University of Duhok College of Medicine Module of Metabolism Student Book 2021-2022

University of Duhok-College of Medicine- Metabolism Module Workbook 2021-2022
University of Duhok
College of Medicine
Module of Metabolism
Student Book
2021-2022
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Introduction
In this module we shall be considering the chemical processes which go on within cells and
tissues in order to maintain their proper function, and which make the energy content of food
available to do biological work. We will also be considering how these processes are controlled
and what happens when this control breaks down.
There are three major areas of study in the module:
1. Nutrition and Whole-Body Metabolism: considers the energy and nutrient

requirements of the whole body, along with the regulation of body weight.
2. Cellular Metabolism: considers the chemical reactions and transformations that go on
inside cells and tissues, and how they are controlled.
3. Endocrinology: considers how the metabolism of cells and tissues is integrated to serve
the needs of the whole body under different physiological conditions.
At all stages clinical conditions that arise as a consequence of metabolic or hormonal disorders
will be considered.
Summary of Intended Learning Outcomes:
On completion of this module you should be able to:
• List the essential components of the human diet and explain why they are essential.
• Calculate Body Mass Index and describe the factors involved in the long term
regulation of body weight.
• Define homeostasis and discuss control systems in the body.
• Explain how the energy required for cellular activity is derived from the food eaten.
• Describe the general features and clinical relevance of the metabolic pathways by which
carbohydrates, lipids, amino acids and alcohol are oxidized and may be synthesized
from appropriate precursors.
• Outline the pathways involved in drug metabolism
• Describe the metabolic problems of the anaerobic conditions and explain their clinical
consequences.
• Describe in outline how glucose and lipids are transported and stored in the body and
explain the clinical consequences of defects in these pathways.
• Describe how and why ketone bodies are produced and explain the clinical importance
of these molecules.
• Analyze simple clinical case histories involving disturbances to metabolism such as
marasmus, kwashiorkor, obesity, galactosemia, lactose intolerance, glucose 6-
phosphate dehydrogenase deficiency, hypercholesterolemia, phenylketonuria,
glycogen storage diseases, and hypoglycemia.
• List the major metabolic activities of the following: central nervous system, liver, heart
muscle, skeletal muscle, adipose tissue, red blood cells.
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• Describe in outline the structures, functions, modes of action and the control of
secretion of the major hormones involved in the control of metabolism.
• Describe in outline the metabolic changes that occur during feeding, fasting, starvation,
pregnancy and exercise and explain how they are controlled.
• Explain why the blood glucose concentration is normally held relatively constant and
explain the metabolic and clinical consequences of untreated type 1 and type 2-
diabetes.
• Analyze simple clinical case histories involving disorders of the thyroid, pituitary and
adrenal glands.
Feedback:
You will obtain some feedback during the group work sessions, when you will be able to
apply your knowledge and ask questions. Following the formative assessment, feedback will
be posted on Blackboard. Each week you can use the self-assessment questions in the Module
Workbook to test whether you are achieving the learning outcomes. During the module you
can post questions on the Discussion Board in Blackboard and get feedback on them.
Following ESA1, feedback will be available on your examination performance from your
Personal Tutor.
Teachers:
The lectures in the module will be given by:

1. Dr. Sherwan Ferman Salih (Clinical Biochemistry, FICMS) (Module Leader)
2. Dr. Alaa Hani Raziq (Pathology, FICMS)
3. Dr. Nadir Abdullah Garjees (pediatric, FIBMS)
4. Dr. Hivi Mohammad (Clinical Biochemistry, Ph.D.)
5. Dr. Hishyar Azo Najeeb (Clinical Biochemistry, Ph.D.)
6. Dr. Aveen Hassan Mustafa (Chemical Pathologist, FKBMS)
7. Dr. Saaed Mohammad Sabri (Clinical Biochemistry, M.Sc.)
8. Dr. Kajeen Rashid Hussein (Clinical Biochemistry, M.Sc.)
9. Dr. Donya Yahya Hussein (Clinical Biochemistry, M.Sc.)
Group Work:
There will be group work sessions each week, in which you will be split into smaller groups
to work on case studies or applied problems under the supervision of a tutor. The group work
sessions are important as it is where quite a large proportion of the learning occurs, so please
be prepared for each group work session. The more you put into it the more you will get out
of it. It is also important for medical practice to learn to function effectively in a team. For
those new to higher education it is important to take on responsibility for your own learning
quickly. This may take some adaptation from being 'taught' (passive) to 'learning' (active).
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Please read the relevant case study before each Group Work session. You may also need to
read the appropriate lecture notes, read relevant pages in the recommended textbook and
perhaps do some searching on the internet or in the library. Please note that answers to the
group work session questions will not be posted on Blackboard, so it is important to attend
the sessions and check your answers during the sessions.
Student Assessment:
Each session of the module has a set of self-assessment questions for you to monitor your
own progress. These questions and those used in the clinical case studies will be used as the
basis of the formative and summative assessments. A formative assessment consisting of 6
short-answer questions will be posted on Blackboard for Session 6. The results of the formative
assessment will give you an indication of how well you are achieving the learning outcomes
of the module. At the end of the semester there will be a written assessment covering all of the
modules in semester one, with both questions specific to the metabolism module and questions
linking it to other modules in the semester. Material from the metabolism module will continue
to appear in all subsequent end of semester assessments, which are designed to test your
cumulative acquisition of understanding. Learn and forget is not an option for the material in
this or any other module. Make sure you learn and understand the material as you go along,
otherwise you will get caught out and end up taking qualifying examinations as the course
proceeds. Try to aim for understanding of key concepts in the subject area (deep learning)
rather than rote learning of facts (shallow learning). As the course progresses you will be
expected to integrate your knowledge and understanding across the different subject areas in
order to build up a holistic view of medicine.
Reference Material:
Answers to self-assessment questions: Answers to the self-assessment questions for each

session will be posted on Blackboard one week after the Session takes place.
PowerPoint presentations: PowerPoint presentations will normally be posted on blackboard

before the presentation is given.
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Reference books:
The module workbook contains much of the information you will need, but you will want to
explore some topics from a different perspective, or in greater detail and the following reference
texts are recommended. It is always worth looking at several textbooks to find one that you like
and which suits your learning style:
• Marks Essential of Medical Biochemistry- A Clinical Approach. M. Lieberman, a

