56. Metabolism, Growth & Appetite Flashcards
Which key area of the hypothalamus is involved in the regulation of food intake?
Arcuate nucleus
What feature of this area allows it to integrate central and peripheral inputs?
It is a circumventricular organ meaning that it has an incomplete blood-brain barrier This means that the arcuate nucleus is exposed to peripheral hormones
What are the two neuronal populations in the arcuate nucleus?
Agrp/NPY = stimulatory (increases food intake) POMC = inhibitory (prevents food intake)
Describe how the melanocortin system works.
Under normal conditions, POMC is broken down to alpha-MSH, which stimulates the MC4R receptor and prevents food intake When you need to eat, there will be an increase in Agrp activity Agrp will block the MC4R receptor and stimulate an increase in food intake
State some CNS mutations that affect this system and can causeobesity.
POMC deficiency – associated with obesity, red hair and pale skin MC4R mutation – associated with obesity There are NO known Agrp or NPY mutations
What are the features of the leptin deficiency ob/ob mouse?
Obesity Diabetes Decreased energy expenditure Decreased body temperature Infertility Stunted linear growth Decreased immune function
What is leptin?
It is a 167 amino acid hormone It is produced by adipocytes and signals to the brain, telling it how much fat there is in storage
What effect does centrally administered leptin have on leptin deficient individuals?
Decreases food intake Increases thermogenesis
What effect does leptin have on the melanocortin system?
Inhibits Agrp/NPY neurones Stimulates POMC Result = decrease in energy expenditure
What issue do obese people without leptin deficiency have, whichmeans that leptin treatment is not effective as an anti-obesity drug?
Circulating leptin is usually proportional to body fat mass So a lot of obese people are leptin resistant
Why won’t people with leptin deficiency go through puberty?
Leptin has a permissive effect on GnRH release Without GnRH release, you will not get sufficient LH and FSH release to cause puberty This is also the reason why people who are severely underweight get secondary amenorrhoea
Describe the central effects of insulin.
Insulin has a similar effect to leptin as it reduces food intake Chronically – reduced body fat Acutely – if you have a big glucose load, you suppress the intake of more sugar
What is ghrelin and how is it activated?
It is a hunger hormone released by the stomach (28 amino acids long) It is activated by Ghrelin-O-acyltransferase (GOAT), which adds a fatty acid to the 3rd amino acid in the chain
What effect does ghrelin have on the melanocortin system?
Stimulates Agrp/NPY neurones Inhibits POMC neurones Result = increase in food intake
Which cells of the GI tract release PYY and GLP-1?
L-cells
What are the effects of PYY and when is it released?
PYY stimulates POMC neurones and inhibits NPY neurones It is released post-prandially
What is GLP-1 and what gene encodes it?
Glucagon-Like Peptide 1 Encoded by pre-proglucagon gene
What are the effects of GLP-1?
Important role in the incretin effect Decreases food intake
Describe the degradation of GLP-1.
It is rapidly broken down by dipeptidyl peptidase-4 (DP-IV) It has a half-life of around 1 minute
State a long-acting GLP-1 receptor agonist that is used for diabetes and obesity.
Saxenda
What is the problem with PYY 3-36 as a drug target?
High levels of PYY can cause nausea There is only a relatively small sweetspot, in terms of concentration, that will have beneficial effects
State some comorbidities associated with obesity.
Stroke, MI, cancer, diabetes, hypertension, osteoarthritis etc.
What is the thrifty gene hypothesis?
It was evolutionarily sensible to put on extra weight because it meant that we could survive the times when food was scarce (thinner people would die in these times)
What is the adaptive drift hypothesis?
There use to be a normal distribution in terms of body weight Predators would kill the fat people But then we got better at evading predators so increased body weight because a neutral change
Name a form of type I diabetes that presents late.
Latent Autoimmune Diabetes in Adults (LADA)
State two monogenic causes of diabetes.
Mitochondrial Diabetes Maturity Onset Diabetes of the Young
Name a form of type I diabetes that presents late.
Latent Autoimmune Diabetes in Adults (LADA)
State two monogenic causes of diabetes.
Mitochondrial Diabetes Maturity Onset Diabetes of the Young
Diabetes can also present with endocrine diseases. Name three endocrine diseases that are associated with diabetes.
Phaeochromocytoma Cushing’s Syndrome Acromegaly
What conditions and triggers are required for the onset of type 1 diabetes mellitus?
Environmental trigger in the presence of a genetic predisposition –> autoimmune attack of islet cells
Which type of diabetes has a bigger genetic component?
Type 2 Diabetes Mellitus
What can be measured in the blood to give an indication of insulin function?
C-peptide
Describe the pathogenesis of T1DM.
You get gradual autoimmune destruction of beta cells resulting in gradually reducing levels of insulin (and C-peptide) One of the first signs will be the loss of first phase insulin There will be eventual destruction of all beta cells
Why is T1DM described as a ‘relapsing-remitting’ disease?
Over time the beta cell mass appears to reduce, then stabilise, then reduce again There is a theory that this is due to the imbalance in effector T-cells and regulatory T-cells
What is the importance of the autoimmune basis of T1DM?
Increased prevalence of other autoimmune diseases (e.g. rheumatoid arthritis, thyroid disease)
What are the histological features of T1DM?
Lymphocyte infiltration of beta cells (which destroys the beta cells)
On which chromosome is the HLA found?
Chromosome 6
Which alleles convey a risk of diabetes? Which of these alleles is associated with the most significant risk?
