in none were insulin levels subnormal. Several investigators have expanded on this observation,
showing that there is a definable pattern to the fasting
insulin level, the so-called inverted-U-shaped curve
(62-64; Fig. 1). Early on, insulin values are slightly increased. With worsening glycemia, they rise, peak at a
glucose value of 7.8 mM, and thereafter fall back to the
control range. Even in the face of marked hyperglycemia, overt hypoinsulinemia is rare (65). Insulin profiles (multiple samples collected throughout the day)
have shown the same results. Severely hyperglycemic
subjects, especially those who are obese, tend to have
delayed and decreased postprandial responses, but lesshyperglycemic subjects maintain insulin levels in the
normal range (66-68) throughout the day.
Based on these results, the prevailing opinion is that
NIDDM is never characterized by hypoinsulinemia and
that, early on, patients are frankly hyperinsulinemic. This
widely held belief needs rethinking because of recent
changes in our understanding of insulin measurements.
All of these studies were conducted with insulin radioimmunoassays that cross-react not only with insulin
but also with insulin precursors, the best known being
proinsulin. The amount of proinsulin secreted compared
with insulin is trivial (69). Its clearance rate, however,
is considerably slower, so that proinsulin comprises 1525% of a normal insulin value (32,70,71). Studies in the
1970s that used chromatographic techniques showed
that proinsulin made up an even larger fraction in
NIDDM (72-74), and this observation has been con-

25

Fasting
Plasma
Insulin
(uU/ml)

20

l5

IO

5 -

L L
60

100

140

180 220 260

300

Fasting Plasma Glucose (mg/dl)


FIG. 1. Fasting immunoreactive plasma insulin levels in
nonobese subjects stratified by level of glycemia. From
DeFronzo et al. (63).

DIABETES CARE, V O L . 13, N O . 9, SEPTEMBER 1990

firmed by several laboratories with specific proinsulin


assays (32,71,75-78). There is remarkable agreement
among these different studies: when insulin values are
adjusted for the proinsulin concentration, subjects with
moderate to severe hyperglycemia (fasting glucose value
>10 mM) have true insulin levels that tend to be or are
frankly below those of weight-matched control subjects.
In other words, excessive amounts of proinsulin have
masked the subnormal insulin levels.
Important questions raised by these results are: When
does the relative increase in circulating proinsulin occur? Are people with mild fasting hyperglycemia truly
hyperinsulinemic? Does the inverted-U-shaped curve
reflect increasing insulin or proinsulin levels (Fig. 1)?
The data generated under fasting conditions are too limited for a definite conclusion. In contrast, insulin responses to oral glucose challenges show the same
inverted-U-shaped curve (62), and a recent study has
quantified proinsulin and true insulin responses over a
wide range of glycemia (76). The inverted U clearly
results because of changing insulin output (Fig. 2).
Proinsulin rises during the same period, but its contribution to overall immunoreactivity is rather minor. Figure 2 also reinforces the claim that insulin responses in
moderate and severe hyperglycemia are subnormal. The
ratio of proinsulin to insulin from the same data is plotted on Fig. 3. The curve rises sharply and plateaus at a
value nearly four times that of the control subjects, and
it is not difficult to see how proinsulin has confused the
interpretation of insulin values. Moreover, Fig. 2 actually minimizes the proinsulin contribution to overall
immunoreactivity because the data are expressed in molarity. Insulin values have traditionally been expressed
in units based on weight (|xU/ml). Proinsulin weighs
50% more than insulin, so in that situation, its contribution is even greater.
Therefore, under basal conditions, circulating insulin
values can be summarized as follows: /) nonobese subjects with impaired glucose tolerance are hyperinsulinemic versus age- and weight-matched control subjects, 2) mildly hyperglycemic subjects (fasting glucose
values 7.2-10.0 mM) have fasting and stimulated insulin values equal to those of control subjects, and 3)
more severely hyperglycemic subjects are overtly hypoinsulinemic. It must be reemphasized that these results do not mean that insulin values are normal in
patients with mild hyperglycemia, just that they are no
different than those in control subjects. Normal insulin
values in the face of any degree of hyperglycemia are
inappropriate (79).
Stimulated insulin responses to standardized challenges. The main regulator of insulin secretion is the
plasma glucose level (80). Raising it above 5.5 mM elicits a biphasic insulin response, the first phase lasting 5
10 min and the second phase persisting for the duration
of hyperglycemia (81,82). The first phase serves an important physiological function. It mediates efficient
clearance of a glucose load, which is demonstrated most
clearly by the observation that experimentally suppress-

995

CELL DYSFUNCTION IN NIDDM

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FIG. 2. Integrated true insulin () and proinsulin () responses to 100-g oral glucose challenge stratified by level
of glycemia. From Yoshioka et al. (76).

ing it in eugylcemic subjects makes them glucose intolerant (83,84). A major confusion in the literature
concerns how to study glucose-induced insulin secretion. Intravenous glucose is the method of choice. In
contrast, oral glucose is an integrated measure of multiple effects on insulin secretion (changing glucose level,
glucose absorption, gut hormones, cephalic-induced insulin release) (16,82). As such, oral glucose does not
only assess P-cell glucose responsiveness, which may
explain why divergent results have at times been obtained with oral and intravenous glucose.
In the late 1960s, it was discovered that insulin release to intravenous glucose was delayed in subjects
with NIDDM (85-88). In quantitative terms, the response was also reduced when hyperglycemia was factored in (82,89). The reason for the delay was because
the first phase was missing (Fig. 4). By the time the
fasting blood glucose level reached 6.4 mM, no trace
of a first phase could be found (90). Paralleling the inability of glucose to stimulate insulin secretion, a lowered glucose level does not suppress insulin output (91).
It would be predicted, based on what we know about
the importance of the first phase, that losing it should
impair the ability to clear a bolus of intravenous glucose.
However, what about glucose homeostasis after meals,
where nutrients are absorbed much more slowly? The
answer, although controversial, is likely to be yes. One
thing that supports this idea is that simulating a burst of
insulin at the beginning of a meal in NIDDM normalizes
the postprandial glycemic excursion (92). In other
words, the exaggerated rise in plasma glucose that occurs after meals in NIDDM subjects seems to be due in
part to delayed insulin release.

996

There is a long list of agents other than glucose that


stimulate insulin secretion. As a group, NIDDM patients
elicit relatively normal-looking insulin responses that are
not delayed (82,87,93-95; Fig. 5). Therefore, glucose's
inability to elicit the early burst of insulin cannot be
blamed on some fundamental problem within the pcell. Instead, the secretory defect is specific for glucose,
and it is commonly referred to as selective glucose unresponsiveness.
An area of active research during the last decade has
been to try to establish why p-cells become refractory
to glucose. Several (96-99) but not all (100) studies
have shown partial return of the first phase after a period
of tight metabolic control. This last study (100) failed to
show improvement after 3 wk of continuous subcutaneous insulin infusion. However, the plasma glucose
values during testing averaged 8.6 mM, which may explain the negative findings. Therefore, the concept is
that a metabolic derangement linked in some way to
the diabetes causes the p-cells to become glucose unresponsive. Our laboratory has pursued the hypothesis
that the hyperglycemia itself is the toxic agent. It has
also been observed that naloxone (101) and inhibitors
of prostaglandin E2, e.g., salicylates (102), improve firstphase release, and a second area of investigation concerns endogenous substances such as opioids and prostaglandins (103,104).
Glucose potentiation of insulin secretagogues. In essentially all nonglucose secretagogues, the magnitude
of their insulin responses depends on the ambient glu-

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100 150 200 250 300

FASTING PU\SMA GLUCOSE (mg/dl)


FIG. 3. Proinsulin-insulin ratio calculated from integrated
responses generated by 100-g oral glucose challenge. Results are stratified by level of glycemia. From Yoshioka et
al. (76).

DIABETES CARE, V O L . 13, N O . 9, SEPTEMBER 1990

I.L LEAHY

400
120

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300

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pU ml

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60

90

120

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30

60

90

200-

120

TIME (MINI

FIG. 4. Plasma insulin response (IRI) to 20-g bolus of intravenous glucose in non-insulin-dependent diabetic
(NIDDM; n = 9 [right]) and nondiabetic control (n = 9
[left]) subjects. Note that 1st phase of insulin response is
totally lacking in NIDDM. Values are means SE. From
Pfeifer et al. (196).

cose concentration, an effect termed glucose potentiation (14,15,82). This process makes teleological sense,
because an unregulated nutrient-based release of insulin
after a period of fasting could cause profound hypoglycemia. Glucose potentiation is studied by administering
a secretagogue at several different glucose levels (attained by short-term glucose infusions). Normally, the
insulin response rises in a linear fashion over a glucose
range of 4.4-25 mM (15; Fig. 6). The PG50 (glucose
value at which the response is 50% of maximum) reflects glucose responsiveness, and the AIRmax (maximum
response) reflects the secretory capacity. In healthy subjects, infused glucose (105), dexamethasone (106), and
experimental insulin resistance (107) all increase the
maximum response, whereas somatostatin lowers it

6Ch

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FIG. 5. Plasma insulin responses (IRI) to intravenous boluses of arginine (2.5 g) and glucose (20 g) in non-insulindependent diabetic (NIDDM; dashed line) and nondiabetic control (solid line) subjects. Note that arginine
causes brisk insulin response in NIDDM, whereas glucose
is without effect. From Palmer et al. (95).

DIABETES CARE, V O L . 13, N O . 9, SEPTEMBER 1990

100-

100

200

300

400

500

600

Plasma Glucota-mg/dl

FIG. 6. Acute insulin responses to 5 g arginine i.v. at 5


matched glucose levels in non-insulin-dependent diabetic
(NIDDM; O; n = 8) and nondiabetic control (; n = 8)
subjects. Note that maximum response is markedly attenuated in NIDDM. From Ward et al. (15).

