CARBOHYDRATES

Carbohydrates
are

compounds containing C, H, and O.

The general formula for a carbohydrate
is Cx(H2O)y.
All carbohydrates contain C=O and -OH
functional groups.
There are some derivatives from this
basic formula because carbohydrate
derivatives can be formed by the
addition of other chemical groups, such
as phosphates, sulfates, and amines.

 The

classification of carbohydrates is
based on four different properties:
(1) the size of the base carbon chain
(2) the location of the CO function group
(3) the number of sugar units
(4) the stereochemistry of the compound

Classification of Carbohydrates
generic

classifications based on the number of carbons in

the molecule:
Trioses
contain three carbons

Tetroses
contain four carbons

Pentoses
contain five carbons

Hexoses
contain six carbons

Glyceraldehyde
the smallest carbohydrate
three-carbon compound

 Carbohydrates
are hydrates of aldehyde or ketone

derivatives based on the location of the

CO functional group.
The two forms of carbohydrates:
The Aldose Form
has a terminal carbonyl group (O=CH-) called an
aldehyde group

The Ketose Form

form has a carbonyl group (O=C) in the middle linked
to two other carbon atoms (called a ketone group).

Several models are used to

represent carbohydrates.
The

Fisher projection

has the aldehyde or ketone at the top of the drawing.

The carbons are numbered starting at the aldehyde or

ketone end.
The compound can be represented as a straight chain or
might be linked to show a representation of the cyclic,
hemiacetal form.

The Haworth projection

represents the compound in the cyclic form that is more

representative of the actual structure.

This structure is formed when the functional (carbonyl) group
(ketone or aldehyde) reacts with an alcohol group on the
same sugar to form a ring called either a hemaketal or
hemiacetal ring, respectively.

Monosaccharides, Disaccharides,
and Polysaccharides
Another

classification of
carbohydrates is based on number of
sugar units in the chain:
Monosaccharides
Disaccharides
Oligosaccharides
Polysaccharides

 This

chaining of sugars relies on the

formation of glycoside bonds that
are bridges of oxygen atoms.
When two carbohydrate molecules
join, a water molecule is produced.
When they split, one molecule of
water is used to form the individual
compounds. This reaction is called
hydrolysis.

 Monosaccharides
are simple sugars that cannot be

hydrolyzed to a simpler form.

These sugars can contain three, four,
five, and six or more carbon atoms
(known as trioses, tetroses, pentoses,
and hexoses, respectively).
The most common include glucose,
fructose, and galactose.

 Disaccharides
are formed when two monosaccharide units

are joined by a glycosidic linkage.

On hydrolysis, disaccharides will be split into
two monosaccharides by disaccharide
enzymes (e.g., lactase) located on the
microvilli of the intestine. These
monosaccharides are then actively absorbed.
The most common disaccharides are maltose
(comprising 2--D-glucose molecules in a 1 4
linkage), lactose, and sucrose.

 Oligosaccharides
are the chaining of 2 to 10 sugar units

Polysaccharides
are formed by the linkage of many monosaccharide units.
more than 10 monosaccharides.
Amylase hydrolyzes starch to disaccharides in the duodenum.
The most common polysaccharides are starch (glucose molecules) and

glycogen.
STARCH
Primary CHO in the diet and is found in most plants

GLYCOGEN
Storage form of carbohydrates
Formed from glucose by the liver
CELLULOSE
Another polysaccharide in plants
Not digested by humans, it does provide bulk for proper intestinal functioning

Glucose Metabolism
Glucose

is a primary source of
energy for humans.
The nervous system, including the
brain, totally depends on glucose
from the surrounding extracellular
fluid (ECF) for energy.

 Nervous

tissue cannot concentrate

or store carbohydrates; therefore, it
is critical to maintain a steady supply
of glucose to the tissue. For this
reason, the concentration of glucose
in the ECF must be maintained in a
narrow range.

 When

the concentration falls below a

certain level, the nervous tissue
loses the primary energy source and
are incapable of maintaining normal
function.

Fate of Glucose
Most

of our ingested carbohydrates

are polymers, such as starch and
glycogen.

