Quantitation of insulin sensitivity (SI) with the insulin suppression test, glucose clamp, or the minimal model method has been achieved in various clinical circumstances. The application of these techniques to pregnancy has been limited. It is important to utilize sensitive and reproducible methods to study SI changes in pregnancy to fully understand the normal and pathological metabolic alterations that occur during gestation. These techniques demonstrate that various factors (obesity, body fat distribution, age, dietary manipulation, and exercise) may affect SI measures. The various pregnancy hormones have differential effects on insulin action. There is consensus among the limited in vivo studies in human pregnancy that late gestation is associated with significantly impaired SI compared with the nonpregnant state. Studies with appropriate matching between control and gestational diabetic subjects have failed to demonstrate a significant difference in SI between groups in the third trimester.

Diagnostic criteria for diabetes mellitus (DM) and impaired glucose tolerance from oral glucose tolerance test results in adults are reviewed in the epidemiological context, highlighting the residual differences between World Health Organization (WHO) and National Diabetes Data Group (NDDG) glycemic criteria with respect to the diagnosis of gestational diabetes. Although the value of the diagnosis of DM (WHO/NDDG criteria) in pregnancy is not called into question, attention is drawn to the paucity of evidence linking lesser degrees of glucose intolerance with significant disturbance of pregnancy outcome when confounding variables such as maternal age, adiposity, and parity are allowed for. It is in the area of the detection and treatment of these lesser degrees of glucose intolerance in pregnancy that serious questions of the detriment-to-benefit ratio arise. A population-based multiethnic multicultural inquiry into diagnostic methodology and criteria in pregnancy is proposed, jointly sponsored by the WHO and the International Diabetes Federation, extending, if possible, to a controlled clinical trial of the effects of intervention.

In the United States, glucose tolerance test criteria for the diagnosis of gestational diabetes mellitus are, in plasma glucose after a 100-g challenge, as follows: fasting, greater than 5.8 mM; 1 h, greater than 10.6 mM; 2 h, greater than 9.2 mM; and 3 h, greater than 8.1 mM; any two values must be elevated. The Second International Workshop-Conference on Gestational Diabetes Mellitus recommended in 1985 that, once diagnosed, women should receive dietary therapy. If fasting or 2-h postprandial hyperglycemia later occurs (fasting, greater than 5.8 mM; 2-h, greater than 6.7 mM), insulin therapy should begin. Data from others have suggested both that the criteria for diagnosis may be too liberal and that the thresholds for instituting insulin therapy may be too high. We address these two issues by reviewing several papers with conflicting conclusions. There is controversy over whether women with gestational diabetes diagnosed by glucose tolerance testing, but who have fasting plasma glucose levels less than 5.8 mM and 2-h postprandial values less than 6.7 mM, should also be insulin treated. Finally, the usual clinical criteria for making therapeutic decisions all rely on glycemia. Other fuels (amino acids, lipids, and ketones) are regulated by circulating insulin and have deleterious effects on fetal development. Further study is required to make more sound clinical decisions based not just on glycemia but on the entire metabolic milieu.

Glucose tolerance deteriorates in human pregnancy, but approximately 97-98% of all pregnant women retain a normal glucose tolerance, and only 2-3% develop gestational diabetes mellitus (GDM). Both nondiabetic pregnant women and women with GDM exhibit much higher insulin responses to oral or intravenous administration of glucose or amino acids than found in the nonpregnant state, and the insulin responses to a protein-rich meal are also significantly enhanced in pregnancy. Both quantitative and qualitative differences in insulin secretion exist between pregnant women with normal glucose tolerance (NGT) and women with GDM. Insulin responses to oral glucose and protein-rich meals are thus lower in pregnant women with GDM than in women with NGT, despite significantly higher mean plasma glucose concentrations in the women with GDM. Furthermore, peak plasma insulin concentrations occur later in women with GDM than in pregnant control subjects. Finally, a reduced first-phase insulin response to intravenous glucose can be observed in some women with GDM. Impairment of glucose tolerance in pregnancy is not related to a disproportional secretion of proinsulin nor is increased insulin degradation involved. These observations point to pregnancy as a state of peripheral insulin resistance. Because insulin-receptor binding is only slightly changed in pregnancy and not significantly different in pregnant women with NGT and women with GDM, it follows that the insulin resistance is located at the postreceptor level. Insulin-clamp and "minimal model" studies have shown that the whole-body insulin sensitivity is similarly reduced by about two-thirds of nonpregnant values in pregnant women with NGT and women with GDM.(ABSTRACT TRUNCATED AT 250 WORDS)

Physical training is associated with lower plasma insulin concentrations and increased sensitivity to insulin in skeletal muscle and adipose tissue of individuals with non-insulin-dependent diabetes mellitus (NIDDM). The benefits of exercise to individuals with NIDDM in terms of increased insulin sensitivity could be applied to reversing the insulin resistance associated with gestational diabetes mellitus (GDM). Exercise may also benefit women with GDM by acting as an adjunct to diet in preventing excessive weight gain and preventing or decreasing the severity of hypertension and/or hyperlipidemia during pregnancy. Regular physical exercise should be considered as a potential approach to the prevention and treatment of GDM.

