Carbohydrates metabolism

Learning Objectives

• Carbohydrate catabolism
• Regulation of blood glucose
• Types of DM
• Classification of DM
• Etiopathogenesis of DM
• Laboratory diagnosis and management of
DM
 Three stages of metabolism

• Stage 1: digestion of complex dietary fuels to

monomeric units which are absorbed from the
gut

• Stage 2: conversion of the monomeric units into

simple molecules within cells

• Stage 3: simple molecules oxidized to carbon

dioxide and water
Diabetes Mellitus
 Type 1 Diabetes (T1D)
Family history of diabetes
• The risk of T1D in first degree relatives (FDRs) is 20X more
compared with in the general population
• The offspring of type 1 diabetic mothers have a lower T1D risk
compared to offspring of diabetic fathers.
T1D risk factors – Genes and environmental triggers
• Genes
- Human leukocyte antigen (HLA) genes, non-HLA genes
• Environmental factors
- Viruses
- Nutritional patterns
 Regulation of blood glucose levels

• Regulation of blood glucose is done through endocrine hormones

• A balance of hormones is achieved through a negative feedback
loop
• The main hormones that regulate blood glucose include insulin,
glucagon & somatostatin.
- Insulin lowers blood glucose levels
- Glucagon elevate blood levels
- Somatostatin balances insulin and glucagon
• When blood glucose levels rise, then insulin promotes glucose
conversion into glycogen (glycogenesis) for storage in liver and
muscle cells.
• When blood glucose levels fall, insulin secretion drops, then the
liver breaks down glycogen into glucose (glycogenolysis) for easy
transport through the bloodstream to the cells of the body.
 Diabetes mellitus (DM)

• DM is a chronic disorder induced by absolute deficiency of insulin

which is characterized by metabolic disorders of carbohydrates and
lipids

• The metabolic disturbances are accompanied by loss of glucose

tolerance, fasting hyperglycemia, ketoacidosis, increased lipolysis,
increased proteolysis and some other metabolic disorders
 Classification of diabetes mellitus

I. Type 1 diabetes
A. Immune-mediated

II. Type 2 diabetes

III. Other forms of diabetes

A. Latent autoimmune diabetes in adults (LADA)
C. Diabetes affecting the exocrine pancreas
D. Diabetes secondary to chronic pancreatitis
F. Infection-induced e.g. viruses
G. Maturity Onset Diabetes of the Young (MODY)

IV. Gestational diabetes (GDM)

 Types of Diabetes Mellitus

Type 1 DM: due to destruction of beta cells

of the pancreatic islets.

Type 2 DM: characterized by impaired

insulin secretion & simultaneous insulin
resistance.
 Main differences between “old” and
“new” classification of DM
 In new classification of DM:
• terms IDDM and NIDDM are not used
• terms - primary and secondary DM are not used

 New terms were introduced into new classification of DM:

• impaired fasting plasma glucose(FPG)

• impaired glucose tolerance(IGT)
 New criteria for diagnosis of DM

Reference Range
• Normal fasting value of plasma glucose concentration:  6.5 mmol/l
• Normal value of OGTT – blood glucose concentration 2 hrs after beginning of
test  7.8 mmol/l

1st: classic symptoms and signs of DM are present (polyuria,

polydipsia, weight loss), and increased random blood glucose
concentration of ≥ 11.1 mmol/l
or
2nd: fasting glucose level of 7.0 mmol/l and more
or
3rd: 2 hours glucose level in OGTT is ≥ 11.1 mmol/l

For confirmation of diagnosis DM positivity each of the mentioned

parameters have to be confirmed.
 New criteria for diagnosis of DM

 Impaired fasting plasma glucose:  6.1 but  7.0 mmol/l

 Impaired glucose tolerance (IGT): Glucose tolerance test shows abnormal

values but these patients are asymptomatic and they do not meet the
criteria for diagnosis of DM.
IGT criteria:
- fasting plasma glucose level can be normal
- 2 hours after intake of glucose load plasma glucose level is higher
than normal (from 7.8mmol/L to 11.1mmol/L)