Marks & C. Smith (Lippincott Williams & Wilkins 2006 2nd edition ISBN-10:0-7817-
9340-8). This textbook covers human biochemistry in a concise fashion and aims to
help students learn to use biochemistry in the context of clinical problem solving.
• Medical Biochemistry - J.W. Baynes & M.H. Dominiczak (Mosby 2009 3rd edition
ISBN 978-0-323-05371-6). This textbook is up to date and well-illustrated. It contains
information useful for other modules. You may also wish to look at: Biochemistry 5th
Ed., Harvey & Ferrier
• Lippincott, Williams & Wilkins 2010 ISBN 978-1-60913-998-8. This book is well
illustrated and explains the material in simple, straightforward terms.
• Ganong's Review of Medical Physiology.23rd Ed. Kim E. Barrett, Susan M. Barman,
Scott Boitano, Heddwen Brooks (McGraw-Hill 2009 ISBN:007165673). This textbook
provides concise notes on essential areas of medical physiology and is one of the
recommended physiology textbooks for the systems modules.
• Medical Physiology Walter F. Boron and Emile L. Boulpaep (Saunders 2009 second
edition ISBN: 978-1-4160-3115-4). This textbook is very detailed, well-illustrated and
is a good reference book. It is also recommended for the systems modules.
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Module timetable:
Session One
08:00-09:00 Lecture- Nutrition and body weight
09:00-10:00 Lecture- Homeostasis, circadian rhythm
10:30-01:30 Group work: BMI, obesity, malnutrition
Session Two
08:00-09:00 Lecture- Cell metabolism, bioenergetics, energy balance
09:00-10:00 Lecture- Carbohydrate metabolism 1
10:30-01:30 Group work: Diet analysis
Session Three
08:00-09:00 Lecture- Carbohydrate metabolism 2
09:00-10:00 Lecture- TCA cycle and gluconeogenesis
10:30-01:30 Group work: Galactosaemia
Session Four
08:00-09:00 Lecture- Oxidative phosphorylation, oxidative stress
09:00-10:00 Lecture- Fuel storage and lipid metabolism
10:30-01:30 Group work: Glucose 6-phosphate dehydrogenase deficiency
Session Five
08:00-09:00 Lecture- Lipid metabolism and transport
09:00-10:00 Lecture- Protein and nitrogen metabolism
10:30-01:30 Group work: Hyperlipidaemia, hypercholesterolaemia
Session Six
08:00-09:00 Lecture - Control of energy metabolism
09:00-10:00 Lecture- Drug metabolism
10:30-01:30 Group work- PKU, amino acid metabolism
Session Seven
08:00-10:00 Review
10:30-01:30 Review
Session Eight
08:00-09:00 Lecture- Introduction to endocrinology
09:00-10:00 Lecture- Endocrine pancreas
10:30-01:30 Group work: Glycogen storage diseases, hypoglycaemia
Session Nine
08:00-09:00 Lecture- Clinical presentation-Diabetes mellitus
09:00-10:00 Lecture- Control of appetite, metabolic syndrome
10:30-01:30 Group work- Type 1 & type 2 diabetes
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Session Ten
08:00-09:00 Lecture- Thyroid gland
09:00-10:00 Lecture- Clinical presentation :Disturbances thyroid function
10:30-01:30 Group work- Hyperthyroidism & hypothyroidism
Session Eleven
08:00-09:00 Lecture- Calcium metabolism
09:00-10:00 Lecture - Pituitary & adrenal glands
10:30-01:30 Group work- Calcium metabolism
Session Twelve
08:00-09:00 Lecture- Clinical presentation: Disorders of the adrenal cortex
09:00-10:00 Lecture- Adaptations of metabolism
10:30-01:30 Group work- Cushing's & Addison's disease
Session Thirteen
08:00-10:00 Review
10:30-01:30 Review
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Session One
Nutrition and body weight

Homeostasis
Aims of the session
The aim of this session is that you understand the overall functions of metabolic processes
in the body, including components of the overall energy utilization of the body, how this is met
by nutrition, the essential components of the human diet and homeostatic control mechanisms.
Structure of the Session:

08:00-09:00 Lecture: Nutrition and body weight.
09:00-10:00 Lecture: Homeostasis, circadian rhythm
10.30-01:30 Group Work: Case studies: BMI, obesity, malnutrition
Intended learning outcomes:

After this session and your self-study you should be able to:
• Define and give approximate values to the components of your daily energy
expenditure.
• List the essential components of the diet and explain why they are essential.
• Explain the clinical consequences of protein and energy deficiency in man.
• Determine the body mass index of a patient and interpret the value.
• Define obesity and describe the factors involved in the regulation of body weight.
• Define homeostasis and explain its importance.
• Describe the main features of control system in the body.
• Discuss examples of biological rhythms.
Directed study:
You should read the case study on gastroenteritis and prepare answers to the questions. Your
answers will be reviewed during the Group Work for Session 2.
Self-assessment:
You should answer the self-assessment questions to ensure that you can meet the learning
objectives for this session.
Reading:
Marks Essential of Medical Biochemistry, Chapter 1.
Medical Biochemistry, Baynes and Dominiczak Chapter 10
Ganong's Review of Medical Physiology Chapter 1, 2, and 18.
Medical Physiology Boron and Boulpaep Chapter 1, 58, 59
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Lecture notes
Nutrition and Body Weight
In order to stay alive, we require fuels in our diet to supply the energy that drives the
chemical reactions of our bodies. These reactions enable us to carry out such diverse functions
as growing, developing, moving, thinking, defending ourselves from infection, recovering
from trauma, and reproducing. The fuels in our diet also provide some of the precursors from
which the body's structural and functional components are derived. The diet also provides
essential cell components such as vitamins, minerals and water. In addition, our diet should
contain indigestible material (fiber) for the normal functioning of the gastrointestinal tract. We
obtain our fuel mainly from the carbohydrates, fats and proteins that we consume in our diet.
Most of the food we eat is digested in our gastrointestinal tract and the products of digestion
are absorbed into the body and circulate in the blood. The tissues of the body continuously
remove the circulating fuels to provide the energy they require. Any dietary fuel that exceed
the body's immediate energy needs is stored as fat in adipose tissue or as glycogen in liver and
muscle. These stores of fuel are mobilized between meals and during periods of starvation and
prolonged exercise. The mobilized fuels (mostly fatty acids and glucose) enter the circulation
and are taken up by cells to provide energy.
Energy
Energy is defined as the capacity to do work. Living cells require energy for:
(1) Biosynthetic work: synthesis of cellular components
(2) Transport work across cell membranes: maintenance of ion gradients, uptake of
nutrients.
(3) Mechanical work: muscle contraction
(4) Electrical work: nervous conduction
(5) Osmotic work: kidney
The Joule (J) is the unit of energy now widely used in countries other than the USA.
However, the term calorie (1 cal = 4.184 Joules) is still used in the medical literature and is
more generally understood by patients. In metabolism energy changes are often expressed in
terms of kJ or kcal where 1 kJ = 1,000 Joules and 1 kcal = 1,000 calories. Energy exists in many
forms: thermal, light, mechanical, electrical, osmotic and chemical, all of which are inter-
convertible. Chemical bond energy is used to drive the energy-requiring activities in the cells
of the human body.
Chemical bond energy
A chemical bond is a form of potential (stored) energy and making or breaking chemical
bonds involves energy changes. In an organic reaction, covalent bonds in the reacting molecules
are split by an input of energy. The free radicals or ion pairs produced then recombine to
produce different molecules (products) and release energy. Thus, a characteristic energy change
accompanies all reactions. When the energy released is greater than the energy input, the
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reaction is described as: Exergonic. When the energy input is greater than the energy released,
the reaction is described as Endergonic.
All cell activities are the result of chemical reactions and chemical bond energy is used to
drive all energy-requiring activities in cells. It is used directly, without prior conversion to heat,
as the human body is isothermal and under this condition heat energy cannot be used for work.
Reactions that require an input of energy are driven by coupling to reactions that release energy.
Coupling is usually via the ATP-ADP cycle.
The chemical bond energy in fuel molecules is released by oxidation. Some of this energy
is conserved by the formation of adenosine triphosphate (ATP) from adenosine diphosphate
(ADP) and phosphate (Pi) and the remainder is lost as heat. The controlled release of energy
from ATP in cells (ATP-ADP cycle) is used to perform biological work such as movement,
membrane transport and biosynthesis.
Daily Energy Expenditure
Assuming moderate physical activity the daily energy expenditure of a 70 kg adult male
would be 12,000 kJ and that of a 58 kg adult female 9,500 kJ. This daily energy expenditure
has three components:
(1) Energy to support our basal metabolism-Basal Metabolic Rate (BMR).
(2) Energy for voluntary physical activities.
(3) Energy required processing the food we eat (diet-induced thermogenesis).
(1) Basal Metabolic Rate (BMR):
The BMR is a measure of the basal energy required to maintain life-the functioning of the
various tissues of the body at physical, digestive and emotional rest. The major tissues
contributing to the BMR are:
1. Skeletal muscle 30%