(108). Their effects on PG50 are more variable. The implication is that 3-cells adapt to changing environmental
demands by altering secretory capacity and/or glucose
responsiveness. This mechanism presumably acts as an
important safeguard against hyperglycemia.
In NIDDM, it is predicted that, because of insulin
resistance and hyperglycemia, there should be a marked
increase in secretory capacity. Instead, glucose potentiation is nearly wiped out (14,15,109,110; Fig. 6). It
has been suggested that this defect appears early in the
evolution of NIDDM, perhaps even before the onset of
glucose intolerance (111). The evidence for this statement is that normoglycemic first-degree relatives of patients with type I (insulin-dependent) diabetes,
normoglycemic partially pancreatectomized dogs, and
normoglycemic streptozocin-induced diabetic (STZ-D)
baboons all show the same profound decrease in maximum secretory capacity (112-114). In theory, this loss
means that an inherent (3-cell mechanism that protects
against hyperglycemia is lost early in the course of
NIDDM. Whether this loss actually accelerates the onset
of hyperglycemia is still unknown.
What do we know about the mechanism of the loss?
It is not simply an effect of a lowered (3-cell mass. In its
full-blown form, AIRmax is reduced 90%, whereas the
greatest reduction in (3-cell mass reported to date is only
50% (15,18). Could the inability of glucose to potentiate
and to directly stimulate insulin release be caused by a
single molecular defect, i.e., one that makes the

997

CELL DYSFUNCTION IN NIDDM

p-cells blind to glucose? A period of improved metabolic control is known to have beneficial effects on
glucose-induced insulin secretion (96-99). An improvement in potentiation would be expected as well,
but this possibility has yet to be tested. The data that do
exist can be construed to either support or deny a single
defect. Phentolamine (115,116) and salicylates
(102,117) improve both the secretory capacity and the
first-phase insulin response. In contrast, the studies
listed above with subclinical [3-cell damage have identified experimental situations where there is a disparity
in the timing of maximum reduction in secretory capacity and maximum reduction in glucose-induced insulin
release (113,114).
Ultradian oscillations of insulin secretion. Like many
hormones, insulin displays a characteristic pulsatile secretory pattern (118). The plasma insulin level oscillates
with a periodicity of 11-13 min (119,120). These oscillations were first described as being in synchrony with
swings in the plasma glucose level and were thus pre-

500

sumed to result from the insulin-glucose negative feedback loop (119). This idea was subsequently questioned
when not all studies could demonstrate a relationship
between glucose and insulin cycles (120,121) and finally discarded when Stagner et al. (122) found the
same type of oscillations in dog pancreases perfused in
vitro with a constant glucose concentration. Our understanding is that they result from an intrinsic p-cell
pacemaker that is under some form of neuronal control
(118). In addition to the oscillations, 10-15 large-amplitude insulin pulses are released each day (4,123).
They occur most prominently (but not exclusively) after
meals, with an ultradian frequency in the range of 1-3
h (Fig. 7). Several kinds of evidence support the concept
that pulsatile release is necessary to maximize insulin
effectiveness (118). First, there is precedence in other
systems that pulsatile release potentiates hormone action (124). Second, insulin pulses are more effective at
inhibiting hepatic glucose production in vitro than is
continuous exposure (125). Furthermore, hepatic glu-

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0600

FIG. 7. Patterns of insulin secretion


over 24 h in non-insulin-dependent diabetic (NIDDM) and nondiabetic control
subjects. Two representative profiles
from NIDDM (C and D) and control (A
and B) subjects are included. Note in
control subjects how pulses after meals
progressively fall in amplitude. In contrast, number of spikes in NIDDM remains relatively normal, but their
amplitude is smaller, and pattern of progressive postprandial fall is no longer
present. From Polonsky et al. (34).

DIABETES CARE, V O L . 13, N O . 9, SEPTEMBER 1990

J.L. LEAHY

cose production in vivo oscillates in an inverse fashion


perfectly in synchrony with insulin pulses (126). Finally,
pulsed insulin has a greater hypoglycemic effect than
continuously infused insulin (127-129). It can be concluded that the pulsatility is not an accident of nature.
Instead, the precisely coordinated pattern is a key component of the glucoregulatory system.
It is interesting then that NIDDM subjects no longer
have the normal pattern of insulin delivery. Rapid oscillations are gone (130,131). Also, the number of postprandial pulses is the same, but their size and temporal
organization are markedly different (34; Fig. 7). It has
yet to be proved that nonpulsatile release has negative
physiological consequences. However, it is an attractive
possibility that not having the pulsatile pattern of insulin
delivery either contributes to or may even cause the
insulin resistance in NIDDM. Supporting this later suggestion, it has been reported that minimally glucoseintolerant first-degree relatives of probands with NIDDM
are without insulin oscillations (33), nor are they found
in NIDDM subjects who attain euglycemia with diet
therapy (130). Finally, in STZ-D baboons, whose fasting
glucose goes from 4.6 to 5.8 mM, the pattern of insulin
pulses is still intact (132). These results strongly support
the idea that the disrupted pattern of insulin release predates the glucose intolerance. Also, there does not appear to be any direct relationship between the loss of
pulsatility and glucose intolerance. A high priority for
the future should be to unravel what role the disorganized pattern of insulin release plays in the pathophysiology of NIDDM.

INDIVIDUALS AT HIGH RISK FOR NIDDM

When trying to work through what is known about (3cell dysfunction in NIDDM and how the different defects might contribute to glucose intolerance, a key parameter is to identify when each one begins. Those
found early are candidates for being genetically mediated. In contrast, those acquired after the onset of hyperglycemia may worsen glucose intolerance, but
clearly, they cannot be the initiating lesion. The strategy
used most often is to study people who carry an increased risk of developing NIDDM, e.g., children of
parents with NIDDM, women in remission from gestational diabetes, and certain ethnic groups with high incidence rates. Usually, some kind of measurement is
made in a group of subjects with varying degrees of
glucose tolerance, and the results are stratified according to the ambient glucose level. The idea is twofold:
to identify functional characteristics that are present in
higher frequency and thus might explain the predisposition for NIDDM in this population, and to determine
at what plasma glucose level they first appear. If they
are present in people with only minimal glucose intolerance, the abnormalities are often presumed to be interrelated with the primary genetic etiology. The biggest

DIABETES CARE, VOL. 13, N O . 9, SEPTEMBER 1990

shortcoming of this kind of study is its inability to determine whether the changes predate the glucose intolerance or result because of it. A more useful approach,
but one that ends up being a formidable undertaking, is
to follow people as they progress from euglycemia to
overt glucose intolerance. Results from two such studies
are available.
Lillioja et al. (22) studied insulin secretion and sensitivity in 24 Pima Indians as they progressed from normal
to impaired glucose tolerance. The average follow-up
period was 6 yr. When their subjects were euglycemic,
the authors could identify no defects in insulin secretion.
Fasting insulin levels and insulin responses to an oral
glucose challenge were both appropriate for their insulin
sensitivity. Moreover, the first-phase response to intravenous glucose was fully intact. Conversion to impaired
glucose tolerance was associated with a reduction in
insulin sensitivity and appropriate increases in insulin
levels. Again, the first-phase response was more or less
intact.
Warram et al. (133) followed 155 nondiabetic offspring from two NIDDM parents for an average of 13
yr. Twenty-five (16%) went on to develop NIDDM during the study. This subset was more hyperinsulinemic
and insulin resistant at the start of the study (when they
were normally glucose tolerant) than those who remained persistently euglycemic. Also, their first-phase
insulin response at the start of the study was close to
that of a control group, which had no family history of
NIDDM.
Taken together, these results support the notion that
the onset of glucose intolerance in genetically susceptible people cannot be blamed on inadequate insulin
output nor on a reduction in the first-phase insulin response. Both of these defects evolve after glucose intolerance begins. A second conclusion that is often
reached is considerably more controversial. It is stated
that insulin resistance is the earliest finding in these studies and thus must be the primary defect. Other studies
in high-risk ethnic groups (134-137) and relatives of
NIDDM patients (138,139) seem to support this claim.
Collectively, they have found that hyperinsulinemia is
a risk factor for impaired glucose tolerance regardless of
differences in age, weight, and body-fat distribution.
The presumption is that the insulin levels are raised because of insulin resistance and that insulin resistance is
the real risk factor.
The biggest flaw in this reasoning is that insulin resistance is presumed to be of genetic origin. It is just as
likely that a form of |3-cell dysfunction other than a reduction in insulin output could cause the insulin resistance. O'Rahilly et al. (33) were unable to find insulin
pulsations in a group of minimally glucose-intolerant
first-degree relatives of NIDDM subjects, making this
defect a prime candidate. Therefore, despite statements
to the contrary, the jury remains out as to whether pJcell dysfunction, insulin resistance, or a combination of
the two initiate NIDDM.

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CELL DYSFUNCTION IN NIDDM

NATURAL HISTORY OF INSULIN SECRETION IN NIDDM


When the results detailed above are viewed together,
we can start to put together a profile of what happens
to insulin secretion during the evolution of NIDDM. It
remains speculative whether there is a genetic lesion
directed at the (3-cell and what the nature of it could
be. It has been known for well over a decade that,
among normoglycemic individuals, low insulin responders are the ones most prone to develop NIDDM
(16,140,141). Not much is known about how secretory
capacity is regulated. One factor is fJ-cell mass, and low
insulin responders could simply be at the lower end of
the curve. Alternatively, a gene mutation could lower
the actual or functional (3-cell mass through early senescence or amyloid accumulation. A second factor is
quantitative insulin output independent of (3-cell mass.
It is not known whether genetics plays any part in its
regulation. Another kind of possibility, which has previously been discussed, concerns genetically mediated
alterations in the pattern and timing of insulin release.
Progression from normal to impaired glucose tolerance is accompanied by rising basal and postprandial
insulin levels, which presumably reflect worsening hyperglycemia and insulin resistance. Quantitative insulin
output seems to be appropriate for the metabolic conditions, but the timing of delivery is totally off (22,33).
There are too few data to know exactly when glucose
potentiation is lost, but that may also occur at this early
stage. Therefore, the characteristic p-cell defect is nonpulsatility of insulin delivery. Key areas of investigation
for the future are to determine whether the nonpulsatile
pattern is genetically mediated or acquired and to unravel how the defect in timing interrelates with the insulin resistance.
As the individual progresses to measurable glucose
intolerance (impaired glucose intolerance), overall insulin output continues to rise and peaks at a plasma
glucose level of 7.8 mM (22). p-Cells now become refractory to glucose, which results in further deterioration
in the timing of insulin delivery (90). The net effect is
to worsen postprandial hyperglycemia. Therefore, this
stage is characterized by the onset of selective glucose
unresponsiveness.
The risk to progress from impaired glucose tolerance
to overt NIDDM is in part based on the (3-celI's capacity
to rise to the challenge. Kadowaki et al. (142) followed
288 Japanese subjects with impaired glucose tolerance
for 8 yr. Forty-eight progressed to overt NIDDM. When
they went back and reexamined the data from the beginning of the study, they found that the subgroup with
the lowest insulin responses during an oral glucose challenge were the ones who developed NIDDM. The identical observation has been made by other investigators
(136,143). This observation is perfectly consistent with
those made in nondiabetic subjects showing that low
insulin responders are the group at highest risk for
NIDDM (16,140,141).