The individuals with IGT are recognized as being at higher risk than the general
population for the development of DM (about 1.5 - 4.0 % of patients with IGT
develop DM).
 Metabolic syndrome

 frequently occurs in people suffering form visceral obesity

Characteristic features:
• insulin resistance
• compensatory hyperinsulinemia
• visceral obesity
• dyslipidemia ( LDL,  TG,  HDL)
• systemic hypertension
Increased probability of DM-type2 development
 Etiopathogenesis of DM
 Type 1 DM - characteristics
• it is most common in individuals under 30 years of age
• 80 % - 90 % of beta cells in the islets of Langerhans are destroyed
Possible mechanisms of beta cells destruction:
 T cell mediated autoimmunity

Evidence suggest that type 1 DM is caused by a gradual process of

autoimmune destruction of beta cells in genetically susceptible
individuals:
The result of beta cell destruction:
• no insulin production
• glucagon is present in relative excess
• individuals are prone to ketoacidosis
• patients are insulin-dependent
 Etiopathogenesis of DM
 Type 2 DM - characteristics
• Primary disturbance:  biological activity of insulin
• is rare in populations not affected by urban modernization
• adult onset (mostly after 35 years of age, slow, insidious onset)
• associated with obesity (mainly visceral)
• islet cell antibodies are rare
• increased insulin resistance
• usually not insulin dependent
• individuals are not usually ketosis prone
General Characteristics of Type 1 and Type 2 DM
 Main symptoms and signs of DM
and mechanisms of their onset
 Hyperglycaemia:
• relative or absolute deficiency of insulin effect   transport of
glucose to muscle cells  glycemia
•  insulin effect  gluconeogenesis in liver  blood level of
glucose
•  glycogenolysis
 Glycosuria: hyperglycaemia (8-15 mmol/l)  glycosuria

 Polyuria: high blood level of glucose  increased amount of glucose

filtered by the glomeruli of the kidney absorption capacity of renal
tubules for glucose is exceeded glycosuria results, accompanied by large
amounts of water lost in the urine (osmotic effect of glucose)
 Main symptoms and signs of DM
and mechanisms of their onset
 Polydipsia : high blood level of glucose  hyperosmolality of
plasma water moves from inside cells, ICF to ECF
 intracellular dehydration
 creation of thirst feeling (in hypothalamus)
 intake of fluids
 Polyphagia: depletion of cellular stores of carbohydrates, fats, and
proteins results in cellular starvation and a corresponding
increase in hunger
 Weight loss : fluid loss in osmotic diuresis, loss of body tissue as
fats and proteins are used for energy creation
 Fatigue : metabolic changes result in poor use of food products 
lethargy and fatigue
 Complications of DM
 Acute complications
• Hypoglycemia
• Ketoacidosis
• Hyperosmolar hyperglycemic nonketotic coma

 Chronic complications
• Diabetic micro- and macrovascular changes
• Diabetic neuropathy
• Diabetic retinopathy
• Diabetic nephropathy
Investigations of CHO Disorders
 Laboratory Investigation for Diabetes
Mellitus
• Fasting plasma glucose (FPG) is the basic test for DM. FPG is
useful for both diagnosis and follow-up.
 Glucose determination by glucometer is accepted as a very useful tool
in monitoring of DM

 Postprandial glucose: an alternative measurement for blood glucose

• Sometimes, the FPG test is not feasible hence the postprandial glucose is
examined. This is an alternative test for diagnosis of hyperglycemia.

• One with abnormal high postprandial glucose level needs further

verification by FPG test.
 Laboratory Investigation for Diabetes
Mellitus
 Glycated hemoglobin (HbA1c) test – reflects the average level of
plasma glucose for the past 2-3 months.

 Oral glucose tolerance test (OGTT) is the main test for diagnosis of DM
– OGTT is generally indicated after positive urine glucose test and glucose challenge test.

 Urine ketone and blood ketone:

– Tool for diagnosis of diabetic ketoacidosis
 Laboratory Investigation for Diabetes Mellitus

 C-peptide is considered as a new test in diabetic

medicine.
– It is produced in equal amounts to insulin by islet cells
– Plasma C-peptide concentration reflects the effectiveness of the pancreas to
secrete insulin & is a measure of residual islet cell function.