To monitor the severity of metabolic disturbances during gestational diabetes mellitus (GDM), some risk factors existing at the time of diagnosis must be considered, including age of the pregnant women, early gestational age at diagnosis, high fasting blood glucose level, high HbA1c or fructosamine levels, or high amniotic fluid insulin level. The degree of OGTT abnormality will also influence the therapeutic approach, although the insulin response to the glucose challenge seems to be of little discriminating value. Effectiveness of the treatment can be appreciated by self-monitoring of blood glucose, although the practical precision of these measures and their necessary repetitions will limit clear-cut evaluation of borderline cases. HbA1c and fructosamine are of little help because of lack of sensitivity and time delay between changes in blood glucose and associated glycosylated protein changes. Whether other parameters such as amino acids, growth factors, or related compounds are more specifically linked to the physiopathology of GDM complications remains to be established but would help in monitoring GDM metabolic disturbances in the future. Meanwhile, prophylactic insulin treatment may still constitute a pragmatic approach, taking into account possible and poorly appreciated drawbacks from overtreatment, e.g., maternal hyperinsulinism and chronic hypoglycemia.

International agreement is lacking with regard to diagnostic criteria for gestational diabetes and its treatment. Consensus is not possible without agreement on the objectives in making the diagnosis. The most commonly used criteria in North America were validated by their predictive value for the subsequent development of overt diabetes in the years after affected pregnancies. The diagnosis is also deemed by many to be important as a risk factor for adverse perinatal outcome in the present pregnancy. Attempts have been made, in various parts of the world, to derive diagnostic criteria based on pregnancy outcome; unfortunately, these have not been so intensively studied as the standards cited above. There is also a lack of agreement on whether gestational diabetes should be considered a disease or merely a risk factor. In addition, consensus has not been reached on whether population-specific criteria should be used in each location or universally accepted diagnostic thresholds should be applied. Many philosophical questions remain unanswered, and numerous opportunities for investigation present themselves. Many of these are dealt with in this workshop-conference, whereas others remain as goals to be attained.

gamma-Aminobutyric acid (GABA), a prominent inhibitory neurotransmitter, is present in high concentrations in beta-cells of islets of Langerhans. The GABA shunt enzymes, glutamate decarboxylase (GAD) and GABA transaminase (GABA-T), have also been localized in islet beta-cells. With the recent demonstration that the 64,000-M, antigen associated with insulin-dependent diabetes mellitus is GAD, there is increased interest in understanding the role of GABA in islet function. Only a small component of beta-cell GABA is contained in insulin secretory granules, making it unlikely that GABA, coreleased with insulin, is physiologically significant. Our immunohistochemical study of GABA in beta-cells of intact islets indicates that GABA is associated with a vesicular compartment distinctly different from insulin secretory granules. Whether this compartment represents a releasable pool of GABA has yet to be determined. GAD in beta-cells is associated with a vesicular compartment, similar to the GABA vesicles. In addition, GAD is found in a unique extensive tubular cisternal complex (GAD complex). It is likely that the GABA-GAD vesicles are derived from this GAD-containing complex. Physiological studies on the effect of extracellular GABA on islet hormonal secretion have had variable results. Effects of GABA on insulin, glucagon, and somatostatin secretion have been proposed. The most compelling evidence for GABA regulation of islet hormone secretion comes from studies on somatostatin secretion, where it has an inhibitory effect. We present new evidence demonstrating the presence of GABAergic nerve cell bodies at the periphery of islets with numerous GABA-containing processes extending into the islet mantle. This close association between GABAergic neurons and islet alpha- and delta-cells strongly suggests that GABA inhibition of somatostatin and glucagon secretion is mediated by these neurons. Intracellular beta-cell GABAA and its metabolism may have a role in beta-cell function. New evidence indicates that GABA shunt activity is involved in regulation of insulin secretion. In addition, GABA or its metabolites may regulate proinsulin synthesis. These new observations provide insight into the complex nature of GABAergic neurons and beta-cell GABA in regulation of islet function.