1000

As overt NIDDM sets in, insulin output falls off, and


by the time the fasting glucose value is 10 mM the insulin concentration is frankly subnormal. It is not clear
what the relationship is between these two. Higher glucose values could cause insulin output to fall because
of glucotoxicity. Alternatively, insulin output could fall
due to reductions in (3-cell mass and/or secretory capacity and worsen hyperglycemia on that basis. Therefore, this stage is characterized by the shift from relative
to absolute insulin deficiency. Glucose unresponsiveness, absolute insulin deficiency, and nonpulsatile insulin delivery are now all present, so that the picture of
P-cell secretory dysfunction is complete.

MECHANISM OF p-CELL DYSFUNCTION IN NIDDM


The fundamental purpose of fJ-cells is to keep the
plasma glucose concentration in a relatively narrow
range. It can be inferred that deviations either above or
below are undesirable and might have major consequences. The danger of an abnormally low glucose level
is obvious. Moreover, there is a growing literature that
prolonged elevations cause a number of cell types to
dysfunction. In NIDDM, plasma glucose stays above the
normal range- When the pathophysiology of this observation was investigated, it was found that the (3-cells
had effectively become refractory to glucose. Understanding that fact then ties together most of what has
been described in this article about (3-cell mass/morphology and insulin secretion. Loss of glucose-stimulated insulin release and glucose potentiation are
obvious examples. The anatomic findings are also consistent. A reduced p-cell mass, lack of evidence for
accelerated (3-cell growth, and relatively normal granulation are all contrary to what would be expected given
the high glucose environment (3,43). As such, a major
problem that stems from the p-cell's inability to recognize glucose is that the hyperglycemia-induced compensatory changes in p-cell mass and function that
should occur do not. Therefore, glucose unresponsiveness is rightfully considered to be a major (3-cell defect,
and there has been intense interest over the last decade
to define its cause.
A guiding principle has been the appreciation that
whatever mechanism is finally decided on must be able
to explain all of the experimental observations. Three of
the most important ones are 7) the biphasic pattern of
insulin release is intact in nondiabetic individuals destined to become glucose intolerant (22,133), 2) the first
phase is lost during the time that the fasting glucose level
goes from 5.5 to 6.4 mM (90), and 3) tight metabolic
control partially restores the first phase (96-99). Therefore, the underlying defect must result in part because
of some metabolic change induced by the diabetes, and
that change must occur after the glucose intolerance has
started but when it is still rather mild. Our group has
pursued the hypothesis that the rising glucose level itself

DIABETES CARE, V O L . 13, N O . 9, SEPTEMBER 1990

I.L. LEAHY

makes the fi-cells unresponsive to glucose, a process


recently termed glucotoxicity.
The suggestion that hyperglycemia induces changes
in fJ-cell function is not a new one (5,144,145). Classic
studies in the 1940s showed that glucose injections in
partially pancreatectomized cats caused permanent diabetes (146). A recent study has reproduced the same
results with glucose infusions in partially pancreatectomized dogs (60). There are also data in humans that
are consistent with a link between hyperglycemia and
glucose unresponsiveness. Dimitriadis etal. (147) found
that healthy subjects made hyperglycemic for 12 h failed
to suppress insulin output during hypoglycemia. Studies
in humans are faced with a number of limitations, not
the least of which is the inability to make healthy subjects hyperglycemic for any significant period of time
(148,149). Thus, we have performed our studies in rat
models, and have generated a large amount of data that
support the concept of hyperglycemia-induced (3-cell
dysfunction. Our work has been described in two comprehensive reviews (41,150). As such, I will only highlight the major findings and our current thoughts.
p-CELL DYSFUNCTION IN RAT MODELS

Reduced p-cell mass. The first step was to determine


whether inducing hyperglycemia in normal rats, by lowering their (3-cell mass, would alter the remaining pcells. Rats were given STZ in the neonatal period (151)
or underwent a 90% pancreatectomy at 5 wk of age
(152). Both models are characterized by modest nonfasting hyperglycemia and, germane to this discussion,
p-cell masses that average 4 0 - 5 0 % of normal
(151,152). Insulin-secretion studies were conducted in
vitro with an organ perfusion system (153,154). This
technique allows the operator to map out secretory responses on a minute-to-minute basis under precisely defined conditions. The results obtained for both models
were similar. Glucose failed to stimulate insulin release
(152,155,156). In contrast, nonglucose responses were
present and at times were abnormally large
(152,155,157). Therefore, the remaining (3-celIs
showed the pattern of selective glucose unresponsiveness (Fig. 8). Similar results have been reported by other
laboratories (158-160).
We went on to study other aspects of P-cell function
and obtained results that were reminiscent of human
NIDDM. Insulin output failed to suppress when the glucose concentration was lowered (161). The relative proportion of proinsulin in pancreas extracts and portal vein
samples was increased (162,163). Glucose potentiation
was essentially wiped out (157). This last result needs
further comment. The 90%-pancreatectomized rats
showed a potentiation pattern that was like what has
been described in NIDDM subjects, i.e., a marked decrease in maximum secretory capacity (15,157). In contrast, the neonatal STZ model had near-maximum
responses at both low and high glucose concentrations
(157). In other words, the STZ-D rats failed to suppress
insulin responses at a low glucose concentration, and

DIABETES CARE, VOL. 13, N O . 9, SEPTEMBER 1990

15

25

35

40

TIME (minutes)

FIG. 8. Insulin secretion in response to glucose and arginine in rats 8-11 wk after 90% pancreatectomy (solidline;
n = 9). Data were obtained with in vitro perfused pancreas
technique. Note that there is brisk response to arginine,
whereas glucose is without effect. In contrast, control rats
(dashed line; n = 7) show clear responses to both secretagogues. From Bonner-Weir et al. (152).

the pancreatectomy model failed to augment them at a


high glucose level. The pattern in the STZ-D rats ended
up being an important milestone in our studies. The
pattern resembled what would be expected from hyperglycemia, the (3-cells seeming to behave as if the
glucose level was high even when it really was not, and
we were able to establish a direct link between the two
by reproducing the pattern in normal rats with glucose
infusions (164). The connection is further strengthened
by two other observations. Insulin treatment restores potentiation to normal in STZ-D rats (165,166), and the
same abnormality is found in a spontaneously occurring
diabetic rat model (167). The reason for the different
pattern in the pancreatectomy model is still puzzling.
That model has a milder level of hyperglycemia, which
may result in a less pronounced defect.
Quantitative morphometric studies were conducted to
ascertain (3-cell mass. In the pancreatectomized model,
P-cell mass 6 wk postsurgery was 42% of normal (152).
It was only 10% at the end of the surgery, so that impressive regeneration had taken place. Six weeks postSTZ, p-cell mass was 46% of normal (151). Again, there
was a period of active regeneration after the STZ. For
reasons that are still unexplained, the growth rate rises
soon after the insult but then slows after 2 wk, despite
continuing hyperglycemia. In this regard, we have primarily studied the pancreatectomy model and found a
gradual falling off of p-cell mass over time compared
with control rats (152,168). Interestingly, a ventromedial hypothalamic lesion again accelerates (3-cell replication, so that the falloff is not because the reserve
capacity is overextended (169). Instead, these results are

1001

CELL DYSFUNCTION IN NIDDM

in agreement with the idea that a change in recognition


of the stimulus (glucose unresponsiveness) causes the
compensatory growth to slow.
Normal p-cell mass. We concluded that hyperglycemia
caused the glucose unresponsiveness in the other
models and that the only role served by the reduced (3cell mass was to cause the hyperglycemia. For further
proof, we turned to chronic glucose infusions in normal
rats, expecting to find similar results. Eight-week-old
200-g rats are infused with large amounts of glucose
through an indwelling catheter in the jugular vein (164).
Depending on the glucose concentration of the infusate,
blood glucose levels as high as 22.2 mM are attainable
for periods of up to 48 h. Thereafter, the level gradually
falls off (170). There are many unique advantages to this
model. The level of blood glucose and duration of the
infusion can be precisely controlled. This means that
the effects of varying degrees of hyperglycemia can be
compared. Also, the 3-cell mass starts out normal, so
that quantitative and qualitative insulin responses can
be assessed. Reversal studies are easily conducted by
simply turning off the pump and studying the rat after a
waiting period. Finally, plasma insulin levels rise along
with the blood glucose level, often to as much as 10
times normal (164). More traditional diabetic rat
models, including the two we initially studied, are hypoinsulinemic, making it impossible to separate out hyperglycemia causing the (3-cell dysfunction versus an
effect of insulin deprivation. The infused rats are hyperinsulinemic, so that shared defects effectively rule out
that possibility. The only disadvantage is that the infusions are relatively short term; in our laboratory, we
have not tried to carry them out beyond 96 h. Thus,
results are open to the criticism that they have little relevance to NIDDM where the p-cell defects evolve
slowly in the face of mild hyperglycemia. For this reason, all major observations are subsequently tested in
one of the other models.
Markedly hyperglycemic rats show insulin-secretion
characteristics that are identical to those described in
the models with reduced (3-cell mass (162,164,171): 7)
within 48 h insulin output is blind to changes in glucose
concentration, 2) arginine elicits large insulin responses,
3) glucose potentiation of arginine-induced insulin release is altered in a fashion identical to that of the STZD rats, and 4) the proinsulin-insulin ratio is increased
in pancreas extracts. (3-Cell morphometric results have
also mirrored the other models. f}-Cell replication is
markedly accentuated by the infusion (42). This last result is particularly interesting. Hyperglycemia is known
to be a potent stimulus for (3-cell growth (3,41). However, it is generally believed that fJ-cells of adult animals
have almost no growth potential. Instead, we found that
(3-cell mass rose 50% over the course of a 96-h infusipn
(42). When added to what we had observed in the
models with reduced p-cell mass (3- to 4-fold rise in (3cell mass during first few weeks after insult [151,152]),
it is clear that our concept of (B-cell growth potential
needs to be revised. Based on the other models, we