2. Central nervous system 20%
3. Liver 20%
4. Heart 10%
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A very rough estimate of BMR (in kJ/24hr), in individuals who are not obese, may be
obtained by multiplying the body weight in kg by 100 (BMR = 100 × weight in kg). In an adult,
the BMR is 7,000 kJ for men (70 kg) and 5,800 kJ for women (58 kg). Although an individual's
BMR is related mainly to body weight many other factors affect it. BMR is mainly controlled
by the thyroid hormones, which will be covered in detail later in the module. The BMR is lower
for women than men of the same weight as women have more adipose tissue that is less
metabolically active than lean tissue. The BMR increases by ~10% for every 10◦C increase in
body temperature. Excessive secretion of thyroid hormones (hyperthyroidism) increases the
BMR as do pregnancy and lactation.
(2) Voluntary Physical Activity:
In addition to the BMR, the energy required by skeletal and cardiac muscle for voluntary
physical activity contributes to our daily energy expenditure. Tables exist which relate energy
expenditure to various types of physical activity (appendix i). A very rough estimate of the total
daily energy required for physical activity can be made using the following values:
BMR + 30% of the BMR for a sedentary person

BMR + 60% - 70% of the BMR for a person who engages in ~2hr of moderate exercise a day
BMR + 100% of the BMR for a person who does several hours of heavy exercise a day
(3) Diet-Induced Thermogenesis (DIT):
Our daily energy expenditure includes a component related to processing the food we eat.
Following the ingestion of food, our metabolic rate increases because energy is required to
digest, absorb, distribute and store nutrients. The energy required to process the food is equal
to 10% of the energy content of the ingested food.
Calculations of Daily Energy Expenditure
The total daily energy expenditure is usually calculated as the sum of the BMR plus the
energy required for the amount of time spent in each of the various types of physical activity
(appendix i) plus 10% of these values to reflect diet induced thermogenesis.
Nutritional Requirements
An adequate diet is one which contains sufficient fat (lipid) and carbohydrate to satisfy the
body's energy requirement, and which provides the minimal amounts of protein, vitamins,
minerals and water to prevent deficiency. To maintain our body weight we must stay in energy
balance i.e. the energy in the food we eat must match our energy consumption over time.
Nutrients, such as carbohydrate, fat and protein, required in relatively large amounts are
sometimes called macronutrients while vitamins and minerals are micronutrients.
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Recommended Dietary Allowance/Amount (RDA)
RDA represents the quantities of nutrients required to keep the general population in good
health and are considerably higher than the minimum amounts required to prevent deficiency
symptoms. Since 1991 the RDA has been replaced by Dietary Reference Values in the UK. Of
these the Estimated Average Requirement (EAR) for energy or a nutrient is the amount that
any stated group of people will on average need (appendix iii). The RDA and EAR represents
an average need over a number of days. The amounts vary with age and gender and are often
higher during pregnancy and lactation (appendix iii). Much of the food we eat is processed by
manufacturers who are required to publish nutritional information about their products. These
often list the major nutrients in terms of energy, protein, carbohydrate, fat (total and saturated),
fibre and sodium content per 100 g of the food. Minerals and vitamins may be listed in terms
of % RDA.
Energy Requirement
Fat (energy content 37 kJ/g) and carbohydrate (energy content 17 kJ/g) are the major energy
containing components of the diet. We can, however, derive energy from the metabolism of
proteins (~17kJ/g) and from alcohol (~29kJ/g). In a typical Western diet containing ~300g
carbohydrate, 150g fat and ~100g protein, 45% of the energy requirement is derived from fat,
40% from carbohydrate and the remainder from protein. However, the excessive intake of
saturated fats (derived from animal sources) is associated with high blood cholesterol and a
number of pathological conditions including heart disease. To prevent this nutritionists
recommend that about 30% of our energy should be supplied by fat (mostly unsaturated derived
from plant oils), 55% by carbohydrate with the remaining 15% coming from protein. Some
tissues, such as the brain and red blood cells need a constant supply of glucose as a source of
energy. However, there is no absolute requirement for glucose in the diet, provided adequate
protein is ingested, as the body can make glucose from certain amino acids by the process of
gluconeogenesis (Session 4). In addition, glucose can be synthesized from dietary sugars such
as galactose and fructose. There is no absolute requirement for fat as an energy source, and
definitely no need for alcohol.
Fats are important to the diet, however, because:
o They have energy yield some 2.2 times greater than carbohydrates or proteins, so that
if we were to rely upon a fat free diet then we would have to eat almost twice the normal
amount of food.
o Fat is necessary for absorption of fat soluble vitamins (A, D, E & K) from the gut. Thus,
a fat free diet may lead to a deficiency of these vitamins.
o Certain polyunsaturated fatty acids (the essential fatty acids) notably linoleic and
linolenic acids, which are structural components of cell membranes and precursors of
important regulatory molecules (eicosanoids), are not synthesized in the body and must
be consumed in the diet.
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Protein Requirement
Amino acids, the products of the digestion of proteins, are indispensable for the normal
structure and function of the body. They are the building blocks of proteins and are used in the
synthesis of a number of essential N-containing compounds including creatine, purines,
pyramidines and haem (part of haemoglobin). There is a continuous turnover (breakdown &
resynthesize) of tissue protein (400g/day in an adult male). Most of the amino acids released
during breakdown are reused for the synthesis of new protein. However, about 35g/day is lost
by further degradation and must be replaced from the diet. The nitrogen of the degraded amino
acids is excreted in the urine as urea. To remain in zero nitrogen balance (N intake = N loss)
an adult male has an average daily requirement of ~35 g protein (0.5 g/Kg body weight).
Growing children and women during pregnancy need proportionally more and normally show
a positive nitrogen balance (N intake > N loss). In starvation and tissue wasting diseases the
nitrogen balance may be negative. The body needs dietary protein to supply specific or
essential amino acids (appendix ii), which are not synthesized by the body. Other amino acids
(non-essential amino acids) can be synthesized by the body and are not therefore a dietary
requirement as long as total protein intake is sufficient. Proteins of animal origin usually
contain a high proportion of the essential amino acids unlike proteins of vegetable origin that
may be deficient in one or more of the essential amino acids. The protein of wheat for example
is low in lysine, and protein deficiency disease may follow a vegetarian diet based solely upon
cereals. This can be avoided if the vegetarian diet contains a mixture of vegetables.
Other Dietary Requirements
In addition to the nutrients required to supply energy and to replace structural and other
components, a number of other substances are necessary:
Water: In the adult 50-60% of the body weight is water. This is relatively larger in children
(70%) and smaller in the elderly (~50%) and obese. The average water loss from the body
is ~2.5 liters/day. Most of this is lost in the urine (~1,500ml). In addition, water is lost in
the expired air (~400ml), through the skin (~500ml) and in the faeces (~100ml). Part of this
water is produced during cellular metabolism (̴ 350) and the remainder must be made up
by drinking to maintain the body's fluid balance.
Dietary fiber: non-digestible plant material such as cellulose is necessary for normal bowel
function.
Minerals and vitamins (appendix IV): Vitamins are classified as water-soluble or lipid-
soluble. You should be aware of the important deficiency diseases associated with the
absence (& excess) of these in the diet.
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Body Weight
Body weight (in Kg) is the sum of the following:
Adult male Adult female Adult obese male