Salivary

amylase and pancreatic

amylase
are responsible for the digestion of these

non-absorbable polymers to dextrins and

disaccharides

 Maltase
an enzyme released by the intestinal

mucosa
Hydrolyze disaccharides to
monosaccharides
Sucrase
Hydrolyzes sucrose to glucose and fructose

Lactase
Hydrolyzes to glucose and galactose

 When

disaccharides are converted to

monosaccharides, they are absorbed by
the gut and transported to the liver by
the hepatic portal venous blood supply.
Glucose is the only carbohydrate to be
directly used for energy or stored as
glycogen.
Galactose and fructose must be converted

to glucose before they can be used.

After glucose enters the cell, it is quickly

shunted into one of three possible metabolic
pathways, depending on the availability of
substrates or the nutritional status of the cell.

The ultimate goal of the cell is to convert

glucose to carbon dioxide and water. During
this process, the cell obtains the high-energy
molecule adenosine triphosphate (ATP) from
inorganic
phosphate
and
adenosine
diphosphate (ADP).

 Gluconeogenesis
The conversion of amino acids by the

liver and other specialized tissue, such

as the kidney, to substrates that can be
converted to glucose.
also encompasses the conversion of
glycerol, lactate, and pyruvate to
glucose.

 Glycogenesis
When the cells energy requirements are being met,

glucose can be stored as glycogen.

Glucose-6-phosphate is converted to glucose- 1phosphate, which is then converted to uridine
diphosphoglucose and then to glycogen by glycogen
synthase.
Several tissues are capable of the synthesis of
glycogen, especially the liver and muscles.
Hepatocytes are capable of releasing glucose from
glycogen or other sources to maintain the blood
glucose concentration. This is because the liver
synthesizes the enzyme glucose-6-phosphatase.

 Glycogenolysis
is the process by which glycogen is

converted back to glucose 6-phosphate

for entry into the glycolytic pathway.

Regulation of Carbohydrate
Metabolism
The

liver, pancreas, and other endocrine

glands are all involved in controlling the
blood glucose concentrations within a
narrow range.
During a brief fast, glucose is supplied to
the ECF from the liver through
glycogenolysis.
When the fasting period is longer than 1
day, glucose is synthesized from other
sources through gluconeogenesis.

Hormones Produced By The

Pancreas:
1.

Insulin

is the primary hormone responsible for the entry of glucose

into the cell.

synthesized by the cells of islets of Langerhans in the
pancreas.
The release of insulin causes an increased movement of
glucose into the cells and increased glucose metabolism.
It decreases plasma glucose levels by increasing the
transport entry of glucose in muscle and adipose tissue by
way of nonspecific receptors.
It also regulates glucose by increasing glycogenesis,
lipogenesis, and glycolysis and inhibiting glycogenolysis.
Insulin is the only hormone that decreases glucose levels
and can be referred to as a hypoglycemic agent

 2.

Glucagon

is the primary hormone responsible for increasing

glucose levels.
It is synthesized by the cells of islets of Langerhans
in the pancreas and released during stress and
fasting states.
When these cells detect a decrease in body
glucose, they release glucagon.
Glucagon acts by increasing plasma glucose levels
by glycogenolysis in the liver and an increase in
gluconeogenesis.
It can be referred to as a hyperglycemic agent (

Hormones Produced By The

Adrenal Gland:

1. Epinephrine
produced by the adrenal medulla
increases plasma glucose by inhibiting insulin secretion,

increasing glycogenolysis, and promoting lipolysis.

is released during times of stress
2.

Glucocorticoids

primarily cortisol
Are released from the adrenal cortex on stimulation by

adrenocorticotropic hormone (ACTH).

Cortisol increases plasma glucose by decreasing intestinal
entry into the cell and increasing gluconeogenesis, liver
glycogen, and lipolysis.

Hormones Produced By The

Anterior Pituitary Glands:
1.

Growth hormone

increases plasma glucose by decreasing the entry of

glucose into the cells and increasing glycolysis.

Its release from the pituitary is stimulated by
decreased glucose levels and inhibited by increased
glucose.
2.

ACTH

Decreased levels of cortisol stimulate the anterior

pituitary to release ACTH.

