Mechanisms Underlying the Pathogenesis of Isolated Impaired Glucose Tolerance in Humans

Abstract

Context: Prediabetes is a heterogeneous disorder classified on the basis of fasting glucose concentrations and 2-hour glucose tolerance.

Objective: We sought to determine the relative contributions of insulin secretion and action to the pathogenesis of isolated impaired glucose tolerance (IGT).

Design: The study consisted of an oral glucose tolerance test and a euglycemic clamp performed in two cohorts matched for anthropometric characteristics and fasting glucose but discordant for glucose tolerance.

Setting: An inpatient clinical research unit at an academic medical center.

Patients or other participants: Twenty-five subjects who had normal fasting glucose (NFG) and normal glucose tolerance (NGT) and 19 NFG/IGT subjects participated in this study.

Intervention(s): Subjects underwent a seven-sample oral glucose tolerance test and a 4-hour euglycemic, hyperinsulinemic clamp on separate occasions. Glucose turnover during the clamp was measured using tracers, and endogenous hormone secretion was inhibited by somatostatin.

Main outcome measures: We sought to determine whether hepatic glucose metabolism, specifically the contribution of gluconeogenesis to endogenous glucose production, differed between subjects with NFG/NGT and those with NFG/IGT.

Results: Endogenous glucose production did not differ between groups before or during the clamp. Insulin-stimulated glucose disappearance was lower in NFG/IGT (24.6 ± 2.2 vs 35.0 ± 3.6 μmol/kg/min; P = .03). The disposition index was decreased in NFG/IGT (681 ± 102 vs 2231 ± 413 × 10^-14 dL/kg/min² per pmol/L; P < .001).

Conclusions: We conclude that innate defects in the regulation of glycogenolysis and gluconeogenesis do not contribute to NFG/IGT. However, insulin-stimulated glucose disposal is impaired, exacerbating defects in β-cell function.

Figure 1.

Glucose (A), insulin (B), C-peptide (C), and glucagon (D) in response to a 75-g oral glucose challenge in subjects with NGT (open circles) and IGT (solid squares). Values plotted are means ± SEM. *, P < .05 for a post hoc unpaired, two-tailed t test.

Figure 2.

Insulin action (S_i; A), β-cell responsivity (Φ; B), and disposition index (C) in subjects with NGT (open circles) and IGT (solid squares) in response to a 75-g oral glucose challenge. The P values represent the results of a nonparametric, two-tailed, Mann-Whitney test.

Figure 3.

Glucose (A), insulin (B), C-peptide (C), and glucagon (D) during a euglycemic clamp infusion in subjects with NGT (open circles) and IGT (solid squares). Values plotted are means ± SEM. *, P < .05 for a post hoc unpaired, two-tailed t test.

Figure 4.

EGP (A), glucose disappearance (B), glucose infusion rate (C), and the specific activity of labeled/unlabeled glucose (D) during a euglycemic clamp infusion in subjects with NGT (open circles) and IGT (solid squares). Values plotted are means ± SEM. *, P < .05 for a post hoc unpaired, two-tailed t test.

Figure 5.

Rates of gluconeogenesis (A) and glycogenolysis (B) while fasting, together with rates of gluconeogenesis (C) and glycogenolysis (D) during the clamp in individual subjects with NGT (open circles) and IGT (solid squares). Values plotted are means ± SEM. *, P < .05 for a post hoc unpaired, two-tailed t test.