Total body weight 70 58 100
Water 42 32 44
Minerals 4 3 4
Protein 11 7 12
Fat* 11 15 39
Carbohydrate 1 1 1
*The fat content can vary from <10% in thin individuals to >50% in obese individuals. Body
weight is determined by the difference between the input of substances into the body and the
output of substances and energy from the body.
Ideal/desirable body weight
There is a lot of evidence to suggest that both excessive body weight, and being underweight
are associated with an early death, and that for each of us there is an ideal or desirable weight
that depends upon our height and the general shape of our body. Desirable weight,
underweight, overweight, obesity etc. can be defined on the basis of records kept by insurance
companies, which list the weight associated with the lowest mortality. However, the Body
Mass Index is more commonly used in a clinical setting.
Body Mass Index
A simple way to estimate desirable weight is to derive the Body Mass Index
(BMI) where the BMI = weight (kg) /height2 (m).
Underweight < 18.5 men and women

Desirable ranges 18.5 - 24.9 men and women
Overweight 25 - 29.9 men and women
Obese 30 - 34.9 men and women
Severely Obese >35
Overweight/Obesity
Overweight and obesity are serious problems in people worldwide. These are chronic
conditions characterized by excess body fat and are most often defined on the basis of
determination of the Body Mass Index (BMI). Although some factors may influence the
tendency to put on weight (genetic, drug therapy, endocrine disorders) the body weight in most
adults represents the balance between energy intake and energy expenditure. The prevalence
of obesity worldwide has increased. Excess body fat is associated with increased risk of
hypertension, heart disease, stroke, type 2 diabetes, certain cancers, gall bladder disease and
osteoarthritis. For males at age 25 at the desirable weight ~15% of body weight is fat. This
value can rise to 25% at age 65. For females at age 25 at the desirable weight ~25% of body
weight is fat, rising to 35% at 65. There is evidence that the distribution of fat within the body
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is important clinically. Obese persons having a greater proportion of fat within the upper body,
especially in the abdomen, compared with that on the hips has increased risk of insulin
resistance, hyperinsulinism, type 2 diabetes, hypertension, hyperlipidemia and stroke as well
as premature death.
Weight Loss & Dieting
Many diets and dietary regimes are in common use. However, it is long-term changes in
food choices, eating behavior and lifestyle that are needed, rather than temporary restriction of
specific foods. A theoretical maximum rate of weight loss, for someone who eats nothing can
be calculated. Assuming a person with a daily energy requirement of 12,000 kJ stops eating
altogether, and that the energy requirement is met by the mobilization of fat (energy content =
37kJ/g) from adipose tissue, the theoretical maximum rate of weight loss will be:
12,000/37 = 324 g/day = 2.3 kg/week
Initially the weight loss may be larger than this because water is also lost. This is because
starvation is associated with a reduction in liver glycogen stores that are required to provide
glucose for the brain. The glycogen stores contain more water than fat, and weight reduction
can be quite rapid. As the glycogen stores are used up however, the rapid phase of weight loss
slows toward the theoretical maximum as fat is mobilized. Total starvation is not a preferred
method of weight loss, as protein metabolism increases to maintain blood glucose by
gluconeogenesis (the conversion of amino acids into glucose) so after a relatively short time
lean body mass begins to disappear. In addition, the liver begins to convert fatty acids to ketone
bodies that can be used as a fuel by the CNS but they can disturb blood pH and lead to
dehydration.
Diet Analysis-The Eatwell plate
Despite what the public may think, and the media portray, recommendations for a healthy
diet have not changed since 1980s. To help understanding of what a healthy diet is the foods
Standards Agency (FSA) published the Eatwell Plate, previously known as the balance of good
health and produced by the Health Education Authority. The Eatwell Plate applies to most
people, whether a healthy weight or overweight, people with diabetes, vegetarians and people
of all ethnic origin. It does not apply to children and some people with special dietary needs or
those who are malnourished as they have specific dietary needs. The plate aims to give an
easily understood message about foods and the proportions present in a healthy diet on a daily
basis. It does not include salt but FSA literature on the Eatwell plate explains that if processed
foods high in fat and sugar are reduced salt intake will be lessened (two thirds of salt in the
British diet comes from processed foods). For more information see www.eatwell.gov.uk
Malnutrition
Obesity is the public health challenge of the 21st century although malnutrition is
recognized to cost the country twice as much (over £13billion, BAPEN 2009). More than 7
million people in the UK are at risk of malnutrition: 150,000 people in hospitals, 600,000 in
care homes, 700,000 people in sheltered accommodation and 6 million people who are
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dependent on others for food and hydration needs. Malnourished patients are likely to have
longer hospital admissions and respond less well to treatment, are 3 times more likely to
develop complications after surgery and have higher mortality rates. It is recognized over 40%
of patients are malnourished on admission to hospital and nutritional risk increases during their
stay. Different tools are available to screen for malnutrition. Most are not evidence based and
the only recognized evidence based tool is the Malnutrition Universal Screening Tool (MUST).
It is more important that nutrition screening happens rather than using MUST, and not using
effectively. Nutrition Support in Adults (NICE clinical guideline 32) stated that screening for
malnutrition should be carried out by health care professionals with appropriate skills and
training and should take place for:
• All people on registration for surgeries