1002

predict that the accelerated growth rate should wane


with time, but unfortunately, it is not possible to carry
infusions out that long.
To summarize, there is remarkable similarity between
the insulin secretion and p-cell morphometric characteristics of these models and those described previously
for NIDDM. We conclude that normal p-cells chronically exposed to hyperglycemia will invariably develop
functional defects characterized by glucose unresponsiveness. Moreover, the results in our rat models so
closely resemble what has been described in NIDDM
subjects that it is easy to conclude that the pathophysiology in both situations must be the same.
Modest hyperglycemia. The studies described previously in NIDDM subjects have clearly shown that glucose-induced insulin secretion is lost when the plasma
glucose level is only slightly above normal (90). We
have shown the same phenomenon in rats (17). Rats
underwent a 60% pancreatectomy, which, of itself, will
not raise glucose levels. Six weeks later, glucose-induced insulin responses were perfectly normal when
adjusted for the lower p-cell mass. In contrast, another
group was given 10% sucrose as their water supply.
Three weeks postsurgery, plasma glucose levels in these
rats rose by 0.84 mM and stayed at this level for the
duration of the experiment. Four weeks postsurgery,
glucose-induced insulin secretion was appropriate for
the (3-cell mass. In contrast, after another 2 wk, the
response was reduced 75%. These results are the first
to establish a direct link between (3-cell dysfunction and
minimal elevations in plasma glucose. Understanding
this fact strengthens the concept that the same mechanism can explain the glucose unresponsiveness in
NIDDM subjects.
REVERSAL OF (i-CELL DYSFUNCTION IN RAT MODELS
The next major step was to show that hyperglycemia
and not some other metabolic effect of the diabetes was
causing the (3-cell dysfunction. The most direct evidence
comes from reversal studies. We found that 24 h of insulin treatment normalizes glucose potentiation in neonatal STZ-D rats, i.e., the exaggerated arginine response
at a low glucose background was no longer present
(165). In contrast, there was no improvement in glucose-induced insulin release. Kergoat et al. (166) did
get an improvement after 5 days of insulin. Studies such
as these are complicated by erratic glucose control. As
such, it is safe to state that insulin treatment can improve
glucose responsiveness, but caution must be used when
trying to glean much about specific details.
Reversal studies are considerably easier in the chronically infused rats; the infusion pump is simply turned
.off. Six hours postinfusion, glucose-induced insulin secretion is back to normal (172). The rats are hypoglycemic(4..4-5.5 mM) during that period. To see how the
same experimental conditions affected a model characterized by a longer duration of hyperglycemia, we
produced comparable hypoglycemia in 90%-pancreatectomized rats for 6 h with an insulin infusion. Again,

DIABETES CARE, V O L . 13, N O . 9, SEPTEMBER 1990

J.L LEAHY

there was a marked improvement in glucose-induced


insulin release (172). Therefore, one kind of data supporting the deleterious effect of hyperglycemia is that
insulin treatment restores glucose responsiveness.
More direct evidence comes from the use of phloridzin. Phloridzin reduces renal tubular reabsorption of
glucose, so that diabetic animals are rendered euglycemic because of an increase in glycosuria (173). It can
be argued that the improvements noted with insulin
therapy could be because of the raised insulin level and
not because of the lowered glucose value. The advantage of phloridzin is that it is presumed to act selectively
only on the glucose concentration. Rossetti et al. (174)
found in 90%-pancreatectomized rats that 4 wk of
phloridzin improved both glucose-induced insulin secretion and glucose potentiation. The treatment was
started 2 wk postoperatively, so these results probably
represent prevention of secretory defects. We have
shown in glucose-infused rats that phloridzin can also
reverse preexisting secretory defects (170).
The third kind of evidence has been obtained in vitro
with the perfused pancreas. We reported in the STZ
model that perfusing the pancreas with a low glucose
concentration caused insulin output to paradoxically increase (161). It was as if the chronically elevated glucose level was holding insulin secretion in check.
Support for this last suggestion comes from Grill et al.
(175), who found that mannoheptulose, an inhibitor of
glucose phbsphorylation and therefore also of insulin
secretion, caused the same paradoxical rise in insulin
output. In that same article, they found that perfusing
the pancreas of diabetic rats with 0 glucose for 40 min
restored glucose's ability to induce an insulin response.
In contrast, 3.9 mM glucose did not have the same effect. We obtained identical results in the glucose-infusion model (unpublished observations).
Taken together, these results are consistent with hyperglycemia having an ongoing suppressive effect on
glucose responsiveness and that, in its absence, glucose
responsiveness rapidly returns. The results with 0 vs. 3.9
mM glucose deserve further comment. The improvement with 0 glucose cannot simply represent the glucose
level being returned to normal. If that were the case,
the same results with 3.9 mM glucose would have been
expected. Instead, the intracellular changes that restore
glucose responsiveness must occur at a rate that is inversely related to the ambient glucose concentration.
The nature of this relationship has yet to be defined.
MECHANISM OF HYPERGLYCEMIA-INDUCED
P-CELL DYSFUNCTION

The mechanism of the deleterious effect of hyperglycemia has not been identified. Part of the problem has
been that biochemical studies are classically conducted
in isolated islets, and the profound secretory defects
noted in vivo and in the in vitro perfused pancreas are
no longer present when islets are isolated from diabetic
rats (176-178). We assume that removal of the islets
from the hyperglycemic environment and the time re-

DIABETES CARE, V O L . 13, N O . 9, SEPTEMBER 1990

quired for islet isolation together allow glucose responsiveness to recover. Culturing of islets at high glucose
levels also fails to reproduce the defects. There has been
a rash of articles purporting to show glucose desensitization in islets perifused at a high glucose concentration
(179,180). These results were initially quite exciting, but
enthusiasm has been tempered by the recent demonstration that the effect is evanescent (181). Failure to get
glucose unresponsiveness in cultured islets may seem
like evidence against hyperglycemia causing (S-cell dysfunction. However, islets are complex microorgans with
important vascular and cellular relationships that are lost
in a culture system (182). Also, culturing islets is tricky
business, with central necrosis being a common observation. Therefore, the significance of the negative culture data is not at all clear.
There has been a great deal of interest in impaired
glucose transport into the (3-cell explaining the glucose
blindness (145). The concept is a particularly attractive
way to unify the (3-cell dysfunction and insulin resistance in NIDDM. Impaired glucose transport is well established as a key mechanism for the insulin resistance
in peripheral tissues (183,184); a global problem could
then explain the (3-cell defects. Also, several kinds of
data seemed to point in that direction. Insulin secretion
and insulin resistance are both improved by tightened
metabolic control (96-99,185,186). Also, (J-cell dysfunction is unique for glucose.
To address this possibility, we initially measured glucose utilization in isolated islets from our models and
could find no problem (187). However, as stated previously, isolated islets show relatively normal glucoseinduced insulin responses, so that the results were not
definitive. In collaboration with Matschinsky, transport
was assessed in the 90%-pancreatectomy and glucoseinfused models with a novel technique that gets around
the problem of defects reversing. Pancreases were perfused in vitro. After a washout period, glucose was infused for 30 s, and the pancreas was then rapidly removed
and snap frozen. The glucose content of individual islets
was measured with microsurgical and microanalytical
techniques (188). In neither model could we find a decrease in content, thereby essentially ruling out an impairment in transport (189). Based on these results, we
do not believe that 3-cell glucose transport is impaired
or that such a mechanism explains the glucose unresponsiveness.
We are more interested in the opposite concept, that
an abundance of fuel leads to a change in the intracellular microenvironment of the 3-cell, which as an offshoot suppresses glucose responsiveness. The results
obtained in the perfused pancreas with mannoheptulose
and 0 glucose are most easily explained by this idea
(175). Moreover, Sako and Grill (190) have found that
infusion of intralipid, another (3-cell fuel, into normal
rats results in the same kind of 3-cell secretory dysfunction. The nature of the intracellular pathway that is involved remains unknown. Matschinsky's laboratory
(191) has been interested for some time in glucokinase,

1003

CELL DYSFUNCTION IN NIDDM

the first step in glucose metabolism. Malaisse (192) has


listed a number of other possibilities. An important focus
for future research will be to identify the biochemical
basis for the glucose unresponsiveness and to determine
how hyperglycemia ties in with it.

SUMMARY

IDDM is characterized both by insulin resistance and p-cell dysfunction. The p-cell abnormalities fall into two distinct types. Early on,
perhaps when glucose tolerance is still normal,
pulsatile insulin delivery is lost. In current understanding, this defect is unrelated to metabolic disruptions attributable to the diabetes. Whether it is acquired or
genetically induced remains a key question. After the
onset of glucose intolerance, a number of other functional abnormalities develop at the same time that pcell glucorecognition is being lost. An important consequence of the glucose blindness is that the inherent
compensatory mechanisms within (B-cells to mitigate
against hyperglycemia are bypassed. This fact is most
clear when the results described in this article are compared to what is known about obesity, another state of
insulin resistance (193). Compensatory increases in (3cell mass (18), quantitative insulin output (194), and
maximum secretory capacity (195) all expand the ability
to protect against hyperglycemia. Also, these changes
occur without any disruption in the pulsatile pattern of
insulin delivery (4). In NIDDM, the combination of hyperglycemia and insulin resistance should be a stronger
stimulus. Instead, (3-cell mass is reduced (18), secretory
capacity is only 10-20% of normal (15), and quantitative insulin output is deficient either in relative or absolute terms, depending on the level of glycemia (9,32).
We have proposed that the glucose unresponsiveness
develops as a direct result of the elevated glucose concentration and have generated substantial data to support this idea in rat models. For instance, normal rats
made hyperglycemic, either by lowering (3-cell mass or
with glucose infusions, develop many of the (3-cell secretory and anatomic features described in NIDDM subjects. A feedforward cycle then exists in which hyperglycemia abolishes the major protective mechanisms
that are in place to guard against hyperglycemia. In theory, a period of improved metabolic control should
break the cycle, and there are a number of short-term
studies showing improvements in both insulin secretion
and insulin resistance (96-99,185,186). Longer-term
data are harder to find, although one study has documented persisting improvements in secretion and sensitivity for 2 wk after cessation of insulin treatment (186).
Therefore, in today's world, the clinical approach to
maximizing endogenous (3-cell function is to aim for the
best metabolic control possible. The measures used
have not changed in 25 years. We still try to lower insulin needs by recommending the things known to increase insulin sensitivity such as physical activity,

1004

normal body weight, and prudent diet. If these measures


are not sufficient, sulfonylureas or insulin is added. Clinicians are painfully aware that these therapies prove
inadequate in many patients. As we begin to unravel
the biochemical and genetic basis for the p-cell dysfunction and insulin resistance in NIDDM, we hopefully
will see the start of a new era, one in which novel therapies will be targeted at specific cellular abnormalities.

ACKNOWLEDGMENTS

This work was supported by National Institutes of Health


Grants DK-38543, DK-35449, and DK-36836 (Diabetes
Endocrinology Research Center animal research core).