ACTH, in turn, stimulates the adrenal cortex to release
cortisol and increases plasma glucose levels by
converting liver glycogen to glucose and promoting
gluconeogenesis.

 Two

other hormones affect glucose levels:

Thyroxine
The thyroid gland is stimulated by the production of

thyroid-stimulating hormone (TSH) to release thyroxine

that increases plasma glucose levels by increasing
glycogenolysis, gluconeogenesis, and intestinal
absorption of glucose.
Somatostatin
Produced by the cells of the islets of Langerhans of the

pancreas, increases plasma glucose levels by the

inhibition of insulin, glucagon, growth hormone, and
other endocrine hormones.

HYPERGLYCEMIA
is an increase in plasma glucose levels.
In healthy patients, during a

hyperglycemia state, insulin is secreted

by the cells of the pancreatic islets of
Langerhans.
Insulin enhances membrane permeability
to cells in the liver, muscle, and adipose
tissue. It also alters the glucose
metabolic pathways.
is caused by an imbalance of hormones.

Diabetes Mellitus
Diabetes

mellitus is actually a group

of metabolic diseases characterized by
hyperglycemia resulting from defects in
insulin secretion, insulin action, or both.

Two

broad categories:

Type 1, insulin-dependent diabetes mellitus

(IDDM)
Type 2, noninsulin-dependent diabetes
mellitus (NIDDM)

The ADA/world health organization

(WHO) guidelines recommend the following categories of
diabetes:

Type 1 diabetes
Type 2 diabetes
Other specific types of diabetes
Gestational diabetes mellitus
(GDM)

Type 1 Diabetes
Juvenile

Onset
Insulin Dependent Diabetes Mellitus
Brittle Diabetes
Ketosis-Prone Diabetes
is characterized by inappropriate hyperglycemia primarily a result of

pancreatic islet cell destruction and a tendency to ketoacidosis.

a result of cellular-mediated autoimmune destruction of the cells of
the pancreas, causing an absolute deficiency of insulin secretion.
constitutes only 10% to 20% of all cases of diabetes
commonly occurs in childhood and adolescence.
usually initiated by an environmental factor or infection (usually a
virus) in individuals with a genetic predisposition and causes the
immune destruction of the cells of the pancreas and, therefore, a
decreased production of insulin.

CHARACTERISTICS:

abrupt
onset

ketosis
insulin
tendency dependence

Signs and Symptoms:

Polydipsia
(excessive
thirst)

polyphagia
(increased
food intake)

Polyuria
(increased
urination)

rapid weight
loss

Hyperventilat
ion

mental
confusion

possible loss
of
consciousnes
s

(due to
increased
glucose to
brain)

One or more of the following markers are

found in 85% to 90% of individuals with
fasting hyperglycemia:

Islet cell
autoantibodies

insulin
autoantibodies

glutamic acid
decarboxylase
autoantibodies

tyrosine
phosphatase
IA-2 and IA-2B
autoantibodies

Idiopathic Type 1 Diabetes

is a form of type 1 diabetes that has no

known etiology, is strongly inherited,

and does not have -cell autoimmunity.
Individuals with this form of diabetes
have episodic requirements for insulin
replacement.

Type 2 Diabetes Mellitus

Non-Insulin Dependent Diabetes Mellitus

Adult-type/Maturity Onset Diabetes Mellitus
Stable Diabetes
Ketosis-resistant Diabetes
Receptor-Deficient Diabetes Mellitus
Is characterized by hyperglycemia as a result of an individuals
resistance to insulin with an insulin secretory defect.
This resistance results in a relative, not an absolute, insulin
deficiency.
Constitutes the majority of the diabetes cases.
Most patients in this type are obese or have an increased
percentage of body fat distribution in the abdominal region.

 is

associated with a strong genetic

predisposition, with patients at increased risk
with an increase in age, obesity, and lack of
physical exercise.
Characteristics usually include adult onset of
the disease and milder symptoms than in
type 1, with ketoacidosis seldom occurring.
However, these patients are more likely to
go into a hyperosmolar coma and are at an
increased risk of developing macrovascular
and microvascular complications.

