THE ENDOCRINE SYSTEM, METABOLISM AND DISORDERS

Insulin Secretion and Action and Its

Disorders

Division of Endocrinology and Metabolism, Department of Internal Medicine,

Faculty of Medicine, Udayana University
 Anatomy and Histology

Copyright © 2009 Pearson Education, Inc., publishing as Pearson Benjamin Cummings

 Hormones of the Endocrine Pancreas

Approximat
e
Cell Types Percentage Secretory Products
of Islet
Volume
α Cell 25 Glucagon, proglucagon

b Cell 55 Insulin, C peptide,

proinsulin, IAPP, Ucn3,
γ-aminobutyric acid
(GABA)
d Cell 10 Somatostatin-14

e Cell 3 Ghrelin

PP Cell 5IAPP: Islet

Pancreatic
amyloidpolypeptide
polypeptide
Human islet of Langerhans. Staining
for insulin (red), glucagon (green), Ucn: urocortin
and somatostatin (blue) was
performed by immunofluorescence
and imaged by confocal microscopy
Insulin Secretion
Insulin biosynthesis and processing

Proinsulin

Prohormone convertase 3 Prohormone convertase 2

Split (32-33) Split (65-66)

proinsulin proinsulin

Carboxypeptidase
Cleaved
dipeptides
Des (31,32) Des (64,65)
proinsulin proinsulin

Insulin C peptide
 Biosynthesis, Biochemistry and
Secretion of Insulin
(A) Insulin maturation along the granule
secretory pathway. Preproinsulin mRNA is
transcribed from the INS gene and translated to
preproinsulin peptide. As this transits through
the RER and TGN, the prepropeptide is processed
to its mature form and ultimately stored as
hexameric insulin/Zn2+ crystals within mature
secretory granules. (B) Glucose sensing and
metabolic signals leading to insulin granule
secretion. The release of insulin via exocytosis of
secretory granules from pancreatic β-cells is
controlled by a series of metabolic and electrical
signals arising as a result of glucose entry
through GLUTs, phosphorylation by GK, and
entry into the TCA cycle. The closure of ATP-
dependent K+ (KATP) channels triggers electrical
events that culminate in Ca2+ entry through
voltage-dependent Ca2+ channels (VDCCs),
which triggers exocytosis mediated by SNARE
complex proteins. The overall secretory response
is modulated by numerous receptors, channels,
intracellular Ca2+ stores, metabolic signals, and
cytoskeletal elements. (C) Islet communi- cation
for coordinated pulsatile insulin secretion. Within
an islet, β-cells communicate with each other
and with glucagon-producing α-cells and
somatostatin (SST)–producing δ-cells to
coordinate their activity. Many putative intraislet
messengers have been implicated, including ATP,
Zn2+, γ-aminobutyric acid (GABA), glucagon-like
peptide-1 (GLP-1), acetylcholine (ACh), and
others. These, along with electrical coupling via
gap junctions, are likely important for the
physiological coordination of pulsatile insulin
secretion. Tokarz VL. J. Cell Biol. 2018. https://doi.org/10.1083/jcb.201802095 1
Structure of human proinsulin C peptides and insulin
molecules connected at two sites by dipeptide links

Proinsulin consists of a single chain of 86 amino acids, which includes the A and B chains of the insulin molecule plus a connecting
segment of 35 amino acids. Two proteins—the prohormone-converting enzymes type 1 and 2 (PCSK1 and PCSK2)—are packaged
with proinsulin in the immature secretory granules. These enzymes recognize and cut at pairs of basic amino acids, thereby
removing the intervening sequence. After the two pairs of basic amino acids are removed by carboxypeptidase E, the result is a 51
amino acid insulin molecule and a 31 amino acid residue, the C peptide
The regulated (normal) and constitutive (active in
Type 2 diabetes) pathways of insulin processing

b cell

Regulated pathway
Golgi Maturing secretory
apparatus granules Insulin
>> proinsulin

Crinophagy
Lysosome

Endoplasmic Constitutive pathway

reticulum
Proinsulin
> insulin

William and Pickup. Handbook of Diabetes, 2000

 Regulation of insulin release

Stimulants of Insulin • Glucose

Release • Amino acids: Leucine
• Neural: Vagal stimulation, acetylcholine
• Drugs: Sulfonylureas, meglitinides
Amplifiers of Glucose- • Enteric hormones: Glucagon-like peptide 1 (7-37)
Induced Insulin (GLP1), Gastric inhibitory peptide (GIP),
Release Cholecystokinin, Gastrin, Secretin
• Neural: β-adrenergic effect of catecholamines
• Amino acids: arginine
• Drugs: GLP1 agonists