REFERENCES
1. Horton ES: Role of environmental factors in the development of noninsulin-dependent diabetes mellitus. Am
} Med75 (Suppl. 1):32-40, 1983
2. Weir GC, Bonner-Weir S, Leahy JL: Islet mass and function in diabetes and transplantation. Diabetes 39:401405, 1990
3. Hellerstrom C, Swenne I, Andersson A: Islet cell replication and diabetes. In The Pathology of the Endocrine
Pancreas in Diabetes. Lefebvre PJ, Pipeleers DG, Eds.
Heidelberg, FRG, Springer-Verlag, 1988, p. 141-70
4. Polonsky KS, Given BD, Van Cauter E: Twenty-four-hour
profiles and pulsatile patterns of insulin secretion in normal and obese subjects. I Clin Invest 81:442-48, 1988
5. Weir GC: Non-insulin-dependent diabetes mellitus: interplay between B-cell inadequacy and insulin resistance. Am } Med 73:461-64, 1982
6. Reaven GM: Insulin secretion and insulin action in noninsulin-dependent diabetes mellitus: which defect is primary? Diabetes Care 7 (Suppl. 1): 17-24, 1984
7. Leahy JL, Weir GC: Noninsulin-dependent diabetes mellitus: current concepts of pathogenesis. In Insulin Secretion: Molecular and Cellular Biology of Diabetes Mellitus. Draznin B, Melmed S, LeRoith D, Eds. New York,
Liss, 1989, p. 149-58
8. Gerich JE: Role of insulin resistance in the pathogenesis
of type 2 (non-insulin-dependent) diabetes mellitus.
Bailliere's Clin Endocrinol Metab 2:307-26, 1988
9. Turner RC, Matthews DR, Clark A, O'Rahilly S, Rudenski AS, Levy J: Pathogenesis of NIDDMa disease of
deficient insulin secretion. Bailliere's Clin Endocrinol
Metab 2:327-42, 1988
10. Kahn SE, Porte D Jr: Islet dysfunction in non-insulindependent diabetes mellitus. Am I Med 85 (Suppl. 5A):
4-8, 1988
11. DeFronzo RA: The triumvirate: (3-cell, muscle, liver: a
collusion responsible for NIDDM. Diabetes 37:667-87,
1988
12. Reaven GM: Role of insulin resistance in human disease.
Diabetes 37:1595-607, 1988
13. Cerasi E, Efendic S, Luft R: Dose-response relation between plasma insulin and blood glucose levels during
oral glucose loads in prediabetic and diabetic subjects.
Lancet 1:794-97, 1973
14. Halter JB, Graf RJ, Porte D Jr: Potentiation of insulin

DIABETES CARE, V O L . 13, N O . 9, SEPTEMBER 1990

I.L LEAHY

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.
26.
27.

28.

29.

secretory responses by plasma glucose levels in man:


evidence that hyperglycemia in diabetes compensates
for impaired glucose potentiation. / Clin Endocrinol Metab 48:946-54, 1979
Ward WK, Bolgiano DC, McKnight B, Halter JB, Porte
D Jr: Diminished B cell secretory capacity in patients
with noninsulin-dependent diabetes mellitus. j Clin Invest 74:1318-28, 1984
Cerasi E: Insulin secretion in diabetes mellitus. In The
Pathology of the Endocrine Pancreas in Diabetes. Lefebvre PJ, Pipeleers DG, Eds. Heidelberg, FRG, Springer-Verlag, 1988, p. 191-218
Leahy JL, Bonner-Weir S, Weir GC: Minimal chronic
hyperglycemia is a critical determinant of impaired insulin secretion after an incomplete pancreatectomy. I
Clin Invest 81:1407-14, 1988
Kloppel G, Lohr M, Habich K, Oberholzer M, Heitz PU:
Islet pathology and the pathogenesis of type 1 and type
2 diabetes mellitus revisited. Surv Synth Pathol Res
4:110-25, 1985
Clark A, Wells CA, Buley ID, Cruickshank JK, Vanhegan
Rl, Matthews DR, Cooper GJS, Holman RR, Turner RC:
Islet amyloid, increased A-cells, reduced B-cells and exocrine fibrosis: quantitative changes in the pancreas in
type 2 diabetes. Diabetes Res 9:151-59, 1988
Olefsky J, Farquhar JW, Reaven G: Relationship between
fasting plasma insulin level and resistance to insulinmediated glucose uptake in normal and diabetic subjects. Diabetes 22:507-13, 1973
Hollenbeck CB, Chen N, Chen Y-DI, Reaven GM: Relationship between the plasma insulin response to oral
glucose and insulin-stimulated glucose utilization in
normal subjects. Diabetes 33:460-63, 1984
Lillioja S, Mott DM, Howard BV, Bennett PH, Yki-Jarvinen H, Freymond D, Nyomba BL, Zurlo F, Swinburn
B, Bogardus C: Impaired glucose tolerance as a disorder
of insulin action: longitudinal and cross-sectional studies
in Pima Indians. N Engl J Med 318:1217-25, 1988
Johnston C, Ward WK, Beard JC, McKnight B, Porte D
Jr: Islet function and insulin sensitivity in the non-diabetic offspring of conjugal type 2 diabetic patients. Diabetic Med 7-A 19-25, 1990
Polonsky KS, Licinio-Paixao J, Given BD, Pugh W, Rue
P, Galloway J, Karrison T, Frank B: Use of biosynthetic
human C-peptide in the measurement of insulin secretion rates in normal volunteers and type 1 diabetic patients. / Clin Invest 77:98-105, 1986
Kruszynska YT, Home PD, Hanning I, Alberti KGMM:
Basal and 24-h C-peptide and insulin secretion rate in
normal man. Diabetologia 30:16-21, 1987
Bergman RN: Toward physiological understanding of
glucose tolerance: minimal-model approach. Diabetes
38:1512-27, 1989
Eaton RP, Allen RC, Schade DS: Hepatic removal of
insulin in normal man: dose response to endogenous
insulin secretion. / Clin Endocrinol Metab 56:1294-300,
1983
Sando H, Lee YS, Iwamoto Y, Ikeuchi M, Kosaka K:
Isoproterenol-stimulated C-peptide and insulin secretion
in diabetic and nonobese normal subjects: decreased
hepatic extraction of endogenous insulin in diabetes. I
Clin Endocrinol Metab 51:1143-49, 1980
Bonora E, Zavaroni I, Coscelli C, Butturini U: Decreased
hepatic insulin extraction in subjects with mild glucose
intolerance. Metabolism 32:438-46, 1983

DIABETES CARE, VOL. 13, N O . 9, SEPTEMBER 1990

30. Lazarus NR, Penhos JC, Tanese T, Michaels L, Gutman


R, Recant L: Studies on the biological activity of porcine
proinsulin. j Clin Invest 49:487-96, 1970
31. Porte D Jr, Kahn SE: Hyperproinsulinemia and amyloid
in NIDDM: clues to etiology of (3-cell dysfunction? Diabetes 38:1333-36, 1989
32. Temple RC, Carrington CA, Luzio SD, Owens DR,
Schneider AE, Sobey WJ, Hales CN: Insulin deficiency
in non-insulin-dependent diabetes. Lancet 1:293-95,
1989
33. O'Rahilly S, Turner RC, Matthews DR: Impaired pulsatile secretion of insulin in relatives of patients with noninsulin-dependent diabetes mellitus. N Engl J Med
318:1225-30, 1988
34. Polonsky KS, Given BD, Hirsch LJ, Tillil H, Shapiro ET,
Beebe C, Frank BH, Galloway JA, Van Cauter E: Abnormal patterns of insulin secretion in non-insulin-dependent diabetes mellitus. N Engl I Med 318:1231-39,
1988
35. Maclean N, Ogilvie RF: Quantitative estimation of the
pancreatic islet tissue in diabetic subjects. Diabetes
4:367-76, 1955
36. Saito K, Yaginuma N, Takahashi T: Differential volumetry of A, B, and D cells in the pancreatic islets of
diabetic and nondiabetic subjects. Tohoku ) Exp Med
129:273-83, 1979
37. Stefan Y, Orci L, Malaisse-Lagae F, Perrelet A, Patel Y,
Unger RH: Quantitation of endocrine cell content in the
pancreas of nondiabetic and diabetic humans. Diabetes
31:694-700, 1982
38. Rahier J, Goebbels RM, Henquin JC: Cellular composition of the human diabetic pancreas. Diabetologia
24:366-71, 1983
39. Albright F: Cushing's syndrome. Harvey Lect 38:12386, 1942
40. Norris C: A case of acromegalia. Proc NY Pathol Soc
7:19-35, 1907
41. WeirGC, Leahy JL, Bonner-Weir S: Experimental reduction of B-cell mass: implications for the pathogenesis of
diabetes. Diabetes Metab Rev 2:125-61, 1986
42. Bonner-Weir S, Deery D, Leahy JL, Weir GC: Compensatory growth of pancreatic p-cells in adult rats after
short-term glucose infusion. Diabetes 38:49-53, 1989
43. Gepts W, Lecompte PM: The pancreatic islets in diabetes. Am J Med 70:105-15, 1981
44. Bell ET: The incidence and significance of degranulation
of the beta cells in the islets of Langerhans in diabetes
mellitus. Diabetes 2:125-29, 1953
45. Clark A: Islet amyloid and type 2 diabetes. Diabetic Med
6:561-67, 1989
46. Johnson KH, O'Brien TD, Betsholtz C, Westermark P:
Islet amyloid, islet-amyloid polypeptide, and diabetes
mellitus. N Engl I Med 321:513-18, 1989
47. Nishi M, Sanke T, Nagamatsu S, Bell Gl, Steiner DF:
Islet amyloid polypeptide: a new (3-cell secretory product related to islet amyloid deposits. / Biol Chem
265:4173-76, 1990
48. Opie EL: The relation of diabetes mellitus to lesions of
the pancreas: hyaline degeneration of the islands of Langerhans. y Exp Med 5:527-40, 1900-1901
49. Westermark P, Wilander E: The influence of amyloid
deposits on the islet volume in maturity onset diabetes
mellitus. Diabetologia 15:417-21, 1978
50. Westermark P, Wernstedt C, Wilander E, Hayden DW,
O'Brien TD, Johnson KH: Amyloid fibrils in human in-

1005

P-CELL DYSFUNCTION IN NIDDM

51.

52.

53.

54.
55.
56.

57.

58.

59.

60.

61.

62.
63.

64.

65.
66.