TYPE I
DIABETES
PATHOGENESIS
B-cells
destruction
INCIDENCE RATE
10-15%
ONSET
Childhood/teens
RISK FACTORS
Genetic;autoimmune
C-PEPTIDE LEVELS Decreased or
undetectable
PRE-DIABETES
Autoantibodies(+)
SYMPTOMATOLOG Symptoms
Y
develop abruptly
KETOSIS

Common;poorly

TYPE II
DIABETES
Insulin resistance
90-95%
Over 40 y/o
Genetic, obesity,
lifestyle
Detectable
Autoantibodies(-)
Symptoms
develop
gradually
Rare

Other specific types of diabetes

are
associated
with
certain
conditions
(secondary), including genetic defects of -cell
function or insulin action, pancreatic disease,
diseases of endocrine origin, drug- or chemicalinduced insulin receptor abnormalities, and
certain genetic syndromes.
The characteristics and prognosis of this form
of diabetes depend on the primary disorder.
Maturity-onset Diabetes Of Youth (MODY)

is a rare form of diabetes that is inherited in an

autosomal dominant fashion.

 Gestational

Diabetes Mellitus(GDM)

is any degree of glucose intolerance with onset or first recognition

during pregnancy.
Causes of GDM include metabolic and hormonal changes.
Patients with GDM frequently return to normal postpartum.
However, this disease is associated with increased perinatal
complications and an increased risk for development of diabetes in
later years.
Infants born to mothers with diabetes are at increased risk for
respiratory distress syndrome, hypocalcemia, and hyperbilirubinemia.
Fetal insulin secretion is stimulated in the neonate of a mother with
diabetes.
However, when the infant is born and the umbilical cord is severed,
the infants oversupply of glucose is abruptly terminated, causing
severe hypoglycemia.

Pathophysiology of Diabetes
Mellitus
In both type 1 and type 2 diabetes, the individual
will be hyperglycemic, which can be severe.
Glucosuria
can also occur after the renal tubular transporter system
for glucose becomes saturated.
160-180 mg/dL Renal Threshold
As hepatic glucose overproduction continues, the plasma
glucose concentration reaches a plateau around 300 to
500 mg/dL (1728 mmol/L).
Provided renal output is maintained, glucose excretion will
match the overproduction, causing the plateau.

type 1 diabetes:
has a higher tendency to produce ketones.
type 2 diabetes:
seldom generate ketones but instead have a greater
tendency to develop hyperosmolar nonketotic
states.

The difference in glucagon and insulin

concentrations in these two groups appears to be
responsible for the generation of ketones through
increased -oxidation.

type 1:
there is an absence of insulin with an excess of
glucagon.
This permits gluconeogenesis and lipolysis
to occur.
Presence of Ketone bodies.
type 2:
insulin is present, as is (at times)
hyperinsulinemia; therefore, glucagon is
attenuated.
Fatty acid oxidation is inhibited in type 2.
No lipolysis, no Ketone bodies.

Type II Diabetes:
Mortality is high with this condition.
Ketones are not observed because the severe
hyperosmolar state inhibits the ability of glucagon to
stimulate lipolysis.

NONKETOTIC HYPEROSMOLAR COMA

plasma glucose values exceeding 1,000 mg/dL (55

mmol/L), normal or elevated plasma sodium and
potassium, slightly decreased bicarbonate, elevated
blood urea nitrogen (BUN) and creatinine, and an
elevated osmolality (greater than 320 mOsm/dL).
The gross elevation in glucose and osmolality, the
elevation in BUN, and the absence of ketones
distinguish this condition from diabetic ketoacidosis.