• All people in care homes on admission
• All hospital inpatients on admission
• All outpatients at their first appointment and upon clinical concern
Malnutrition is any condition caused by an in-balance between what individual eats and
what that individual requires to maintain health. This can result from eating too little (under-
nutrition) or too much (over-nutrition) and may also be caused by an incorrect balance of
nutrients. Malabsorption conditions (e.g., Coeliac disease and Crohns disease caused by failure
to digest and/or absorb ingested nutrients). Under-nutrition may result from eating disorders
such as anorexia nervosa and bulimia nervosa or more commonly from reduced availability of
food such as occurs in many developing countries producing the condition known as protein-
energy malnutrition.
Protein-energy malnutrition
This covers a spectrum of clinical conditions seen in starving adults and children. Starvation
in adults leads to loss of weight due to loss of subcutaneous fat and muscle wasting. They
complain of cold and weakness. Infections of the GI tract and lungs are common.
Marasmus: is the type of protein-energy malnutrition most commonly seen in children under
the age of 5. The child looks emaciated with obvious signs of muscle wasting and loss of body
fat although there is no edema. The hair is thin and dry, diarrhea is common and anemia may
be present.
Kwashiorkor: occurs typically in a young child displaced from breastfeeding by a new baby
and fed a diet with very low protein content, such as cassava. The child is apathetic, lethargic
and anorexic (loss of appetite). There is generalized edema. The abdomen is distended owing
to hepatomegaly (enlarged liver) and/or ascites (accumulation of fluid in peritoneal cavity). The
serum albumin is always low and anemia is common.
16
Lecture notes
Homeostasis, Control Systems and Biological Rhythms
The term homeostasis is derived from Greek words for same and state. It is sometime known
as a steady state through this is not strictly correct. The concept of homeostasis underpinning
all physiology was developed by Claude Bernard, a French physiologist working in the 19
century. One of his famous statements: the constancy of the internal environment is the
condition for a free and independent life Homeostasis then is the control of the internal
environment within set limits and is a dynamic equilibrium rather than a fixed steady state.
Homeostatic mechanisms are operating continuously to counteract changes in the internal
environment. It is an important concept to understand that failure of homeostasis leads to
disease. Homeostasis operates at all levels in the body, inside cells, in organs and in the whole
body. Some examples of parameters which are under homeostatic control include: supply of
nutrients, supply of oxygen, blood flow, body temperature, removal of metabolites.
Characteristics of control systems
There are some key features which are common to all control systems, including those in
the body:
1- Communication
For a control system to operate there must be communication between the different
components. In the body the main communication pathways are the nervous system and the
endocrine system (hormones). Some hormones are released locally rather than into the blood
and they act locally, which is known as paracrine control. A variety of agents can be released
by cells which can have an effect on the releasing cell, and this is known as autocrine control.
The peripheral nervous system can be divided into the afferent branch (signal direction towards
the brain; sensory input) and the efferent branch (signal direction away from the brain; motor
output).
2- Control centre
The role of the control centre is to determine the reference set point, to analyze the afferent
input and to determine the appropriate response. Two important control centers in the brain are
the hypothalamus in the diencephalon and the medulla oblongata in the brain stem. The
hypothalamus is involved in the control of the endocrine system and regions of the medulla are
involved in the control of ventilation and the cardiovascular system. Trauma to the
hypothalamus or medulla has serious clinical consequences and is usually fatal.
3- Receptor
Sensors are required to detect stimuli such as changes in the environment. In the body
sensors are usually specialized nerve endings, such as chemoreceptor, thermo receptors,
proprioreceptors or nociceptors. Sensors communicate input to the control center via afferent
nerves.
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4- Effecter
Effectors are agents that cause change. The control centre produces an output which is
communicated via efferent pathways to effectors. For example, in the body effectors could be
sweat glands which are activated to produce more sweat which causes heat loss via
evaporation. The loss of this response in paraplegic patients seriously reduces their ability to
lose heat.
Feedback
Feedback is also an important feature of control systems. In feedback, the output (effect) has
an effect on the control centre. In negative feedback the output inhibits the function of the
control centre and the effecter acts to oppose the stimulus.
Negative feedback gives stability to control systems and allows the set point to be controlled
within fine limits. An example of negative feedback in the body would be hyperglycaemia
stimulating the release of insulin from beta cells in the Islets of Langerhans in the pancreas,
which acts to decrease the level of glucose in the blood, thus returning the glucose level to the
normal range. A feature of negative feedback is a tendency to overshoot the set point several
times until the system returns to rest at the set point. This is known as hunting behavior and is
indicative of a dynamic equilibrium.
In positive feedback (sometimes known as positive feed-forward) the stimulus produces a
response which increases its effect, rather than counteracts it i.e., the output adds on to the input.
Clearly the system will rapidly go out of control under these circumstances. So positive
feedback can cause a rapid, catastrophic change (change in state).
Fortunately, there are not many examples of positive feedback in the body. One example is
blood clotting, which involves a complex signaling cascade incorporating positive feedback
resulting in a change of state in blood from liquid to solid. Failure of the clotting mechanism
can cause hemorrhage. Another example is ovulation in which a buildup of the hormone follicle
stimulating hormone (FSH) causes release of an oocyte from a follicle in the ovary.
Please note that many textbooks use the example of oxytocin released during labor as an
example of positive feedback. Historically this is known as the Ferguson reflex, however recent
research has suggested that this reflex may not be important in humans, although it is in other
mammals.
Biological Rhythms
Rather than the set point being a fixed, steady value it can vary over time, giving rise to
biological rhythms. For example, the levels of the hormone cortisol in the blood vary during
the day from a peak at about 7:00 am to a trough at about 7:00 pm. For this reason, the time
should always be noted when taking a sample of blood for cortisol measurement and repeated
measurements should be taken at the same time of day.
The menstrual cycle is an obvious example of a biological rhythum and women's core body
temperature varies during the cycle. A sudden increase in core body temperature can be used
as a marker of ovulation. There is a ‘biological clock’ in the brain which has been narrowed
down to a small group of neurones in the suprachiasmatic nucleus in the hypothalamus, but it
is still not understood how it works.
18
Recent research has shown that humans have a free-running time (natural diurnal cycle) of
24 hours 11 minutes. Keys from the environment (called Zeitgebers) keep us on a 24 hour cycle.
In these days of long haul flights it is possible to move across many time zones quickly. This
results in a mismatch between environmental keys and our ‘body clocks’, causing ‘jet lag’. It
is known that a hormone called melatonin released from the pineal gland in the brain is involved
in setting the biological clock, but beyond that this hormone is still a mystery.
Homeostasis in the Body
Homeostasis occurs continuously at all levels from cells up to the whole body. For example,
in cells the level of free calcium ions (Ca+2) in the cytoplasm is finely controlled at around 7-
10 M. Increases in Ca+2 is used as a signaling system in cells, for example initiating the
contraction process in muscle. At the organ level many parameters are under homeostatic
control. In working skeletal muscle, local blood flow is adjusted by auto-regulation depending
on the metabolic demands. At the whole body level thermoregulation is a good example of
homeostasis involving negative feedback.
Key point: it is important to understand the concept that homeostasis underpins