1006

sulinoma and islets of Langerhans of the diabetic cat are


derived from a neuropeptide-like protein also present in
normal islet cells. Proc Natl Acad Sci USA 84:3881-85,
1987
Cooper GJS, Willis AC, Clark A, Turner RC, Sim RB,
Reid KBM: Purification and characterization of a peptide
from amyloid-rich pancreases of type 2 diabetic patients.
Proc Natl Acad Sci USA 84:8628-32, 1987
Lukinius A, Wilander E, Westermark GT, Engstrom U,
Westermark P: Colocalization of islet amyloid polypeptide and insulin in the B-cell secretory granules of the
human pancreatic islets. Diabetologia 32:240-44, 1989
Ogawa A, Harris V, McCorkle SK, Unger RH, Luskey
KL: Amylin secretion from the rat pancreas and its selective loss after streptozotocin treatment. J Clin Invest
85:973-76, 1990
Westermark P: Fine structure of islets of Langerhans in
insular amyloidosis. Virchows Arch A Pathol Anat Histol
359:1-18, 1973
Howard CF Jr: Longitudinal studies on the development
of diabetes in individual Macaca nigra. Diabetologia
29:301-306, 1986
Leighton B, Cooper GJS: Pancreatic amylin and calcitonin gene-related peptide cause resistance to insulin in
skeletal muscle in vitro. Nature (Lond) 335:632-35,
1988
Cooper GJS, Leighton B, Dimitriadis GD, Parry-Billings
M, KowalchukJM, Howland K, Rothbard JB, Willis AC,
Reid KBM: Amylin found in amyloid deposits in human
type 2 diabetes mellitus may be a hormone that regulates
glycogen metabolism in skeletal muscle. Proc Natl Acad
Sci USA 85:7763-66, 1988
Ohsawa H, Kanatsuka A, Yamaguchi T, Makino H,
Yoshida S: Islet amyloid polypeptide inhibits glucosestimulated insulin secretion from isolated rat pancreatic
islets. Biochem Biophys Res Commun 160:961-67,
1989
Clark A, Bown E, King T, Vanhegan Rl, Turner RC: Islet
changes induced by hyperglycemia in rats: effect of insulin or chlorpropamide therapy. Diabetes 31:319-25,
1982
Imamura T, Koffler M, Helderman JH, Prince D, Thirlby
R, Inman L, Unger RH: Severe diabetes induced in subtotally depancreatized dogs by sustained hyperglycemia.
Diabetes 37:600-609, 1988
Yalow RS, Berson SA: Plasma insulin concentrations in
nondiabetic and early diabetic subjects: determinations
by a new sensitive immunoassay technic. Diabetes
9:254-60, 1960
Reaven GM, Miller R: Study of the relationship between
glucose and insulin responses to an oral glucose load in
man. Diabetes 17:560-69, 1968
DeFronzo RA, Ferrannini E, Simonson DC: Fasting hyperglycemia in noninsulin-dependent diabetes mellitus:
contributions of excessive hepatic glucose production
and impaired tissue glucose uptake. Metabolism 38:
387-95, 1989
Saad MF, Knowler WC, Pettitt DJ, Nelson RG, Mott DM,
Bennett PH: Sequential changes in serum insulin concentration during development of noninsulin-dependent
diabetes. Lancet 1:1356-59, 1989
Kingston ME, Skoog WC: Maintenance of basal insulin
secretion in severe non-insulin-dependent diabetes. Diabetes Care 9:232-35, 1986
Reaven GM, Hollenbeck C, Jeng C-Y, Wu MS, Chen

67.

68.

69.

70.

71.

72.
73.
74.
75.

76.

77.

78.

79.
80.
81.
82.
83.

Y-DI: Measurement of plasma glucose, free fatty acid,


lactate, and insulin for 24 h in patients with NIDDM.
Diabetes 37:1020-24, 1988
Garvey WT, Olefsky JM, Rubenstein AH, Kolterman
OG: Day-long integrated serum insulin and C-peptide
profiles in patients with NIDDM: correlation with urinary C-peptide excretion. Diabetes 37:590-99, 1988
Liu G, Coulston A, Chen Y-DI, Reaven GM: Does daylong absolute hypoinsulinemia characterize the patient
with non-insulin-dependent diabetes mellitus? Metabolism 32:754-56, 1983
Horwitz DL, Starr Jl, Mako ME, Blackard WG, Rubenstein AH: Proinsulin, insulin, and C-peptide concentrations in human portal and peripheral blood. I Clin Invest
55:1278-83, 1978
Glauber HS, Revers RR, Henry R, Schmeiser L, Wallace
P, Kolterman OG, Cohen RM, Rubenstein AH, Galloway
JA, Frank BH, Olefsky JM: In vivo deactivation of proinsulin action on glucose disposal and hepatic glucose
production in normal man. Diabetes 35:311-17, 1986
Ward WK, LaCava EC, Paquette TL, Beard JC, Wallum
BJ, Porte D Jr: Disproportionate elevation of immunoreactive proinsulin in type 2 (noninsulin-dependent) diabetes mellitus and in experimental insulin resistance.
Diabetologia 30:698-702, 1987
Duckworth WC, Kitabchi AE, Heinemann M: Direct
measurement of plasma proinsulin in normal and diabetic subjects. Am j Med 53:418-27, 1972
Gorden P, Hendricks CM, Roth J: Circulating proinsulinlike component in man: increased proportion in hypoinsulinemic states. Diabetologia 10:469-74, 1974
Mako ME, Starr Jl, Rubenstein AH: Circulating proinsulin in patients with maturity onset diabetes. Am / Med
63:865-69, 1977
Deacon CF, Schleser-Mohr S, Ballmann M, Willms B,
Con Ion JM, Creutzfeldt W: Preferential release of proinsulin relative to insulin in non-insulin-dependent diabetes mellitus. Ada Endocrinol 119:549-54, 1988
Yoshioka N, Kuzuya T, Matsuda A, Taniguchi M, Iwamoto Y: Serum proinsulin levels at fasting and after oral
glucose load in patients with type 2 (non-insulin-dependent) diabetes mellitus. Diabetologia 31:355-60, 1988
Yoshioka N, Kuzuya T, Matsuda A, Iwamoto Y: Effects
of dietary treatment on serum insulin and proinsulin response in newly diagnosed NIDDM. Diabetes 38:26266, 1989
Saad MF, Kahn SE, Nelson RG, Pettitt DJ, Knowler WC,
Schwartz MW, Kowalyk S, Bennett PH, Porte D Jr: Disproportionately elevated proinsulin in Pima Indians with
noninsulin-dependent diabetes mellitus. ] Clin Endocrinol Metab 70:1247-53, 1990
Turner RC, McCarthy ST, Holman RR, Harris E: Betacell function improved by supplementing basal insulin
secretion in mild diabetes. Br Med) 1:1252-54, 1976
Hedeskov CJ: Mechanism of glucose-induced insulin secretion. Physiol Rev 60:442-509, 1980
Curry DL, Bennett LL, Grodsky GM: Dynamics of insulin
secretion by the perfused rat pancreas. Endocrinology
83:572-84, 1968
Ward WK, Beard JC, Porte D Jr: Clinical aspects of islet
B-cell function in non-insulin-dependent diabetes mellitus. Diabetes Metab Rev 2:297-313, 1986
Calles-Escandon J, Robbins DC: Loss of early phase
of insulin release in humans impairs glucose tolerance
and blunts thermic effect of glucose. Diabetes 36:

DIABETES CARE, V O L . 13, N O . 9, SEPTEMBER 1990

I.L LLAHY

1167-72, 1987
84. Luzi L, DeFronzo RA: Effect of loss of first-phase insulin
secretion on hepatic glucose production and tissue glucose disposal in humans. Am ) Physiol 257:E241-46,
1989
85. Seltzer HS, Allen EW, Herron ALJr, Brennan MT: Insulin
secretion in response to glycemic stimulus: relation of
delayed initial release to carbohydrate intolerance in
mild diabetes mellitus. ) Clin Invest 46:323-35, 1967
86. Cerasi E, Luft R: The plasma insulin response to glucose
infusion in healthy subjects and in diabetes mellitus.
Acta Endocrinol 55:278-304, 1967
87. Simpson RC, Benedetti A, Grodsky GM, Karam JH, Forsham PH: Early phase of insulin release. Diabetes 17:
684-92, 1968
88. Lerner RL, Porte D Jr: Acute and steady-state insulin
responses to glucose in nonobese diabetic subjects. I
Clin Invest 51:1624-31, 1972
89. Perley MJ, Kipnis DM: Plasma insulin responses to oral
and intravenous glucose: studies in normal and diabetic
subjects. I Clin Invest 46:1954-62, 1967
90. Brunzell JD, Robertson RP, Lerner RL, Hazzard WR, EnsinckJW, Bierman EL, Porte D Jr: Relationships between
fasting plasma glucose levels and insulin secretion during intravenous glucose tolerance tests. / Clin Endocrinol
Metab 42:222-29, 1976
91. Hosker JP, Burnett MA, Matthews DR, Turner RC:
Suppression of insulin secretion by falling plasma glucose levels is impaired in type 2 diabetes. Diabetic Med
5:856-60, 1988
92. Bruce DG, Chisholm DJ, Storlien LH, Kraegen EW:
Physiological importance of deficiency in early prandial
insulin secretion in non-insulin-dependent diabetes. Diabetes 37:736-44, 1988
93. Deckert T: Insulin secretion following administration of
secretin in patients with diabetes mellitus. Acta Endocrinol 59:150-58, 1968
94. Deckert T, Lauridsen UB, Madsen SN, Mogensen P: Insulin responses to glucose, tolbutamide, secretin, and
isoprenaline in maturity-onset diabetes mellitus. Dan
Med Bull 19:222-26, 1972
95. Palmer JP, Benson JW, Walter RM, EnsinckJW: Argininestimulated acute phase of insulin and glucagon secretion
in diabetic subjects. / Clin Invest 58:565-70, 1976
96. Kosaka K, Kuzuya T, Akanuma Y, Hagura R: Increase in
insulin response after treatment of overt maturity-onset
diabetes is independent of the mode of treatment. Diabetologia 18:23-28, 1980
97. Savage PJ, Bennion LJ, Flock EV, Nagulesparan M, Mott
D, Roth J, Unger RH, Bennett PH: Diet-induced improvement of abnormalities in insulin and glucagon secretion and in insulin receptor binding in diabetes
mellitus. / Clin Endocrinol Metab 48:999-1007, 1979
98. Vague P, Moulin J-P: The defective glucose sensitivity of
the B-cell in noninsulin dependent diabetes: improvement after twenty hours of normoglycemia. Metabolism
31:139-42, 1982
99. Glaser B, Leibovich G, Nesher R, Hartling S, Binder C,
Cerasi E: Improved beta-cell function after intensive insulin treatment in severe non-insulin-dependent diabetes. Acta Endocrinol 118:365-73, 1988
100. Garvey WT, Olefsky JM, Griffin J, Hamman RF, Kolterman OG: The effect of insulin treatment on insulin secretion and insulin action in type II diabetes mellitus.
Diabetes 34:222-34, 1985