Criteria for Testing for Prediabetes

and Diabetes

Acc. to ADA:
>45 years:
Normal FBS result: should have their FBS tested every 3 years
Abnormal FBS result: should have their FBS tested more
frequently
Overweight individuals(high BMI), testing should be carried out
at an earlier age or more frequently

The

ff. are risk factors:

Habitually physically inactive
Family history of diabetes in a first-degree relative
In a high-risk minority population (e.g., African American,
Latino, Native American, Asian American, and Pacific
Islander)
History of cardiovascular disease

Cont.: Criteria for Testing for

Prediabetes and Diabetes
History of GDM or delivering a baby weighing more

than 9 lb (4.1 kg)

Hypertension (blood pressure 140/90 mm Hg)
Low high-density lipoprotein (HDL) cholesterol
concentrations (35 mg/dL [0.90 mmol/L])
Elevated triglyceride concentrations 250 mg/dL (2.82
mmol/L)
History of impaired fasting glucose/impaired glucose
tolerance
Women with polycystic ovarian syndrome (PCOS)
Other clinical conditions associated with insulin
resistance (e.g., severe obesity and acanthosis nigricans)

Criteria for the Diagnosis of Diabetes

Mellitus

Three methods of diagnosis are suggested:

(1) symptoms of diabetes plus a random plasma glucose level of 200
mg/dL
(2) a fasting plasma glucose of 126 mg/dL
(3) an oral glucose tolerance test (OGTT) with a 2-hour postload (75-g
glucose load) level 200 mg/dL

Impaired Fasting Glucose Group

Impaired Glucose Tolerance Group

First, those patients with fasting glucose levels 100 mg/dL but 126
mg/dL

Another set of patients who had 2-hour OGTT levels of 140 mg/dL but
200 mg/dL

Prediabetes

Criteria for the Testing and Diagnosis of

Gestational Diabetes Mellitus
The

diagnostic criteria for gestational diabetes follow the

guidelines established by the American College of Obstetrics
and Gynecology.

The

criteria for women at high risk include any of the following:

age older than 25 years

Overweight
strong family history of diabetes
history of abnormal glucose metabolism
history of a poor obstetric outcome
presence of glycosuria
diagnosis of PCOS
member of an ethnic/racial group with a high prevalence of diabetes

(e.g., Hispanic American, Native American, Asian American, African

American, Pacific Islander)

 FBS:

The first step in screening for

gestational diabetes should

In

the absence of a positive

confirmation, evaluation for
gestational diabetes in women with
average or high-risk characteristics
should follow one of two approaches.

 The

one-step approach would be the

immediate performance of a 3-hour Oral
Glucose Tolerance Test(OGTT)without prior
screening.
GDM is diagnosed when any two of the
following four values are met or exceeded:
fasting, 95 mg/dL
1 hour, 180 mg/dL
2 hours, 155 mg/dL
3 hours, 140 mg/dL

HYPOGLYCEMIA

involves decreased plasma glucose levels and

can have many causessome are transient and
relatively insignificant, but others can be life
threatening.

65 and 70 mg/dL (3.63.9 mmol/L)

plasma glucose concentration at which glucagon and

other glycemic factors are released

50 to 55 mg/dL (2.83.0 mmol/L)

observable symptoms of hypoglycemia appear

The warning signs and symptoms of hypoglycemia are all

related to the central nervous system.

The release of epinephrine into the systemic circulation

and of norepinephrine at nerve endings of specific neurons
act in unison with glucagon to increase plasma glucose.

Glucagon is released from the islet cells of the

pancreas and inhibits insulin.

Epinephrine is released from the adrenal gland and

increases glucose metabolism and inhibits insulin. In
addition, cortisol and growth hormone are released and
increase glucose metabolism.

Symptoms
increased
hunger

Sweating

Nausea

Vomiting

Dizziness

Nervousnes
s

Shaking

blurring of
speech and
sight

mental
confusion

Methods of Glucose
Determination

 I.

Chemical Methods

A. Reduction-Oxidation Method
1. Alkaline Copper Reduction

a. Folin Wu
b. Nelson Somogyi
c. Neocuprine method
d. Shaffer Hartmann Somogyi
e. Benedicts Method

2. Alkaline Ferric Reduction

a. Hagedorn Jensen
b. Condensation Methods
1.) with Phenols
2.)with Aromatic amines

 II.