Inhibitors of Insulin • Neural: α-adrenergic effect of catecholamines

Release • Humoral: somatostatin
• Drugs: diazoxide, thiazides, β-blockers, clonidine,
phenytoin, vinblastine, colchicine
A simplified outline of glucose-sensing and
regulated insulin secretion from the β cell
 GLP-1 action in the β cell

GLP-1 RA
Glucose

GLP-1R
Potassium Channel Glut2

AC
Calcium Channel
Gsα Gsα

K+ cAMP ATP
Pyruvate
ATP

TCA
Ca2+

Ca2+ Epac Amplifying

Triggering

Insulin exocytosis Hinke SA et al. J Physiol 2004;558:369–380; Henquin JC. Diabetes 2000;49:1751–1760; Henquin JC. Diabetes
2004;53:S48–S58; Drucker D. Cell Metab 2006;3:153–165
Effect of incretins in normal glucose-tolerance
and patients with Type 2 diabetes
Normal glucose tolerance Patient with type 2 diabetes
<20%
~ 67%

In matched oral and intravenous glucose challenges, incretin effect accounted for ~67% of the insulin secretory
response in normal subjects, whereas it was <20% in patients with Type 2 diabetes
Source: Pratley, RE, et al. Rev Diabet Stud. 2008;5:73-94; Nauck MA, et al. J Clin Endocrinol Metab 1986;63:492–498; Sari R, et al. J Natl Med Assoc
2005;97:1113–1118
 Multiphasic response of the in vitro perfused rat
pancreas during constant stimulation with glucose
Review of the Physiologic Insulin Profile

Mealtime insulin excursions

50 Rapid rise; short duration

40
Serum Insulin (mU/L)

30
Smooth, steady
20 basal insulin profile

10

0
0800 1200 1600 2000 2400 0400 0800
Breakfast Lunch Dinner

Adapted from Kruszynska Y et al. Diabetologia 1987;30:16.

14
Insulin Action
 Activation of insulin signalling

Haeusler RA et al. Nature Rev Mol Cell Biol 2017. doi:10.1038/nrm.2017.89

Insulin Receptors and Insulin Action
 Tissue Effect of Insulin
Liver Catabolic Pathways
Inhibits glycogen breakdown (inhibits glycogen phosphorylase)
Inhibits conversion of fatty acids and amino acids to keto acids
Inhibits conversion of amino acids to glucose (gluconeogenesis)
Anabolic Pathways
Promotes glucose storage as glycogen (induces glucokinase and
glycogen synthase)
Increases triglyceride synthesis and VLDL formation
Muscle Protein Synthesis
Increases amino acid transport
Metabolic Increases ribosomal protein synthesis
Glycogen Synthesis
Effects of Increases glucose transport
Induces glycogen synthase
Insulin Inhibits glycogen phosphorylase
Adipose Triglyceride Storage
tissue Lipoprotein lipase is induced by insulin to hydrolyze triglycerides
in circulating lipoproteins for delivery of fatty acids to the
adipocytes
Glucose transport into cell provides glycerol phosphate to permit
esterification of fatty acids supplied by lipoprotein transport
Intracellular lipase is inhibited by insulin

Brain Decreased appetite

Increased energy expenditure
 The adipocyte-
hepatocyte axis
and insulin
suppression of
gluconeogenesis