physiology and that a failure of homeostasis leads to a disease.
Thermoregulation
Measurement of core temperature
The normal range of core temperature is 36.1 - 37.8 °C. The most common method of
measuring core temperature clinically is by infrared measurement of the temperature of the
tympanic membrane. This is close to the core temperature, but is slightly lower.
Hyperthermia
Hyperthermia is defined as a core temperature above 38°C. Core temperatures above 40°C
can be life-threatening. At 41°C, brain death begins, and at 45°C death is almost certain. Internal
temperatures above 50°C will cause rigidity in the muscles and certain, immediate death. A
condition called malignant hyperthermia is a rare complication in anesthesia, which can be
triggered by some anesthetic agents in susceptible individuals. Artificially induced
hyperthermia can be used in the treatment of some cancers. Research has shown that
radiotherapy and chemotherapy can be more effective in a higher core temperature
environment.
Pyrexia
The body's normal response to infection is to raise core temperature to a higher set point,
causing fever (pyrexia). This is affected by an inflammatory mediator called prostaglandin E2
acting on the thermoregulatory centre in the hypothalamus. The increased metabolic rate which
results from the raised temperature is beneficial for components of the immune system in
combating the infection. Ironically perhaps, the usual treatment for pyrexia is to give an
antipyretic drug such as paracetamol or ibuprofen which inhibits the production of
19
prostaglandins and reduces core temperature. Of course, high degrees of fever can be life-
threatening and urgent treatment is required.
Classification of fever
Grade °C
Low grade 38 - 39
Moderate 39 - 40
High grade 40 - 41
Hyperpyrexia > 41
Hypothermia
Hypothermia is defined as a core temperature of less than 35°C. At a lower temperature the
metabolic rate decreases and the oxygen demands of tissues decrease. This is why some
patients can be successfully revived after relatively prolonged periods of hypothermia.
Artificially induced hypothermia which lowers the metabolic demands and can reduce cell
damage has been used in the treatment of stroke, traumatic head injury and preterm infants.
Cooling of the brain has been found to be beneficial in reducing tissue damage following
trauma. Cooling is also used in brain and cardiac surgery to reduce tissue damage.
Body Water Homeostasis
Normally the total body water is 50-60% of the lean body weight in men and 45-50% in
women. In a healthy 70 Kg male the total body water is ~ 42 liters, which is contained in three
main compartments:
1- Intracellular fluid (~28 liters, ~35% of lean body weight)
2- Extracellular fluid- the interstitial fluid (~9.4 liters, ~12%)
3- Blood plasma-extracellular (~4.6 liters, ~4-5%
Gaining an understanding of these compartments will be useful for when you study
pharmacology later on the course. The movement of water between these compartments is
governed partially by osmotic pressure and the osmotic pressure of the blood is carefully
controlled within set limits. The control of osmotic pressure and blood volume is complex and
will be covered in more detail in the Cardiovascular and Urinary Modules later in the course.
The osmolality and sodium ion concentration of blood plasma is monitored constantly by
osmoreceptors in the supraoptic and paraventricular nuclei of the hypothalamus. Cells in these
nuclei influence feelings of thirst and also release a hormone form the posterior pituitary gland
called anti-diuretic hormone (ADH), also known as vasopressin. ADH has an effect on the
kidney, causing an increase in the permeability of the collecting ducts to water, thus increasing
the reabsorption of water from the urine into the blood. This has the effect of making the urine
more concentrated and decreasing the loss of water in the urine. The mechanism will be covered
in detail in the Urinary Module. This control system is important clinically as dehydration is
quite common, particularly among elderly in-patients in hospital and in infants. Increased thirst
can be a presenting factor for a range of disease states.
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Example of a control system: the Hypothalamic-Pituitary-Adrenal Axis
The hypothalamic-pituitary-adrenal (HPA) axis is a good example of an important control

system in the body involving negative feedback. The hypothalamus controls the endocrine
system via the anterior pituitary gland. In the HPA axis corticotrophin releasing hormone (CRH;
also known as corticotrophin releasing factor, CRF) is released from the hypothalamus into the
local portal circulation. CRH binds to specific receptors on corticotroph cells of the anterior
pituitary gland which stimulates the release of adrenocorticotrophic hormone (ACTH) into the
circulation. ACTH is transported in the blood to the cortex of the adrenal glands where it binds
to specific receptors on cells in the zona fasciculata and stimulates the release of cortisol into
the circulation. Negative feedback occurs at two levels in the HPA axis: ACTH inhibits release
of CRH and cortisol inhibits the release of CRH and ACTH. Activation of the HPA axis is part
of the body's normal response to stress and levels of ACTH and cortisol in the blood correlate
with stress levels. The HPA axis will be covered again in more detail towards the end of the
module and you will be expected to know about the HPA axis, due to its importance.
21
Group work
BMI, Obesity and Malnutrition

Case Study 1
Ahmed, a 19-year-old male student consulted a physician due to that he had gained so much
weight since going to the University that his clothes no longer fitted. He was living in a Hall of
Residence and took very little regular exercise. The physician weighed him, measured his
height and took a simple dietary history. His findings were:
Height = 170 cm
Weight = 90kg
Daily energy intake ~ 15,000 kJ
Daily intake of carbohydrate ~300g
Daily intake of fat ~ 200g
Daily intake of protein ~ 30g
a. What is Ahmad's body mass index?
b. What do you conclude from the value of his BMI (reference value = 18.5-24.9) and the
information in the history?
c. How much energy did Ahmed obtain each day from the carbohydrate and lipid that he
consumed?
d. The energy content of the carbohydrate and fat he consumed each day is less than his total
daily energy intake. Where could any extra energy have come from?
e. List three aspects of Ahmed's diet that give you cause for concern.
f. What would be your dietary and lifestyle advice to this young man?
22
Case Study 2
In famines in the arid north-eastern region of Ethiopia and in the humid equatorial southern
region of Sudan, protein-rich food supplements were used by the aid agencies. Famine relief
workers in Ethiopia reported that about 80% of the children in their region were saved by the
food supplements. In contrast, the famine relief workers in Sudan found that less than 15%
survived and they even claimed that the protein appeared to have hastened the children's deaths.
Striking difference was noticed in the physical appearance of many of the children before the
food supplements were given. The children in Ethiopia were clearly emaciated (wasted),
whereas the Sudanese children often had a deceptively plump appearance with swollen
abdomens and oedematous limbs. The Sudanese children were found to have much lower serum
albumin concentrations than the Ethiopian children (~20 g/L compared with 30 g/L, the
reference mean being ~40 g/L). In addition, the livers of the Sudanese children, unlike those of
the Ethiopian children, contained significant amounts of fat (Fatty Liver). In contrast to the
situation in Ethiopia, starchy food was available to the Sudanese children. However, as a result
of poor storage in humid conditions, the food was contaminated by fungal toxins (aflatoxins).
The metabolism of aflatoxins in the liver produces toxic intermediates that damage the liver by
binding to DNA and impairing gene expression.
a. What nutritional deficiencies were the Ethiopian children likely to have been suffering from?
b. What is the basic biochemistry behind the Ethiopian children's emaciated (wasted)
appearance?
c. What does fatty infiltration of the Sudanese children's liver suggest about their liver function?
d. What reasons could there be for the reduced liver function in the Sudanese children?
23
e. Why did the Sudanese children have very low serum albumin concentrations?
f. Why did the Sudanese children have oedema and swollen abdomens?
g. Is it likely that the plumpness of the Sudanese children masks underlying muscle wasting and
poor growth? Explain you answer.
h. Both groups of children were weak and lethargic. What are the likely reasons for this?
i. Would you expect the malnourished children to be more susceptible to infection than well-
nourished children? Explain your answer.
24
j. What is the fate of protein supplied in excess of the body's immediate requirement?
k. Why was feeding protein-rich food detrimental to the Sudanese children?
l. How would you recommend the Sudanese relief workers modify their feeding procedures in
the future?
25
Self-assessment
You should answer these self-assessment questions to ensure that you can meet the learning
objectives for this session.
a. What are the essential components of a normal healthy diet? Explain why they are essential.
b. Explain the clinical consequences of severe protein deficiency in children.
c. Define the components of your daily energy expenditure.
d. Define obesity. List four chronic diseases for which obesity is a risk factor.
e. Define catabolism and explain how it differs from anabolism? Explain why catabolism is
generally inhibited by high-energy signals and activated by low-energy signals.
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f. Define homeostasis
g. List four key components of control systems
h. Briefly discuss one example of negative feedback and one example of positive feedback
i. Describe in outline the hypothaamic-pituitary-adrenal (HPA) axis.
27
Session Two
Cell Metabolism
Carbohydrate Metabolism 1
Aims of the session

The aim of this session is that you should understand the important features of cell
metabolism, the basic structure of carbohydrates, and how they are metabolized within cells.