DIABETES CARE, VOL. 13, N O . 9, SEPTEMBER 1990

101. Giugliano D, Ceriello A, Di Pinto P, Saccomanno F,


Gentile S, Cappiapuoti F: Impaired insulin secretion in
human diabetes mellitus: the effect of naloxone-induced
opiate receptor blockade. Diabetes 31:367-70, 1982
102. Robertson RP, Chen M: A role for prostaglandin E in
defective insulin secretion and carbohydrate intolerance
in diabetes mellitus. ) Clin Invest 60:747-53, 1977
103. Giugliano D: Morphine, opioid peptides, and pancreatic
islet function. Diabetes Care 7:92-98, 1984
104. Robertson RP: Type II diabetes, glucose "non-sense,"
and islet desensitization. Diabetes 38:1501-505, 1989
105. Ward WK, Halter JB, Beard JC, Porte D Jr: Adaption of
B and A cell function during prolonged glucose infusion
in human subjects. Am ) Physiol 246:E405-11, 1984
106. Beard JC, Halter JB, Best JD, Pfeifer MA, Porte D Jr:
Dexamethasone-induced insulin resistance enhances Bcell responsiveness to glucose level in normal men. Am
I Physiol 247:E592-96, 1984
107. Kahn SE, Beard JC, Schwartz MW, Ward WK, Ding HL,
Bergman RN, Taborsky GJ Jr, Porte D Jr: Increased 6cell secretory capacity as mechanism for islet adaption
to nicotinic acid-induced insulin resistance. Diabetes
38:562-68, 1989
108. Taborsky GJ Jr, Smith PH, Halter JB, Porte D Jr: Glucose
infusion potentiates the acute insulin response to nonglucose stimuli during the infusion of somatostatin. Endocrinology 105:1215-20, 1979
109. Hollander PM, Asplin CM, Palmer JP: Glucose modulation of insulin and glucagon secretion in nondiabetic
and diabetic man. Diabetes 31:489-95, 1982
110. Dimitriadis GD, Pehling GB, Gerich JE: Abnormal glucose modulation of islet A- and B-cell responses to arginine in non-insulin-dependent diabetes mellitus.
Diabetes 34:541-47, 1985
111. Ward WK, Beard JC, Halter JB, Pfeifer MA, Porte D Jr:
Pathophysiology of insulin secretion in non-insulin-dependent diabetes mellitus. Diabetes Care 7:491-502,
1984
112. McCulloch DK, Klaff LJ, Kahn SE, Schoenfeld SL, Greenbaum CJ, Mauseth RS, Benson EA, Nepom GT, Shewey
L, Palmer JP: Nonprogression of subclinical 3-cell dysfunction among first-degree relatives of IDDM patients:
5-yr follow-up of the Seattle family study. Diabetes
39:549-56, 1990
113. Ward WK, Wallum BJ, Beard JC, Taborsky GJ Jr, Porte
D Jr: Reduction of glycemic potentiation: sensitive indicator of B-cell loss in partially pancreatectomized
dogs. Diabetes 37:723-29, 1988
114. McCulloch DK, Raghu PK, Johnston C, Klaff LJ, Kahn
SE, Beard JC, Ward WK, Benson EA, Koerker DJ, Bergman RN, Palmer JP: Defects in 3-cell function and insulin sensitivity in normoglycemic streptozocin-treated
baboons: a model of preclinical insulin-dependent diabetes. / Clin Endocrinol Metab 67:785-92, 1988
115. Robertson RP, Halter JB, Porte D Jr: A role for alphaadrenergic receptors in abnormal insulin secretion in diabetes mellitus. J Clin Invest 57:791-95, 1976
116. Broadstone VL, Pfeifer MA, Bajaj V, Stagner Jl, Samols
E: a-Adrenergic blockade improves glucose-potentiated
insulin secretion in non-insulin-dependent diabetes mellitus. Diabetes 36:932-37, 1987
117. McRae JR, Metz SA, Robertson RP: A role for endogenous prostaglandins in defective glucose potentiation of
nonglucose insulin secretagogues in diabetics. Metabolism 30:1065-75, 1981

1007

CELL DYSFUNCTION IN NIDDM

118. Weigle DS: Pulsatile secretion of fuel-regulatory hormones. Diabetes 36:764-75, 1987
119. Lang DA, Matthews DR, Peto J, Turner RC: Cyclic oscillations of basal plasma glucose and insulin concentrations in human beings. N Engl j Med 301:1023-27,
1979
120. Hansen BC, Jen K-L, Pek SB, Wolfe RA: Rapid oscillations in plasma insulin, glucagon, and glucose in obese
and normal weight humans. ) Clin Endocrinol Metab
54:785-92, 1982
121. Jaspan JB, Lever E, Polonsky KS, Van Cauter E: In vivo
pulsatility of pancreatic islet peptides. Am ) Physiol
251:E215-26, 1986
122. Stagner Jl, Samols E, Weir GC: Sustained oscillations of
insulin, glucagon, and somatostatin from the isolated
canine pancreas during exposure to a constant glucose
concentration. / Clin Invest 65:939-42, 1980
123. Simon C, Brandenberger G, Follenius M: Ultradian oscillations of plasma glucose, insulin, and C-peptide in
man during continuous enteral nutrition. / Clin Endocrinol Metab 64:669-74, 1987
124. Knobil E: The neuroendocrine control of the menstrual
cycle. Recent Prog Horm Res 36:53-88, 1980
125. Komjati M, Bratusch-Marrain P, Waldhausl W: Superior
efficacy of pulsatile versus continuous hormone exposure on hepatic glucose production in vitro. Endocrinology 118:312-19, 1986
126. Goodner CJ, Horn FG, Koerker DJ: Hepatic glucose production oscillates in synchrony with the islet secretory
cycle in fasting rhesis monkeys. Science 215:1257-60,
1982
127. Matthews DR, Naylor BA, Jones RG, Ward GM, Turner
RC: Pulsatile insulin has greater hypoglycemic effect
than continuous delivery. Diabetes 32:617-21, 1983
128. Bratusch-Marrain PR, Komjati M, Waldhausl WK: Efficacy of pulsatile versus continuous insulin administration on hepatic glucose production and glucose
utilization in type I diabetic humans. Diabetes 35:92226, 1986
129. Ward GM, Walters JM, Aitken PM, Best JD, Alford FP:
Effects of prolonged pulsatile hyperinsulinemia in humans: enhancement of insulin sensitivity. Diabetes
39:501-507, 1990
130. Lang DA, Matthews DR, Burnett M, Turner RC: Brief,
irregular oscillations of basal plasma insulin and glucose
concentrations in diabetic man. Diabetes 30:435-39,
1981
131. Matthews DR, Lang DA, Burnett MA, Turner RC: Control of pulsatile insulin secretion in man. Diabetologia
24:231-37, 1983
132. Goodner CJ, Koerker DJ, Weigle DS, McCulloch DK:
Decreased insulin- and glucagon-pulse amplitude accompanying B-cell deficiency induced by streptozocin
in baboons. Diabetes 38:925-31, 1989
133. Warram JH, Martin BC, Gleason RE, Soeldner JS: Slow
glucose removal rate but not insulin secretion predicts
development of NIDDM in offspring of two NIDDM parents (Abstract). Diabetes 36 (Suppl. 1):14A, 1987
134. Haffner SM, Stern MP, Hazuda HP, Pugh JA, Patterson
JK: Hyperinsulinemia in a population at high risk for
non-insulin-dependent diabetes mellitus. N Engl I Med
315:220-24, 1986
135. Haffner SM, Stern MP, Mitchell BD, Hazuda HP, Patterson JK: Incidence of type II diabetes in Mexican Americans predicted by fasting insulin and glucose levels,

1008

136.

137.

138.

139.

140.
141.
142.

143.
144.
145.

146.
147.

148.

149.

150.

151.

obesity, and body-fat distribution. Diabetes 39:283-88,


1990
Sicree RA, Zimmet PZ, King HOM, Coventry JS: Plasma
insulin response among Nauruans: prediction of deterioration in glucose tolerance over 6 yr. Diabetes 36:
179-86, 1987
Saad MF, Knowler WC, Pettitt DJ, Nelson RG, Mott DM,
Bennett PH: The natural history of impaired glucose tolerance in the Pima Indians. N Engl j Med 319:1500506, 1988
Haffner SM, Stern MP, Hazuda HP, Mitchell BD, Patterson JP: Increased insulin concentrations in nondiabetic offspring of diabetic parents. N Engl J Med
319:1297-301, 1988
Eriksson J, Franssila-Kallunki A, Ekstrand A, Saloranta C,
Widen E, Schalin C, Groop L: Early metabolic defects
in persons at increased risk for non-insulin-dependent
diabetes mellitus. N Engl) Med 321:337-43, 1989
Efendic S, Luft R, Wajngot A: Aspects of the pathogenesis of type 2 diabetes. Endocrinol Rev 5:395-419,
1984
Efendic S, Grill V, Luft R, Wajngot A: Low insulin response: a marker of prediabetes. Adv Exp Med Biol
246:167-74, 1988
KadowakiT, Miyake Y, Hagura R, Akanuma Y, Kajinuma
H, Kuzuya N, Takaku F, Kosaka K: Risk factors for worsening to diabetes in subjects with impaired glucose tolerance. Diabetologia 26:44-49, 1984
Jarrett RJ, Keen H, Fuller JH, McCartney M: Worsening
to diabetes in men with impaired glucose tolerance
("borderline diabetes"). Diabetologia 16:25-30, 1979
Turner RC, Holman RR: Beta cell function during insulin
or chlorpropamide treatment of maturity-onset diabetes
mellitus. Diabetes 27:241-46, 1978
Unger RH, Grundy S: Hyperglycaemia as an inducer as
well as a consequence of impaired islet cell function
and insulin resistance: implications for the management
of diabetes. Diabetologia 28:119-21, 1985
Dohan FC, Lukens FDW: Experimental diabetes produced by the administration of glucose. Endocrinology
42:244-62, 1948
Dimitriadis G, Cryer P, Gerich J: Prolonged hyperglycaemia during infusion of glucose and somatostatin impairs pancreatic A- and B-cell responses to decrements
in plasma glucose in normal man: evidence for induction of altered sensitivity to glucose. Diabetologia
28:63-69, 1985
Seltzer HS, Harris VL: Exhaustion of insulogenic reserve
in maturity-onset diabetic patients during prolonged and
continuous hyperglycemic stress. Diabetes 13:6-13,
1964
Graber AL, Wood FC Jr, Williams RH: Serum immunoreactive insulin response during prolonged glucose
infusions in nondiabetic and diabetic humans. Diabetes
16:145-49, 1967
Leahy JL, Bonner-Weir S, Weir GC: Rat models of noninsulin-dependent diabetes mellitus: evidence that mild
increases in plasma glucose play an important role in
pathogenesis. In The Pathology of the Endocrine Pancreas in Diabetes. Lefebvre PJ, Pipeleers DG, Eds. Heidelberg, FRG, Springer-Verlag, 1988, p. 285-309
Bonner-Weir S, Trent DF, Honey RN, Weir GC: Responses of neonatal rat islets to streptozotocin: limited
B-cell regeneration and hyperglycemia. Diabetes 30:
64-69, 1981