Hypertension is associated with hyperinsulinemia in the presence or absence of obesity or glucose intolerance. Physiological concentrations of insulin decrease the catecholamine-induced production of prostaglandin I2 (PGI2; prostacyclin) and PGE2, two potent vasodilators, in adipose tissue, one of the largest organs in the body. This finding suggests that hyperinsulinemia increases peripheral vascular resistance and blood pressure by inhibiting the stimulatory effect of adrenergic agonists (and perhaps other agonists) on the production of PGI2 and PGE2 in adipose tissue (and perhaps other tissues). This concept is supported by evidence that PGI2 and PGE2 modulate vascular reactivity in states of health and disease. For example, during insulin deficiency, i.e., in diabetic ketoacidosis, PGI2 and PGE2 production by adipose tissue are increased, and peripheral vascular resistance and blood pressure are decreased. This hypothesis is also supported by evidence that blood flow through rat and human adipose tissue is decreased in obesity and that insulin decreases the blood flow through adipose tissue in nonobese rats. Thus, insulin may regulate PGI2 and PGE2 production by adipose tissue (and possibly other tissues) through a wide range of concentrations with important physiological and clinical consequences.

Pancreas transplantation, when successful, is a reproducibly effective method to normalize glycemia without the use of exogenous insulin treatment in patients with diabetes mellitus. Success rates for combined pancreas and kidney transplantation are approximately 70%, and patient survival rates are approximately 90% 1 yr postoperatively. Metabolic benefits of this procedure include normalization of levels of fasting plasma glucose and HbA1C. Glucose-induced insulin secretion and intravenous glucose tolerance are normalized. Improvements are also observed in glucose recovery after insulin-induced hypoglycemia and in glucagon secretion during hypoglycemia. Pancreas transplantation is also associated with normalization of kidney structure and both motor and sensory nerve function. However, no benefits have been observed with regard to pancreatic polypeptide secretion, kidney function, and the retinal pathology of diabetes mellitus. Pancreas transplantation has reached a point in its history where the operative technique and its ancillary medical therapy have been optimized. Improvement in the rates of success, morbidity, and mortality will probably depend on improvement in immunosuppressive drugs and the physical condition of the recipients themselves. The time is at hand when we need to carefully consider whether it is ethical and advisable to make pancreas transplantation available to individuals who have fewer chronic complications of diabetes mellitus. Future studies of pancreas transplantation must incorporate more rigid experimental controls than have been used in the past to better assess the relative merits of this procedure.

Although we can now identify some nondiabetic individuals who will subsequently develop clinical insulin-dependent diabetes mellitus (IDDM), our ability to predict subsequent clinical IDDM is far from perfect. In this article, we discuss the status of knowledge regarding the natural history of preclinical IDDM and discuss, especially in relation to predicting IDDM, the genetic, immunologic, and metabolic components of the IDDM disease process.

Because the pathogenetic understanding of diabetic vascular complications remains fragmentary, and even the best available interventions may prove insufficient to arrest the progression of certain lesions, new avenuses of investigation should be pursued. One of these should be the early in vivo investigation of the cells that endure the pathological process (pericytes and endothelial and mesangial cells), preferably in humans. The abnormal vascular architecture (i.e., capillary acellularity, microaneurysms, thickened basement membranes, and mesangial expansion) and the hemostatic and hemodynamic alterations observed in diabetes point to an adaptive/maladaptive replicative and biosynthetic program triggered by the metabolic perturbation, but positive documentation of cellular changes in vivo remains grossly insufficient. Critical review of current knowledge of microangiopathy permits elaboration of specific questions that, with the tools provided by the new molecular technology, may be posed about vascular cells in situ. Knowing whether and how the cell types involved in the vascular complications of diabetes modify their differentiated functions may offer novel targets for intervention and, most important, should provide a much needed "sounding board" against which to test the viability and refine the focus of pathogenetic hypotheses.

Proposed mechanisms by which insulin exerts its effects are discussed. Evidence for a role for the tyrosine kinase activity of the insulin receptor and of a phosphorylation/dephosphorylation cascade is presented. The possible roles of phospholipid breakdown, diacylglycerol, and protein kinase C are discussed. The hypothesis that insulin elicits the hydrolysis of a glycosyl phosphatidylinositol to form a mediator of certain of its actions is considered in detail. The evidence that a G protein is involved in insulin action is analyzed.