A: in the fasted state, the adipocyte releases

nonesterified fatty acids (NEFA) into the
circulation. Within the hepatocyte, NEFA are
oxidized to mitochondrial acetyl CoA, an
allosteric activator of pyruvate carboxylase
(PC). PC drives gluconeogenic flux. This,
together with net glycogenolysis, facilitates
hepatic glucose production (HGP) during
fasting.
B: during insulin stimulation (e.g.,
postprandially), both direct and indirect
effects of insulin suppress HGP. Adipocyte
insulin signaling suppresses lipolysis,
decreasing plasma NEFA concentrations,
hepatic mitochondrial acetyl CoA
concentrations, PC activity, and
gluconeogenic flux. Simultaneously, direct
insulin action on the hepatocyte promotes
net glycogen synthesis. Both processes
enable insulin to rapidly and potently
suppress net HGP.
Max C. Petersen and Gerald I. Shulman. Physiol Rev 98: 2133–2223, 2018
 Major Glucose Transport (GLUT) Proteins in Tissue
Protein Tissue Properties/characteristics
GLUT1 Most cells Low Km (1–2 mM)
Ensures glucose uptake during hypoglycemia
GLUT2 Pancreatic b-cells, renal tubular cells, small intestinal High Km (15–20 mM)
basolateral epithelial cells that transport glucose, liver
cells, hypothalamus
GLUT3 Expressed mostly in neurons, placenta, testes Low Km (1 mM)
Very high affinity
Probable main glucose transporter in neurons
GLUT4 Skeletal muscle fibers, adipose tissue, cardiac High Km (5 mM)
muscle cells Insulin regulated to help regulate hyperglycemia
GLUT5 Mucosal surface of small intestine cells, hepatocytes, Low Km (1–2 mM)
sperm, skeletal muscle fibers Fructose transporter
GLUT7 Hepatocytes Transports glucose out of the endoplasmic reticulum
after final step in gluconeogenesis
Insulin Secretion
Disorder in T1DM and
T2DM
 The natural history of type 1 diabetes mellitus

Atkinson MA et al. In In William s Textbook of Endocrinology (Melmed S et al. Eds). 14th Edition, 2020
 Beta-cell function progressively declines in T2DM

HOMA: homeostasis model assessment

Lebovitz. Diabetes Reviews 1999;7:139–53
(data are from the UKPDS population: UKPDS 16. Diabetes 1995;44:1249–58)
Beta cells mass in peolple with type 2 diabetes

Cho JH et al. J Diabetes Invest 2011; 2: 6-17

 Proposed sequence of the key pathological
features of type 2 diabetes

Environment stresses and obesity causing

insulin resistance and/or β-cell dysfunction

Fetal or ?b-cell mass b-cell mass b-cell mass

postnatal 40% 60%
environment
Susceptible
b-cells

Genes ?b-cell Acquired-loss Multifactorial

dysfunction first phase secretory
capasity
Postulated b-cell Pathogenesis
Islet amyoid ER stress
Oxidative stress (Gluco)lipotoxicity
Leahy JL and Pratley RE. Translational Endocrinology & Glucose toxicity Islet inflammation
Metabolism, Volume 2, Number 1, 2011; 2: 9-42 Defective incretin regulation
 Insulin secretion profiles in Type 2
diabetic patients and healthy people

800
Healthy people
Insulin secretion (pmol/min)

700
Type 2 diabetic patients
600

500

400

300

200

100

6am 10am 2pm 6pm 10pm 2am 6am

Time
 Loss of early-phase insulin secretion
in type 2 diabetes

Pattern of insulin secretion is altered early in type 2 diabetes

Normal Type 2 diabetes

120
Plasma insulin (µU/ml)

120

Plasma insulin (µU/ml)

20g
20g glucose
glucose
100 100
80 80
60 60
40 40
20 20
0 0
–30 0 30 60 90 120 –30 0 30 60 90 120
Time (minutes) Time (minutes)

Ward WK, et al. Diabetes Care 1984;7:491–502.

Effect of incretins in normal glucose-tolerance
and patients with Type 2 diabetes
Normal glucose tolerance Patient with type 2 diabetes
<20%
~ 67%

In matched oral and intravenous glucose challenges, incretin effect accounted for ~67% of the insulin secretory
response in normal subjects, whereas it was <20% in patients with Type 2 diabetes
Source: Pratley, RE, et al. Rev Diabet Stud. 2008;5:73-94; Nauck MA, et al. J Clin Endocrinol Metab 1986;63:492–498; Sari R, et al. J Natl Med Assoc
2005;97:1113–1118
Insulin Action Disorder
(Insulin Resistance):
Genetics and Environment
 Genetic Disorders of Insulin Action

Simplified schematic of key insulin signaling pathways, including the MAPK/ERK and PI3K-AKT pathways. Sites of
known pathogenic mutations and their corresponding syndromes are shown by the dashed red arrows and boxes,
respectively
Challis BJ and Semple RK. Curr Obes Rep (2013) 2:293–300
 Acanthosis nigricans (AN) in severe IR.