08:00-09:00 Lecture: Cell metabolism, bioenergetics, energy balance
09:00-10:00 Lecture: Carbohydrate metabolism 1
10:30-01:30 Group Work: Case study: gastroenteritis, pyrexia
Intended learning outcomes

• Define cell metabolism and explain its functions.

• Describe the origins fates of cell nutrients.
• Describe the relationship between catabolism and anabolism.
• Explain why cells need a continuous supply of energy.
• Explain the biological roles of ATP, creatine phosphate and other molecules containing
high energy of hydrolysis phosphate groups.
• Explain the roles of redox reactions and H-carrier molecules in metabolism.
• Explain the roles of high and low energy signals in the regulation of metabolism.
• Describe the general structures and functions of carbohydrates.
• Describe how dietary carbohydrates are digested and absorbed.
• Explain why cellulose is not digested in the human gastrointestinal tract.
• Describe the glucose-dependency of some tissues.
• Describe the key features of glycolysis.
• Explain why lactic acid (lactate) production is important in anaerobic glycolysis.
• Explain how the blood concentration of lactate is controlled.
Directed study: You should prepare the case study of galactosaemia and prepare answers to
the questions. Your answers will be reviewed during the Group Work during Session 3.
Self-assessment: You should answer the self-assessment questions to ensure that you can meet
the learning objectives for the Session.
Reading:
Marks Essential of medical biochemistry, chapter 3, chapter 18, chapter 23.
Ganong's Review of Medical Physiology Chapter 1
Medical physiology Boron and Boulpaep Chapter 5
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Lecture notes
Cell metabolism
Cell nutrients
The blood normally contains a wide range of chemical substances. Some of these are
required by the cells of the body (cell nutrients) to maintain normal cell function; others include
waste products produced by cells. Clinician’s measure some of these substances as an aid to the
diagnosis of metabolic diseases and in monitoring patient treatment.
The blood concentration of cell nutrients and their waste products is normally held relatively
constant but changes do occur under a variety of situations. Physiological changes are seen after
meals, during fasting, starvation, exercise, pregnancy and stress. Pathological changes are seen
in diabetes, atherosclerosis, obesity, shock, malnutrition and certain enzyme deficiency states.
Clinically important cell nutrients and waste products
Nutrient/waste product Normal fasting plasma concentration
mmol/L mg/dL
Glucose 5 90
Amino acids 3 40
Triacylglycerols 2 150
Cholesterol 5 200
Fatty acids 0.5 30
Lactic acid < 1.0
Total CO2 (Mostly HCO3 -) 27
Urea 5 30
NH3 25 µM
Origins and fates of cell nutrients
Cell nutrients circulating in the blood come from a variety of sources:

• The diet
• Synthesis in body tissues from precursors (not essential fatty acids or amino acids)
• Released from storage in the body tissues
They are on their way to body tissues where they undergo various chemical transformations
(metabolism) including:
• Degradation to release energy-all tissues.
• Synthesis of cell components- all tissues except mature erythrocytes.
• Storage-liver, adipose tissue, skeletal muscle.
• Interconversion to other nutrients liver, adipose tissue, kidney cortex.
• Excretion-liver, kidney, lungs.
29
Cell metabolism
Cell metabolism is defined as the highly integrated network of chemical reactions that occur
within cells. The network consists of a number of distinct chemical pathways (metabolic
pathways) which link together. The network can be described using metabolic maps-the wiring
diagrams or route maps of the cell. So pathways of the network occur in all cells whilst
others are confined to cells with specific functions.
Functions of cell metabolism
Cells metabolize nutrients to provide:

• Energy for cell function and synthesis of cell components (ATP)
• Building block molecules that are used in the synthesis of cell components needed for
the growth, maintenance, repair and division of the cell.
• Organic precursor molecules that are used to allow the inter-conversion of building
block molecules (e.g., acetyl-CoA).
• Biosynthetic reducing power in the synthesis of cell components (NADPH).
Simple overview of metabolism
30
Catabolism and Anabolism
Cell metabolism consists of pathways in which the overall reaction is the breakdown of
larger molecules into smaller ones (catabolism, catabolic pathways) linked to those in which
smaller molecules are built up into larger ones (anabolism, anabolic pathways). In general,
catabolic pathways are oxidative, release large amounts of free energy (some of which is
conserved as ATP) and produce intermediary metabolites. In contrast, anabolic pathways are
usually reductive and use the intermediary metabolites and energy (ATP) produced by
catabolism to drive the synthesis of important cell components.
Biological oxidation
Cells release the energy from fuel molecules by oxidation reactions that involve removal of
electrons (e-) or removal of H-atoms (H+ + e-). All oxidation reactions are accompanied by
reduction reactions (REDOX reactions). Oxidation involves the addition of oxygen or the
removal of H atoms or electrons, whereas reduction involves the addition of H atoms or
electrons or the removal of oxygen. When fuel molecules are oxidized (A-2H→A) H-atoms are
transferred initially to carrier molecules that become reduced (C→C-2H).
The major carrier molecules are:

Carrier Oxidized form Reduced form
Nicotinamide adenine dinucleotide NAD+ NADH + H+
Nicotinamide adenine dinucleotide phosphate NADP+ NADPH + H+
Flavin adenine dinucleotide FAD FADH2
NAD+, NADP+ and FAD are complex molecules which contain components that cannot be
synthesized in the body and have to be supplied in the diet (vitamins). Nicotinamide comes
from the vitamin niacin and flavin from the vitamin riboflavin. The total concentration of carrier
molecules in cells (oxidized form plus reduced form) is constant. Thus, for example, if all of
the NAD in the cell was in the reduced form (NADH), oxidation reactions which require NAD+
would not be possible as there would be no NAD+ available. Thus, carrier molecules must cycle
between oxidative and reductive processes if cell function is to be maintained. They therefore
act as carrier of reducing power.
31
The reactions that serve to deoxidize reduced carrier molecules include:

• Cell respiration: NADH and FADH2 formed during catabolism are oxidized in a series
of reactions (electron transport) that ultimately reduce oxygen to water (as above). The
free energy released is used to drive ATP synthesis and the oxidised carriers (NAD+ &
FAD) can be reused in catabolism.
• Reactions in which the substance is reduced (use NADH or FADH2)
CH3COCOOH + NADH + H+ CH3CHOHCOOH + NAD+