The application of molecular biology to problems in diabetes mellitus has begun to reveal the underlying molecular defects contributing to the development of hyperglycemia. Islet amyloid represents the most common pathological lesion occurring in the islets of NIDDM subjects. The use of both biochemistry and molecular biology has lead to the identification of the major protein component of human islet amyloid and elucidation of the structure of its precursor. This protein, termed islet amyloid polypeptide, is related to two neuropeptides, calcitonin gene-related peptides 1 and 2, and represents a new beta-cell secretory product whose normal physiological function remains to be determined. The use of molecular biology has also led to a better understanding of the molecular defects contributing to insulin resistance. Characterization of the insulin-receptor gene in patients with extreme forms of insulin resistance has resulted in the identification of mutations that impair its function and lead to tissue resistance to the action of insulin. Molecular biological approaches have also led to a better understanding of the regulation of glucose transport. They have revealed that there is a family of structurally related proteins encoded by distinct genes and expressed in a tissue-specific manner that are responsible for the transport of glucose across the plasma membrane. Moreover, they have shown that specific depletion of the glucose-transporter isoform that mediates insulin-stimulated glucose transport is responsible for decreased transport activity in adipose tissue in insulin-resistant states.

N epsilon-(carboxymethyl)lysine, N epsilon-(carboxymethyl)hydroxylysine, and the fluorescent cross-link pentosidine are formed by sequential glycation and oxidation reactions between reducing sugars and proteins. These compounds, termed glycoxidation products, accumulate in tissue collagen with age and at an accelerated rate in diabetes. Although glycoxidation products are present in only trace concentrations, even in diabetic collagen, studies on glycation and oxidation of model proteins in vitro suggest that these products are biomarkers of more extensive underlying glycative and oxidative damage to the protein. Possible sources of oxidative stress and damage to proteins in diabetes include free radicals generated by autoxidation reactions of sugars and sugar adducts to protein and by autoxidation of unsaturated lipids in plasma and membrane proteins. The oxidative stress may be amplified by a continuing cycle of metabolic stress, tissue damage, and cell death, leading to increased free radical production and compromised free radical inhibitory and scavenger systems, which further exacerbate the oxidative stress. Structural characterization of the cross-links and other products accumulating in collagen in diabetes is needed to gain a better understanding of the relationship between oxidative stress and the development of complications in diabetes. Such studies may lead to therapeutic approaches for limiting the damage from glycation and oxidation reactions and for complementing existing therapy for treatment of the complications of diabetes.

Islet amyloid polypeptide (IAPP) or amylin is a newly identified 37-amino acid COOH-terminal-amidated polypeptide that is the major protein constituent of amyloid deposits in insulinomas and amyloid deposits in pancreatic islets of non-insulin-dependent (type II) diabetic humans and adult diabetic cats. IAPP is stored with insulin in beta-cell secretory vesicles and is cosecreted with insulin in response to glucose and several secretagogues. IAPP has been demonstrated in normal pancreatic islets of many species, but IAPP-derived amyloid develops commonly in the islets of only a few species (e.g., humans and cats), especially in association with age-related diabetes. IAPP from the human and cat inherently contains a short amyloidogenic sequence that is not present in species that do not form islet amyloid. Studies in animals indicate that an aberration in the synthesis or processing of IAPP, leading to a local increase in concentration of IAPP in the islet, is also required to facilitate the conversion of IAPP to amyloid. The formation of islet amyloid may contribute to the development of type II diabetes by causing disruption of islet cells and by replacement of islets. It has also been proposed that an abnormality of IAPP homeostasis underlies the pathogenesis of type II diabetes. A significant causal relationship between IAPP and type II diabetes is based on reports that IAPP inhibits glucose-stimulated insulin release by beta-cells and that IAPP inhibits insulin-stimulated rates of glycogen synthesis and glucose uptake by skeletal muscle cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Islet amyloid polypeptide (IAPP) or amylin, a recently discovered minor secretory peptide of the beta-cell related to calcitonin gene-related peptide (CGRP), is a constituent of amyloid deposits in the islets of many non-insulin-dependent (type II) diabetic individuals and some elderly nondiabetic subjects. IAPP is synthesized as a small precursor at a level of approximately 1% that of insulin and is processed, amidated, stored in beta-granules, and released along with insulin and C-peptide. Analysis of its gene (located on chromosome 12) supports an evolutionary relationship to calcitonin and CGRP, peptides with which it shares some biological actions. Like CGRP, IAPP antagonizes the action of insulin mainly at the level of muscle glycogen synthesis, but the levels required for this effect seem to be considerably higher than reported circulating levels. No evidence for overproduction of IAPP in diabetic subjects has been found thus far, but much more work is necessary to define its normal secretory rates and clearance. Other proposed actions of IAPP include serum calcium-lowering effects and smooth muscle relaxation; the latter effect might promote the uptake of insulin into the circulation within the islets. Deposition of amyloid is species selective due to structural differences within the central part of the molecule and may be initiated intracellularly in type II diabetes by several mechanisms. No differences in the structure of IAPP or its precursor have been found in individuals with maturity-onset diabetes of the young or type II diabetes.(ABSTRACT TRUNCATED AT 250 WORDS)