Enzymatic Methods

A. Glucose Oxidase
B. Hexokinase

III.
IV.

Home Monitoring Glucose Method

Methods for Testing Urine Glucose

I. Chemical Methods
A.

Reduction-Oxidation Methods

1. Alkaline Copper Reduction

Method
Principle:
Glucose in hot alkaline solution readily
reduces cupric ions to cuprous ions
forming cuprous oxide.

 a. Folin Wu
Cuprous ions react with

phosphomolybdic acid forming Prussian

blue phospho -molybdenum oxide.
The reaction is measured at 520 nm.
The method requires deproteinization to
remove chromogens.

 b.

Nelson Somogyi method

Cuprous ions react with arsenomolybdic

acid forming Prussian blue

arsenomolybdenum oxide.
The method is considered to be specific
for glucose since during deproteinization
process.

 c.

Neocuprine method

Cuprous ions forms an orange colored

complex with neocuprine reagent(2,9

dimethyl, 1, 10-phenanthroline
hydrochloride) producing cuprousneocuproine complex

 d.

Shaffer Hartmann Somogyi

Method
Cuprous ion react with iodine in acidic

solution and the excess iodine is titrated

with thiosulfate(colorless)
e.

Benedicts method

A modification of the Folin Wu Method

2. Alkaline Ferric Reduction Method

Principle:
Glucose reduces ferricyanide to form a colorless

ferrocyanide.

a. Hagedorn Jensen Method

The decrease in color of ferricyanide is measured

in spectrophotometer at 420 nm(inverse

colorimetry). The result is affected by elevated
values of creatinine and uric acid. This meyhod is
widely used in Technicon Auto Analyzer System.

 B.

Condensation Methods
1. Condensation with Phenols
Hydroxyethyl furfural is form glucose in

hot acidic solution.

The aldehyde of this product condenses
with phenol forming colored compound.

 2. Condensation with Aromatic Amines

The aldehyde group of glucose condenses with aromatic

amines in hot acetic acid solution to form colored

derivatives.
The most widely used is ortho toluidine method, others
are aniline, 2-amio phenyl.
a. Ortho Toluidine method
Consired to be the most specific non-enzymatic method of
glucose determination
Principle:
O-toluidine forms an equilibrium mixture of glycosylamine and
Schiffs base forming green color with maximum absorption at
630 nm.

II. Enzymatic Method

1. Glucose Oxidase Method

Principle:
This enzyme catalyzes the oxidation of glucose to

gluconic acid and water.

a. Saifer Gernstenfield Method

(Colorimetric glucose oxidase)
Glucose oxidase catalyzes the oxidation of oxidation of

glucose molecular oxygen to form gluconic acid and

water.
The colorimetric reaction is then catalyzes by peroxidase
wherein colorless oxygen acceptor is a colored product.

 b. Polarographic Glucose Oxidase

Method
The oxygen consumed in the oxidation
process of glucose to gluconic acid is
measured using a polarographic oxygen
electrode.

2. Hexokinase Method
Considered to be the most highly specific for
glucose determination.
Principle:
Hexokinase enzyme catalyzes the phosphorylation of

glucose
by
ATP
forming
glucose6-phosphate
dehydrogenase(G6PD) catalyzes the reaction of G-6-P
with NADP to form 6-phosphogluconate and NADPH. The
reaction is measured at 340 nm.
Measuring the reaction at visible region is made possible

by using phenazine methosulfate(PMS) and read at 520

nm.

III. Home Monitoring Glucose

Methods:
1.

Dextrostics (Ames Co.)

Using only a drop of blood, the
reaction on the reagent pad is read
in reflectance colorimeter.
a.

bG Chemstrip

The reaction on the strip is compared

against a color chart on by using

Accucheck bG meter.

IV. Methods for Urine Glucose

Determination:
1.

Clinitest Table Test

2. Reagent Strip Test
3. Benedicts Method

Sample/Test for Glucose

Determination:
1.

Fasting Blood Sugar(FBS)

6-8 hrs fasting

Screening test for DM

2.

Random Blood Sugar(RBS)

Random sample
Indicated during insulin shock and hyper

glycemic ketonic coma

3.

Post Prandial Blood Sugar(PPBS)

1-5 hours after taking regular meal

 4.

Glycosylated Hemoglobin(HbA1c)

Glucose/hemoglobin derivation that

increases as the level of glucose increases.