A, Severe AN on the neck in a prepubertal patient with autosomal dominant IR of unknown cause. B, AN associated with exuberant axillary
acrochordons in a 50-yr-old male with severe IR of unknown cause. C–F, AN in abdominal skin flexures of a 15-yr-old boy with severe IR due to a
heterozygous INSR mutation (C), on the foot of a patient with congenital generalized lipodystrophy and severe IR due to homozygous AGPAT2
mutations (D), on the knuckles in a prepubertal patient with severe IR of unknown cause (E), and on the neck of a prepubertal girl with RMS due to a
homozygous INSR mutation (F). G, Histological appearances from a nuchal skin biopsy showing characteristic papillomatosis (solid arrows),
hyperkeratosis, and some acanthosis (open arrow).
Semple RK. Endocrine Reviews 32: 498–514, 2011
Taniguchi CM et al. Nature Rev Mol Cell Biol 2006; 7: 85
 The Adipocyte

• THE ADIPOCYTE is unique among cells in that one

organelle, the lipid droplet, encompasses greater than 95%
of the entire cell body. This lipid droplet serves as a storage
vessel for triglycerides that can be released through
lipolysis and added to by the process of triglyceride
synthesis.

 Because the lipid droplet can

assume such a large portion
of the entire adipocyte,
increases in lipid storage
result in increased fat cell
size.
 Examples of adipocyte-derived proteins with
endocrine functions

Cytokines and cytokinerelated proteins Leptin

TNF
IL-6
Other immune-related proteins MCP-1
Proteins involved in the fibrinolytic system PAI-1
Complement and complement-related proteins Tissue factor
Adipsin (complement
factor D)
Complement factor B
ASP
Adiponectin
Lipids and proteins for lipid metabolism or transport Lipoprotein lipase (LPL)
Cholesterol ester transfer protein (CETP)
Apolipoprotein E
NEFAs
Enzymes involved in steroid metabolism Cytochrome P450-dependent aromatase
Proteins of the RAS 17HSD
11HSD1
AGT
Other proteins Resistin

Kershaw and Flier. J Clin Endocrinol Metab 2004; 89: 2548-2556

 Chronic inflammation in adipose tissue triggers
insulin resistance in skeletal muscle

a | In the lean state, small adipocytes efficiently store fatty acids as triglyceride (TG input, arrow), which can be mobilized and used to generate
ATP through the mitochondrial β-oxidation pathway in muscle during periods of caloric need. Insulin-stimulated glucose uptake under these
conditions is normal. b | Excess caloric intake leads to metabolic overload, increased TG input and adipocyte enlargement. Nonetheless,
in non-diabetic overweight individuals, TG storage by adipose cells and b-oxidation in muscle can often be maintained to prevent insulin resistance.
c | On further overloading with TG, hypertrophy of adipocytes and increased secretion of macrophage chemoattractants occurs, including
the secretion of monocyte chemoattractant protein-1 (MCP-1; arrows), which recruits additional macrophages. d | Macrophage recruitment in
turn results in a pro-inflammatory state in obese adipose tissue. Infiltrating macrophages secrete large amounts of tumournecrosis factor-α
(TNFα), which results in a chronic inflammatory state with impaired TG deposition and increased lipolysis (arrow and plus signal). The excess of
circulating TG and free fatty acids results in the accumulation of activated lipids in the muscle (yellow dots), disrupting functions such as
mitochondrial oxidative phosphorylation and insulin-stimulated glucose transport, thus triggering insulin resistance.

Guilherme A et al. Nature Rev 2008; 9:367-377

 Chronic inflammation impairs
triglyceride deposition in adipose tissue

The chronic inflammatory state

induced by lipid overload in adipose
cells triggers macrophage
recruitment within the adipose
tissue. Secreted cytokines stimulate
macrophages to produce large
amounts of tumour-necrosis
factor-α (TNFα) through the IKKβ–
NF-κB (inhibitor of nuclear factor
(NF)-κB (IκB) kinase-β–NF-κB) and
the JNK–AP1 (Jun N-terminal
kinase–activator protein-1)
signalling pathways.

Ectopic lipid and FFAs (yellow dots) attenuate expresssion of genes that are involved in mitochondrial
function, such as PPARγ co-activator-1 (PGC-1); enhance ceramide (CM) biosynthesis and inhibit insulin-
stimulated glucose transport through activation of the protein kinases protein kinase C (PKC), IKKβ and
JNK. TNFα can also inhibit insulin-stimulated glucose transporter type-4 (GLUT4) glucose transport in
muscle through activation of MAP4K4 and JNK kinases.

Guilherme A et al. Nature Rev 2008; 9:367-377