Physiologic Effects
of Insulin
Insulin Deficiency and Excess Diseases
Diabetes
mellitus, arguably the most important metabolic disease of man, is an insulin
deficiency state. It also is a significant cause of disease in dogs and cats.
Two principal forms of this disease are recognized:
·Type I or insulin-dependent
diabetes mellitus is the result of a frank deficiency of insulin. The
onset of this disease typically is in childhood. It is due to destruction
pancreatic beta cells, most likely the result of autoimmunity to one or more
components of those cells. Many of the acute effects of this disease can be
controlled by insulin replacement therapy. Maintaining tight control of blood
glucose concentrations by monitoring, treatment with insulin and dietary
management will minimize the long-term adverse effects of this disorder on
blood vessels, nerves and other organ systems, allowing a healthy life.
·Type II or
non-insulin-dependent diabetes mellitus begins as a syndrome of insulin
resistance. That is, target tissues fail to respond appropriately to insulin.
Typically,
the onset of this disease is in adulthood.
Despite
monumental research efforts, the precise nature of the defects leading to type
II diabetes have been difficult to ascertain, and the pathogenesis of this
condition is plainly multifactorial.
Obesity is
clearly a major risk factor, but in some cases of extreme obesity in humans and
animals, insulin sensitivity is normal.
Because
there is not, at least initially, an inability to secrete adequate amounts of
insulin,
insulin injections are not useful for therapy.
Rather the
disease is controlled through dietary therapy and hypoglycemic agents.
Hyperinsulinemia or excessive insulin secretion is most
commonly a consequence of insulin resistance, associated with type 2 diabetes
or the metabolic syndrome.
More rarely, hyperinsulinemia results from an
insulin-secreting tumor (insulinoma) in the pancreas.
Hyperinsulinemia due to accidental or deliberate
injection of excessive insulin is dangerous and can be acutely life-threatening
because blood levels of glucose drop rapidly and the brain becomes starved for
energy (insulin shock).
Insulin is a key player in the control of intermediary metabolism, and the big picture is that it organizes the use of fuels for either storage or oxidation.
Through these activities, insulin has profound effects on both carbohydrate and lipid metabolism, and significant influences on protein and mineral metabolism.
Consequently, derangements in insulin signalling have widespread and devastating effects on many organs and tissues.
The Insulin Receptor and Mechanism of Action
Like
the receptors for other protein hormones, the receptor for insulin is embedded
in the plasma membrane. The insulin receptor is composed of two alpha subunits
and two beta subunits linked by disulfide bonds. The alpha chains are entirely
extracellular and house insulin binding domains, while the linked beta chains
penetrate through the plasma membrane. The insulin receptor is a tyrosine kinase.
In other words, it functions as an enzyme that transfers phosphate groups from ATP to tyrosine residues on intracellular target proteins.
Binding of insulin to the alpha subunits causes the beta subunits to phosphorylate themselves (autophosphorylation), thus activating the catalytic activity of the receptor.
The activated receptor then phosphorylates a number of intracellular proteins, which in turn alters their activity, thereby generating a biological response.
Several intracellular proteins have been identified as phosphorylation substrates for the insulin receptor, the best-studied of which is insulin receptor substrate 1 or IRS-1.
When IRS-1 is activated by phosphorylation, a lot of things happen. Among other things, IRS-1 serves as a type of docking center for recruitment and activation of other enzymes that ultimately mediate insulin's effects.
A more detailed look at these processes is presented in the section on Insulin Signal Transduction.
Insulin and Carbohydrate Metabolism
Glucose is liberated from dietary carbohydrate such as
starch or sucrose by hydrolysis within the small
intestine,
and is then absorbed into the blood. Elevated concentrations of glucose in
blood stimulate release of insulin, and insulin acts on cells throughout the
body to stimulate uptake, utilization and storage of glucose. The effects of
insulin on glucose metabolism vary depending on the target tissue.
Two important effects are:
1.
Insulin facilitates entry of glucose into
muscle, adipose and several other tissues. The only mechanism by which cells can
take up glucose is by facilitated diffusion through a family of hexose
transporters.
In many tissues - muscle being a prime example - the major transporter used for
uptake of glucose (called GLUT4) is made available in the plasma membrane
through the action of insulin.