Indication of glucose control over the last
three months
Monitoring of diet and medication
(effectiveness of treatment)
Methods used:
A. Column chromatography
B. Electrophoresis

 5.

Fructosamine

Glycosylated albumin and other protein

Gives a clear picture of more short-term

glucose levels(serum albumin has a halflife of 2-3 weeks)

Methods:
A. Column Chromatography
B. Colorimetric Assay

 6.

Glucose Tolerance Test(GTT)

Also called glucose challenge
A glucose load is given, the blood glucose rises
higher and returns to a baseline.
A.

Oral Glucose Tolerance Test(OGTT)

fasting, 95 mg/dL
1 hour, 180 mg/dL
2 hours, 155 mg/dL
3 hours, 140 mg/dL

B.

Intravenous Glucose Tolerance Test(IVGTT)

Glucose load given intravenously

 C.

Other Tolerance Tests:

1. Insulin Tolerance Test
Evaluates sensitivity to insulin and the

function of the anterior pituitary gland

and the adrenal cortex
2.

Insulin Glucose Tolerance Test

Glucose is administered orally 30

minutes after injection of insulin

 3.

Galactose Tolerance Test

Detects impaired glycogenolysis or

severe liver damage.

4.

Leucine Tolerance Test

Used for children suffering from

hypoglycemic episodes.

Genetic Defects in
Carbohydrate Metabolism
Glucose-6-phosphatase

Deficiency Type 1

The most common congenital form of glycogen

storage disease
also called von Gierke disease
an autosomal recessive disease
is characterized by severe hypoglycemia that
coincides with metabolic acidosis, ketonemia,
and elevated lactate and alanine.
Hypoglycemia occurs because glycogen cannot
be converted back to glucose by way of hepatic
glycogenolysis.

 A glycogen buildup is found in the liver,

causing hepatomegaly. A liver biopsy will

show a positive glycogen stain.
The
patients usually have severe
hypoglycemia, hyperlipidemia, uricemia,
and growth retardation.
Although the glycogen accumulation is
irreversible, the disease can be kept
under
control
by
avoiding
the
development of hypoglycemia.

Galactosemia
a cause of failure to thrive syndrome in infants,

is a congenital deficiency of one of three

enzymes involved in galactose metabolism,
resulting in increased levels of galactose in
plasma.
The most common enzyme deficiency is
galactose-1-phosphate uridyl transferase.
occurs because of the inhibition of
glycogenolysis and is accompanied by diarrhea
and vomiting.

 Galactose must be removed from the diet to

prevent the development of irreversible

complications. If left untreated, the patient will
develop mental retardation and cataracts.
The disorder can be identified by measuring
erythrocyte galactose-1-phosphate
uridyltransferase activity.
Laboratory findings include hypoglycemia,
hyperbilirubinemia, and galactose
accumulation in the blood, tissue, and urine
following milk ingestion.
Another enzyme deficiency, fructose-1phosphate aldolase deficiency, causes nausea

Specific inborn errors of amino acid metabolism and

long-chain fatty acid oxidation are also responsible
for hypoglycemia.

There
are
also
alimentary
hypoglycemias.
Alimentary hypoglycemia

and

idiopathic

appears to be caused by an increase in the release of

insulin in response to rapid absorption of nutrients after a
meal or the rapid secretion of insulin-releasing gastric
factors.

Idiopathic postprandial hypoglycemia

is a controversial diagnosis that may be overused.

Methods of Glucose Measurement

serum,

plasma, or whole blood.

The glucose concentration in whole blood is approximately
11% lower than the glucose concentration plasma.
Serum or plasma must be refrigerated and separated from the
cells within 1 h to prevent substantial loss of glucose by the
cellular fraction, particularly if the white blood cell count is
elevated.
Sodium fluoride ions (gray-top tubes) are often used as an
anticoagulant and preservative of whole blood, particularly if
analysis is delayed. The fluoride inhibits glycolytic enzymes.
However, although fluoride maintains long-term glucose
stability, the rates of decline of glucose in the first hour after
sample collection in tubes with and without fluoride are
virtually identical. Therefore, the plasma should be separated
from the cells as soon as possible.