DR alleles DR3 and DR4 = significant risk
What are the two most significant markers of diabetes?
Islet Cell Antibodies (ICA) Glutamic Acid Decarboxylase Antibodies (GADA)
State two other antibody markers of diabetes that are not used in clinical practice?
Insulin Autoantibodies (IAA) Insulinoma-associated-2 autoantibodies (IA-2A)- receptor like family
State some symptoms of T1DM.
Polyuria Nocturia Polydipsia Blurring of vision Thrush (due to increased risk of infection) Weight loss Fatigue
What are the signs of T1DM?
Dehydration Cachexia Hyperventilation (kussmaul breathing) Smell of ketones Glycosuria Ketonuria
What are the triglycerides in adipocytes broken down to?
Glycerol Fatty Acids
What does insulin have a negative effect on?
Hepatic glucose output (HGO) Protein breakdown in muscle Ketone body generation by the liver Glycerol release from the fat cells
What does insulin have a positive effect on?
Glucose uptake by tissues
State 4 other hormones that increase hepatic glucose output.
Catecholamines Cortisol Growth Hormone Glucagon
Describe how insulin deficiency leads to diabetic ketoacidosis (DKA).
Insulin has a suppressive effect on hepatic ketone body generation. In insulin deficiency, fatty acids from the breakdown of triglycerides, travel to the liver where they are used to produce ketone bodies.
What is a defining feature of insulin deficiency?
Ketone Bodies NOTE: some cases of T2DM can also get DKA but this is mainly a complication of T1DM
State some long-term complications of T1DM.
Neuropathy Nephropathy Retinopathy Vascular Disease
What is the main treatment for T1DM?
Exogenous insulin
Describe the dietary changes that are recommended in T1DM.
Decreased fat Decreased refined carbohydrates Increased complex carbohydrates Increased soluble fibre
Describe the features of the insulin that is given with meals.
Short-acting Human Insulin Insulin analogues are genetically engineered to mimic normal physiology
State three forms of insulin that are given with meals.
Lipsro Aspart Glulisine
Describe the features of background insulin.
Long-acting Non-C bound to zinc or protamine
State three forms of insulin that is given as background insulin.
Glargine Detemir Degludec
What do insulin pumps do?
Continuous insulin delivery There are pre-programmed basal rates and boluses for meals But these DO NOT measure blood glucose so the feedback loop isn’t complete
Describe the use of islet cell transplants.
Islet cells can be harvested from donors and injected into the liver of a patient with diabetes They must be on immunosuppressants for life
How is capillary monitoring done and what does it give a measure of?
Prick the finger and test the blood drawn It is a measure of venous blood glucose NOTE: you can also get continuous monitors, which aren’t as accurate (need to be calibrated with capillary glucose)
What is HbA1c level used to gage?
Glycaemic control over the past 3 months (red cell life span = 120 days)
What HbA1c level are T1DM patients aiming for?
< 7%
When might the HbA1c level not be accurate?
In any case of increased haemoglobin turnover e.g. haemolytic anaemia and haemoglobinopathies
What are the main acute complications of T1DM?
Hypoglycaemia Metabolic acidosis
What are the two main ketones that circulate in metabolic acidosiscaused by T1DM?
Acetoacetone Hydroxybutyrate
DKA tends to be in patients with T1DM, however, some subsets of T2DM also get ketoacidosis. What are these subsets?
Black and Asian patients with T2DM May be due to pancreatic insufficiency at a time of stress
Define hypoglycaemia.
Blood glucose < 3.6 mmol/L
Define severe hypoglycaemia.
Any level of hypoglycaemia that requires another person to treat it
What can recurrent hypos result in?
Loss of warning (hypoglycaemia unawareness) This can lead to poor glycaemic control
At what times during the day do hypos tend to happen?
Pre-lunch Nocturna
What can trigger a hypo?
Unaccustomed exercise Missed meals Inadequate snacks Alcohol (may make you unaware of hypo symptoms) Inappropriate insulin regime
State some signs and symptoms of hypoglycaemia.
Signs and symptoms are due to increased sympathetic activity and due to impaired CNS function Palpitations Tremor Sweating Pallor/cold extremities Anxiety Drowsiness Confusion Altered behaviour Focal neurology Coma
How is hypoglycaemia treated?
Oral glucose Complex carbohydrate (to maintain blood glucose after initial treatment) Parenteral – if consciousness impaired IV dextrose (e.g. 10% glucose infusion) 1 mg glucagon IM
Diabetes can also present with endocrine diseases. Name three endocrine diseases that are associated with diabetes.
Phaeochromocytoma Cushing’s Syndrome Acromegaly
What conditions and triggers are required for the onset of type 1 diabetes mellitus?
Environmental trigger in the presence of a genetic predisposition –> autoimmune attack of islet cells
How is hypoglycaemia treated?
Oral glucose Complex carbohydrate (to maintain blood glucose after initial treatment) Parenteral – if consciousness impaired IV dextrose (e.g. 10% glucose infusion) 1 mg glucagon IM
State some signs and symptoms of hypoglycaemia.
Signs and symptoms are due to increased sympathetic activity and due to impaired CNS function Palpitations Tremor Sweating Pallor/cold extremities Anxiety Drowsiness Confusion Altered behaviour Focal neurology Coma
What can trigger a hypo?
Unaccustomed exercise Missed meals Inadequate snacks Alcohol (may make you unaware of hypo symptoms) Inappropriate insulin regime
At what times during the day do hypos tend to happen?
Pre-lunch Nocturna