2. When insulin concentrations are low,
GLUT4 glucose transporters are present in cytoplasmic< vesicles, where they
are useless for transporting glucose. Binding of insulin to receptors on such
cells leads rapidly to fusion of those vesicles with the plasma membrane and
insertion of the glucose transporters, thereby giving the cell an ability to
efficiently take up glucose. When blood levels of insulin decrease and insulin
receptors are no longer occupied, the glucose transporters are recycled back
into the cytoplasm.
3.
The animation to the right depicts how
insulin signalling leads to translocation of glucose transporters from the
cytoplasm into the plasma membrane, allowing glucose (small blue balls) to
enter the cell. Click on the "Add Glucose" button to start
it.
It
should be noted here that there are some tissues that do not require insulin
for efficient uptake of glucose: important examples are brain and the liver.
This is because these cells don't use GLUT4 for importing glucose, but rather,
another transporter that is not insulin-dependent.2. Insulin stimulates the liver to store glucose in the form of glycogen. A large fraction of glucose absorbed from the small intestine is immediately taken up by hepatocytes, which convert it into the storage polymer glycogen.
1.
Insulin has several effects in liver which
stimulate glycogen synthesis. First, it activates the enzyme hexokinase, which
phosphorylates glucose, trapping it within the cell. Coincidently, insulin acts
to inhibit the activity of glucose-6-phosphatase. Insulin also activates
several of the enzymes that are directly involved in glycogen synthesis,
including phosphofructokinase and glycogen synthase.
2.
The
net effect is clear: when the supply of glucose is abundant, insulin
"tells" the liver to bank as much of it as possible for use later.
A well-known effect of
insulin is to decrease the concentration of glucose in blood, which should make sense considering
the mechanisms described above. Another important consideration is that, as blood glucose concentrations fall, insulin secretion ceases.
In the absence of insulin, a bulk of the cells in the body become unable to take up glucose, and begin a switch to using alternative fuels like fatty acids for energy.
Neurons, however, require a constant supply of glucose, which in the short term, is provided from glycogen reserves.
When insulin levels in blood fall, glycogen synthesis in the liver diminishes and enzymes responsible for breakdown of glycogen become active.
Glycogen breakdown is stimulated not only by the absence of insulin but by the presence of glucagon, which is secreted when blood glucose levels fall below the normal range.
Insulin and Lipid Metabolism
1.
The metabolic pathways for utilization of
fats and carbohydrates are deeply and intricately intertwined. Considering
insulin's profound effects on carbohydrate metabolism, it stands to reason that
insulin also has important effects on lipid metabolism, including the
following:
Insulin promotes synthesis of
fatty acids in the liver. As discussed above, insulin is stimulatory to synthesis of glycogen in the liver.
However, as glycogen accumulates to high levels (roughly 5% of liver mass), further synthesis is strongly suppressed.
When the liver is saturated with glycogen, any additional glucose taken up by hepatocytes is shunted into pathways leading to synthesis of fatty acids, which are exported from the liver as lipoproteins.
The lipoproteins are ripped apart in the circulation, providing free fatty acids for use in other tissues, including adipocytes, which use them to synthesize triglyceride.
Insulin inhibits breakdown of fat in adipose tissue by inhibiting the intracellular lipase that hydrolyzes triglycerides to release fatty acids.
Insulin facilitates entry of glucose into adipocytes, and within those cells, glucose can be used to synthesize glycerol.
This glycerol, along with the fatty acids delivered from the liver, are used to synthesize triglyceride within the adipocyte.
By these mechanisms, insulin is involved in further accumulation of triglyceride in fat cells.
1.
From a
whole body perspective, insulin has a fat-sparing effect. Not only
does it drive most cells to preferentially oxidize carbohydrates instead of
fatty acids for energy, insulin indirectly stimulates accumulation of fat in adipose
tissue
Other Notable Effects of Insulin
In
addition to insulin's effect on entry of glucose into cells, it also stimulates
the uptake of amino acids, again contributing to its overall anabolic effect.
When insulin levels are low, as in the fasting state, the balance is pushed
toward intracellular protein degradation. Insulin also increases the permeability of many cells to potassium, magnesium and phosphate ions.
The effect on potassium is clinically important. Insulin activates sodium-potassium ATPases in many cells, causing a flux of potassium into cells. Under certain circumstances, injection of insulin can kill patients because of its ability to acutely suppress plasma potassium concentrations.
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