 Fasting

blood glucose (FBG) should be obtained in

the morning after an approximately 8 to 10hours
fast (not longer than 16 hours).
Fasting plasma glucose values have a diurnal
variation with the mean FBG higher in the
morning than in the afternoon.
Diabetes in patients tested in the afternoon may
be missed because of this variation.
Cerebrospinal fluid and urine can also be analyzed.
Urine glucose measurement is not used in
diabetes diagnosis; however, some patients use
this measurement for monitoring purposes.

 Fasting

glucose in whole blood is 15%

lower than in serum/plasma
Venous blood glucose is 7 mg/dL lower
than capillary blood; capillary blood
glucose is same with arterial blood glucose
CSF glucose concentrations should be
approximately 60% of the plasma
concentrations
Peritoneal Fluid glucose is same with
plasma

Specimen consideration:

Serum or plasma must be separated from the cells

within one hour to prevent losses of glucose(preferably
within 30 minutes)

At room temperature(20-25 degrees celsius), glycolysis

decreases glucose by 5-7%/hour(5-10 mg/dL) in normal
un-centrifuged coagulated blood

At refrigerated temperature(4 degrees celsius), glucose

is metabolized at the rate of about 1-2 mg/dL/hour

WBC and RBC metabolize glucose resulting

decreased value in clotted, uncentrifuged blood

in

Ketones
The

ketone bodies are produced by

the liver through metabolism of fatty
acids to provide a ready energy
source from stored lipids at times of
low carbohydrate availability.
The three ketone bodies are:
acetone (2%),
acetoacetic acid (20%)
-hydroxybutyric acid (78%)

A low level of ketone bodies are present

in the body at all times.
However, Ketones increases in cases of
carbohydrate deprivation or decreased
carbohydrate use:

diabetes mellitus
starvation/fasting
high-fat diets
prolonged vomiting
glycogen storage disease

ketonemia

Ketonuria

refers to the accumulation of ketones in blood

refers to accumulation of ketones in urine.

The
measurement
of
ketones
is
recommended for patients with type 1
diabetes
during
acute
illness,
stress,
pregnancy, or elevated blood glucose levels
above 300 mg/dL or when the patient has
signs of ketoacidosis.

Ketone Determination:

The specimen requirement is fresh serum or urine; the

sample should be tightly stoppered and analyzed
immediately.

No method used for determination of ketones reacts with

all three ketone bodies.

Gerhardts Test
used ferric chloride reacted with acetoacetic acid to produce a red
color.
The procedure had many interfering substances, including salicylates.

Sodium nitroprusside (NaFe- [CN]5NO)

reacts with acetoacetic acid in an alkaline pH to form a purple color. If
the reagent contains glycerin, then acetone is also detected.
This method is used with the urine reagent strip test and Acetest
tablets.

Microalbuminuria

Diabetes mellitus causes progressive changes to the kidneys

and ultimately results in diabetic renal nephropathy.
This complication progresses over years and may be delayed
by aggressive glycemic control.
An early sign that nephropathy is occurring is an increase in
urinary albumin.

Microalbumin measurements are useful to assist in diagnosis

at an early stage and before the development of proteinuria.

An annual assessment of kidney function by the

determination of urinary albumin excretion is recommended
for diabetic patients.

Microalbuminuria

persistent albuminuria
range of 30 to 299 mg/24 h
albumin-creatinine ratio: 30 to 300 g/mg.

Clinical proteinuria or macroalbuminuria is

established with an albumin-creatinine ratio of
300 mg/24 h or an albumin-creatinine ratio of
300 g/mg.
three methods for microalbuminuria screening:

random spot collection--is the preferred method.

24 hour urine collection
timed 4-hour overnight collection

Islet Autoantibody and Insulin

Testing
The

presence of autoantibodies to the islet cells of the

pancreas is characteristic of type 1 diabetes.

However,

islet autoantibody testing is not currently

recommended for routine screening for diabetes
diagnosis.

In the future, this testing might identify at risk,

prediabetic patients.

Insulin measurements are not required for the diagnosis

of diabetes mellitus, but in certain hypoglycemic states, it
is important to know the concentration of insulin in
relation to the plasma glucose concentration.