DIABETES CARE, V O L . 13, N O . 9, SEPTEMBER 1990

J.L LEAHY

152. Bonner-Weir S, Trent DF, Weir GC: Partial pancreatectomy in the rat and subsequent defect in glucose-induced insulin release, j Clin Invest 71:1544-53, 1983
153. Penhos JC, Wu C-H, Basabe JC, Lopez N, Wolff FW: A
rat pancreas-small gut preparation for the study of intestinal factor(s) and insulin release. Diabetes 18:733
38, 1969
154. WeirGC, Knowlton SD, Martin DB: Glucagon secretion
from the perfused rat pancreas: studies with glucose and
catecholamines. J Clin Invest 54:1403-12, 1974
155. WeirGC, Clore ET, Zmachinski CJ, Bonner-Weir S: Islet
secretion in a new experimental model for non-insulindependent diabetes. Diabetes 30:590-95, 1981
156. Trent DF, Fletcher DJ, May JM, Bonner-Weir S, Weir GC:
Abnormal islet and adipocyte function in young B-celldeficient rats with near-normoglycemia. Diabetes
33:170-75, 1984
157. Leahy JL, Bonner-Weir S, Weir GC: Abnormal glucose
regulation of insulin secretion in models of reduced Bcell mass. Diabetes 33:667-73, 1984
158. Giroix M-H, Portha B, Kergoat M, Bailbe D, Picon L:
Glucose insensitivity and amino-acid hypersensitivity of
insulin release in rats with non-insulin-dependent diabetes: a study with the perfused pancreas. Diabetes
32:445-51, 1983
159. Portha B, Blondel O, Serradas P, McEvoy R, Giroix M-H,
Kergoat M, Bailbe D: The rat models of non-insulin dependent diabetes induced by neonatal streptozotocin. Diabete Metab 15:61-75, 1989
160. Grill V, Rundfeldt M: Abnormalities of insulin responses
after ambient and previous exposure to glucose in streptozocin-diabetic and dexamethasone-treated rats: role of
hyperglycemia and increased B-cell demands. Diabetes
35:44-51, 1986
161. Leahy JL, Weir GC: Unresponsiveness to glucose in a
streptozocin model of diabetes: inappropriate insulin
and glucagon responses to a reduction of glucose concentration. Diabetes 34:653-59, 1985
162. Leahy JL, Halban PA, Weir GC: Increased pancreatic
proinsulin: insulin ratio in diabetic rats (Abstract). Diabetes 38 (Suppl. 2):206A, 1989
163. Leahy JL, Halban PA, Weir GC: Enhanced proinsulin
secretion in diabetic rats is not explained by abnormal
processing (Abstract). Diabetes 39 (Suppl. 1):137A,
1990
164. Leahy JL, Cooper HE, Deal DA, Weir GC: Chronic hyperglycemia is associated with impaired glucose influence on insulin secretion: a study in normal rats using
chronic in vivo glucose infusions.) Clin Invest 77:90815, 1986
165. Leahy JL, Bonner-Weir S, Weir GC: Abnormal insulin
secretion in a streptozocin model of diabetes: effects of
insulin treatment. Diabetes 34:660-66, 1985
166. Kergoat M, Bailbe D, Portha B: Insulin treatment improves glucose-induced insulin release in rats with
NIDDM induced by streptozocin. Diabetes 36:971-77,
1987
167. Voyles NR, Powell AM, Timmers Kl, Wilkins SD, Bhathena SJ, Hansen C, Michaelis OE, Recant L: Reversible
impairment of glucose-induced insulin secretion in SHR/
N-cp rats: genetic model of type II diabetes. Diabetes
37:398-404, 1988
168. Brockenbrough JS, Weir GC, Bonner-Weir S: Discordance of exocrine and endocrine growth after 90% pancreatectomy in rats. Diabetes 37:232-36, 1988

DIABETES CARE, V O L . 13, N O . 9, SEPTEMBER 1990

169. Bonner-Weir S, Deery D, Weir GC: Growth of regenerating islet tissue is enhanced by VMH lesions (Abstract). Diabetes 35 (Suppl. 1):97A, 1986
170. Leahy JL, Cooper HE, Weir GC: Impaired insulin secretion associated with near normoglycemia: study in normal rats with 96-h in vivo glucose infusions. Diabetes
36:459-64, 1987
171. Leahy JL, Weir GC: Evolution of abnormal insulin secretory responses during 48-h in vivo hyperglycemia.
Diabetes 37:217-22, 1988
172. Leahy JL, Bonner-Weir S, Weir GC: Rapid reversal of Bcell defects caused by chronic hyperglycemia (Abstract).
Diabetes 37 (Suppl. 1):6A, 1988
173. Starke A, Grundy S, McGarry JD, Unger RH: Correction
of hyperglycemia with phloridzin restores the glucagon
response to glucose in insulin-deficient dogs: implications for human diabetes. Proc Natl Acad Sci USA
82:1544-46, 1985
174. Rossetti L, Shulman Gl, Zawalich W, DeFronzo RA: Effect of chronic hyperglycemia on in vivo insulin secretion in partially pancreatectomized rats. / Clin Invest
80:1037-44, 1987
175. Grill V, Westberg M, Ostenson C-G: B cell insensitivity
in a rat model of non-insulin-dependent diabetes: evidence for a rapidly reversible effect of previous hyperglycemia. / Clin Invest 80:664-69, 1987
176. Halban PA, Bonner-Weir S, Weir GC: Elevated proinsulin biosynthesis in vitro from a rat model of non-insulin-dependent diabetes mellitus. Diabetes 32:277-83,
1983
177. Portha B: Decreased glucose-induced insulin release
and biosynthesis by islets of rats with non-insulin-dependent diabetes: effect of tissue culture. Endocrinology
117:1735-41, 1985
178. Portha B, Giroix M-H, Serradas P, Welsh N, Hellerstrom
C, Sener A, Malaisse WJ: Insulin production and glucose
metabolism in isolated pancreatic islets of rats with
NIDDM. Diabetes 37:1226-33, 1988
179. Bolaffi JL, Heldt A, Lewis LD, Grodsky GM: The third
phase of in vitro insulin secretion: evidence for glucose
insensitivity. Diabetes 35:370-73, 1986
180. Grodsky GM: A new phase of insulin secretion: how
will it contribute to our understanding of p-cell function?
Diabetes 38:673-78, 1989
181. Giroix M-H, Serradas P, Portha B: The desensitization
of normal B-cells to glucose in vitro is transient and not
related to high glucose levels. Endocrinology 125:19992007, 1989
182. Weir GC, Bonner-Weir S: Islets of Langerhans: the puzzle of intraislet interactions and their relevance to diabetes. } Clin Invest 85:983-87, 1990
183. Ciaraldi TP, Kolterman OG, Scarlett JA, Kao M, Olefsky
JM: Role of glucose transport in the postreceptor defect
of non-insulin-dependent diabetes mellitus. Diabetes
31:1016-22, 1982
184. Garvey WT, Kolterman OG: Correlation of in vivo and
in vitro actions of insulin in obesity and noninsulin-dependent diabetes mellitus: role of the glucose transport
system. Diabetes Metab Rev 4:543-69, 1988
185. Scarlett JA, Gray RS, Griffin J, Olefsky JM, Kolterman
OG: Insulin treatment reverses the insulin resistance of
type II diabetes mellitus. Diabetes Care 5:353-63, 1982
186. Andrews WJ, Vasquez B, Nagulesparan M, Klimes I,
FoleyJ, Unger R, Reaven GM: Insulin therapy in obese,
non-insulin-dependent diabetes induces imorovements

1009

CELL DYSFUNCTION IN NIDDM

187.

188.

189.

190.
191.

1010

in insulin action and secretion that are maintained for


two weeks after insulin withdrawal. Diabetes 33:63442, 1984
Colella RM, MayJM, Bonner-WeirS, LeahyJL, WeirGC:
Glucose utilization in islets of hyperglycemic rat models
with impaired glucose-induced insulin secretion. Metabolism 36:335-37, 1987
Matschinsky FM, Ghosh AK, Meglasson MD, Prentki M,
June V, von Allman D: Metabolic concomitants in pure,
pancreatic beta cells during glucose-stimulated insulin
secretion. ) Biol Chem 261:14057-61, 1986
WeirGC, Leahy JL, Wilson J, Matschinsky FM: Defective
insulin secretion induced by hyperglycemia is not due
to altered glucose transport in trie B-cell (Abstract). Diabetes 37 (Suppl. 1):100A, 1988
Sako Y, Grill V: A 48 h lipid infusion selectively inhibits
glucose-induced insulin secretion in the rat (Abstract).
Diabetologia 32:536A, 1989
Meglasson MD, Matschinsky FM: New perspectives
on pancreatic islet glucokinase. Am j Physiol 246:E1-

13, 1984
192. Malaisse WJ: Possible sites for deficient glucose recognition in islet cells. In The Pathology of the Endocrine
Pancreas in Diabetes. Lefebvre PJ, Pipeleers DG,
Eds. Heidelberg, FRG, Springer-Verlag, 1988, p. 219
32
193. Kolterman OG, Insel J, Saekow M, Olefsky JM: Mechanisms of insulin resistance in human obesity: evidence
for receptor and postreceptor defects. ) Clin Invest
65:1272-84, 1980
194. Polonsky KS, Given BD, Hirsch L, Shapiro ET, Tillit H,
BeebeC, Galloway JA, Frank BH, KarrisonT, Van Cauter
E: Quantitative study of insulin secretion and clearance
in normal and obese subjects. J Clin Invest 81:435-41,
1988
195. Beard JC, Ward WK, Halter JB, Wallum BJ, Porte D Jr:
Relationship of islet function to insulin action in human
obesity. J Clin Endocrinol Metab 65:59-64, 1987
196. Pfeifer MA, Halter JB, Porte D Jr: Insulin secretion in
diabetes mellitus. Am } Med 70:579-88, 1981

DIABETES CARE, V O L . 13, N O . 9, SEPTEMBER 1990