 Insulin test: A direct measurement of hormone

– Insulin is the major hormone in regulation of blood glucose homeostasis.
– The measurement of insulin can be done but it is not practically used in routine
diabetic clinic
 WHO Criteria for Diagnosis of Diabetes

HbA1C ≥ 6.5%
or
Fasting plasma glucose (FPG) ≥ 7.0 mmol/L
Fasting is defined as no caloric intake for at least 8 h*
or
2-h plasma glucose ≥ 11.1 mmol/L during an OGTT
The test should be performed as described by the WHO, using a glucose load
containing the equivalent of 75 g anhydrous glucose dissolved in water*
or
A random plasma glucose ≥ 11.1 mmol/L
in a patient with classic symptoms of hyperglycemia
 Oral Glucose Tolerance Test

• The OGTT is used as a diagnostic test for the following reasons:

 fasting plasma glucose alone fails to diagnose approximately 30%

of cases of previously undiagnosed diabetes,
 an OGTT is the only means of identifying people with IGT,
 an OGTT is frequently needed to confirm or exclude an
abnormality of glucose tolerance in asymptomatic people.

• An OGTT should be used in individuals with fasting plasma glucose

6.1– 6.9mmol/L to determine glucose tolerance status.
 Oral Glucose Tolerance Test

Conditions for performing OGTT

1. Discontinue, where possible, medications known to affect glucose
tolerance
2. Perform test in the morning after 3 days of unrestricted diet
(containing at least 150g of CHO/day) and activity
3. Perform the test after 10 - 16h fast only in ambulatory patients.
 Oral Glucose Tolerance Test

Procedure
1. dissolve 75g anhydrous glucose load (adults) or 1.75g/kg
(children) in 300ml of water and this should be ingested in 5
min.
2. blood sample is taken at the following intervals: fasting
(before glucose load), then every 30 min for 2 hours and
plasma glucose concentration is measured.
3. patient should remain seated during the procedure without
smoking.
 Laboratory findings in Hyperglycemia

• Increased glucose in plasma and urine

• Increased urine specific gravity
• Increased serum and urine osmolality
• Ketones in serum and urine (ketonemia and
ketonuria)
• Decreased blood and urine pH (acidosis)
• Electrolyte imbalance
 Specimen Collection and Storage

Blood
• Sodium fluoride-oxalate plasma (fluoride inhibit glycolysis
by erythrocytes and leukocytes and oxalate prevents
clotting).
• Fasting or random blood sample
CSF
• Analyze immediately, if not possible, centrifuge and store
supernatant at 40C or -200C.
 Glucose Measurement: Hexokinase (HK)
Method
• widely used assay
• based on a coupled enzyme assay that uses HK and glucose-6-
phosphate dehydrogenase
Hexokinase
Glucose + ATP Glucose-6-Phosphate + ADP
G-6-PD
Glucose-6-Phosphate + NAD 6-Phosphogluconate + NADH

• Absorbance is measured at 340 nm and amount of NAD reduced is

proportional to glucose concentration.
• method is linear up to 27.8mmol/L. Higher values should be diluted
with isotonic saline and reassayed.
• hemolysis (>0.5 g Hb/dL) interferes with the method
• other sources of interference (drugs, bilirubin, lipemia)
 Glucose Measurement: Glucose Oxidase
Method
• widely used assay
Glucose Oxidase
Glucose + 2H2O + O2 Gluconic acid + 2H2O2
Peroxidase
2H2O2 + 4aminophenazone quinoneimine + 4H2O

• Absorbance is measured at 500 nm

• 1st reaction is specific, but 2nd reaction is prone to interference by UA,

ascorbic acid, bilirubin, hemoglobin, and glutathione.

• GOD method suitable for measuring CSF glucose but not urine because of
presence of substances that interfere with peroxidase method.
 Glucose Measurement: Glucose
Dehydrogenase Methods
• Glucose dehydrogenase catalyzes the oxidation of glucose to
gluconolactone.
Glucose
Dehydrogenase
Glucose + NAD 6-Gluconolactone + NADH

• Absorbance is measured at 340 nm and amount of NAD

reduced is proportional to glucose concentration.
• Method is less susceptible to interferences.
 Other Investigations
• Blood ketone bodies
• Blood lactate
• Blood pyruvate
• Glycated proteins
– Glycosylated Hb
– Fructosamine (glycated serum albumin)
• Urinary albumin
• Hormone assays
– insulin
– proinsulin
– C-peptide
– glucagon
 Recommended Textbooks

• Burtis CA, Ashwood ER, Bruns DE. (2008). Tietz

Fundamentals of Clinical Chemistry, 6th edition.
Saunders Elsevier.
• Marshall WJ, Bangert SK. (2008). Clinical Chemistry.
6th edition. Mosby Elsevier.
• Berg JM, Tymoczko JL, Stryer L. (2007). Biochemistry,
6th edition. Freeman and Company.