(Pyruvic acid) (Lactic acid)
• Biosynthetic reactions involving reduction steps

(use NADPH): fatty acid and cholesterol synthesis require NADPH (biosynthetic
reducing power).
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Lecture notes
Bioenergetics
In the cell, reactions that release energy (exergonic reactions) are the only ones that occur
spontaneously and they provide the energy to drive the energy requiring reactions (endergonic
reactions). The energy change in a reaction is known as the enthalpy change (ΔH) and this
represents the difference in energy between the products and reactants of a reaction. When
energy is released the enthalpy change is given a negative sign (ΔH is -ve). However, not all of
the energy released is available to do work. This is because some of the energy may appear in
the form of a decrease in entropy (ΔS). Entropy is a measure of the disorder of the products
relative to reactants and it is given a positive sign when there is an increase in disorder (ΔS =
+ve)
Free energy
The energy released in an exergonic reaction that is available to do work is known as free
energy (sometimes called Gibbs free energy). The free energy change (ΔG) of a reaction is
related to the enthalpy and entropy changes (ΔH and ΔS) by the equation:
ΔG = ΔH - TΔS where T is the temperature in K (o C + 273)
A reaction can only occur spontaneously when ΔG is -ve i.e. free energy is available to do
work. If ΔG is +ve an input of free energy is needed to drive the reaction. The free energy
changes of a reaction when measured under standardized conditions of temperature (25 o C),
concentration of reactants and products (1M) and pH (7.0) is known as the standard free energy
change (ΔGo’) however the actual free energy change of a reaction (ΔG), under the conditions
that occur in the cell, can be different from the standard free energy change as the temperature
is 37o C and the concentration of reactants and products is never 1M (see appendix v).
Coupling of exergonic to endergonic reactions; the roles of ATP and ADP
ATP (adenosine triphosphate) and ADP (adenosine diphosphate) play a major role in
coupling the free energy released during the catabolism of fuel molecules to the energy
requiring activities of the cell. ATP and ADP differ only in the number of covalently-liked
phosphate groups they contain and are related by the following simplified equations where Pi
= phosphate (HPO4-2)
Go = +31kJ/mol equation
Go = -31kJ/mol equation
Go = -31kJ/mol equation
The free energy available when fuel molecules are oxidized during catabolism is used to
drive the synthesis of ATP from Pi and ADP (eq.1). Part of this energy is conserved as the
33
chemical bond energy of the covalent bond that links the terminal phosphate group to the rest
of the ATP molecule. This energy is released when the phosphate group is removed by
hydrolysis (eq.2). Since relatively large amounts of free energy are available during this
reaction the bond is known as a “high energy of hydrolysis bond” (~). This is a limited amount
of ATP and ADP in the cell and the concentration of ATP is only sufficient for a few seconds
of energy requiring cellular activity. Hence ATP must be rapidly re-synthesized from ADP
using the free energy released by the catabolism of fuel molecules. Thus, ATP acts as a carrier
of free energy not a store. The rate of ATP turnover in cells is very high as energy is required
to drive the various activities that occur in cells.
High energy and low energy signals
Catabolic pathways are generally activated when the concentration of ATP falls and the
concentration of ADP and/or AMP increases. Anabolic pathways tend to be activated when the
concentration of ATP rises. ATP is known as a high-energy signal because it signals that the
cell has adequate energy levels for its immediate needs. ADP and AMP are low-energy signals
because they signal the opposite. Other high-energy signals include NADH, NADPH and
FAD2H while NAD+, NADP+ and FAD are considered to be low-energy signals.
Free energies of hydrolysis and phosphoryl-group transfer potential

In addition to ATP a number of other phosphorylated compounds have high energies of
hydrolysis (large –ve ΔG0 values). The phosphorylated components can be arranged in order
of decreasing –ve. ΔG0 values for hydrolysis of phosphate group (Pi):
Compound/hydrolyzed product G0 (kJ/mol)

Phosphoenolpyruvate → pyruvate + Pi -62
1.3 bisphosphoglycerate → 3-phosphoglycerate + Pi -49
Creatine phosphate → creatine + Pi -43
ATP → ADP + Pi -31
Thermodynamically spontaneous phosphoryl-group transfer can occur in a down-wards

direction e.g.
Bisphosphoglycerate + ADP → ATP + pyruvate
1, 3-bisphosphoglycerate + ADP → ATP + 3-phosphoglycerate
Creatine phosphate + ADP → ATP + creatine
The first two reactions are important in producing ATP from ADP in glycolysis via a process
called substrate level phosphorylation
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Creatine phosphate
The reaction of creatine phosphate with ADP is reversible in muscle cells as in the following:
Creatine kinase
Creatine + ATP Creatine phosphate + ADP
When the concentration of ATP is high it can be used to drive the synthesis of creatine
phosphate from creatine. ATP can then be regenerated by the reverse reaction when its
concentration falls. Creatine phosphate can thus act as a small store of free energy in muscle
cells (skeletal & cardiac). This store is important in the first few seconds of vigorous muscle
activity such as sprinting. Creatine and creatine phosphate both undergo non-enzymatic
chemical changes producing creatinine. Creatinine has no function in the body and is readily
excreted via the kidneys in the urine. The rate of production of creatinine is proportional to the
concentration of creatine in muscle and this is related to skeletal muscle mass.
The daily creatinine excreted by males (20-26 mg/kg/24hr) is usually greater than that
excreted by females (14-22 mg/kg/24hr). The daily excretion of creatinine can be used as an
indicator of skeletal muscle mass and increased excretion of creatinine may indicate active
muscle wasting. Measurements of the concentrations of creatinine in blood and urine can also
be used as an indicator of kidney function since the kidney is normally very efficient at
removing creatinine from the blood. Thus, an abnormally high blood creatinine with low
urinary creatinine concentration may indicate reduced kidney function.
35
Lecture notes
Carbohydrate metabolism 1
Overview of Catabolism
Dietary carbohydrates
Carbohydrates are polyhydroxy alcohols that:

• Have the general formula (CH2O) n.
• Contain an aldehyde (-CHO) or keto (-C=O) group and multiple hydroxyl groups (-OH).
• Exist as mono, di, and polysaccharides.
A typical Eastern diet contains ~ 600g of digestible carbohydrate per day (starch, glycogen,
sucrose & lactose) plus variable amounts of indigestible carbohydrates such as cellulose. In
spite of this large intake, the body contains relatively little carbohydrate (~1% wet weight).
This is because most of the dietary carbohydrate is used as a fuel by tissues and is oxidized to
CO2 and H2O. However, a small amount of carbohydrate is present in the body stored as
glycogen (~300g) and as a component of cellular polymers such as nucleic acids, glycolipids
and glycoproteins. Excess carbohydrate in the diet is converted to glycogen for storage and
once the glycogen stores are full storage will be shifted to triacylglycerols that stored in adipose
tissue.
36
Monosaccharides (simple sugar molecules)
These can contain from 3 to 9 C-atoms although the most commonly occurring sugars are
trioses (C3) e.g., glyceraldehyde, pentoses (C5) e.g., ribose and hexoses (C6) e.g., glucose.
They are either aldoses (derived from glyceraldehyde) or ketoses (derived from
dihydroxyacetone):
All monosaccharides, except dihydroxyacetone, contain asymmetric C-atoms (four different

groups attached to a C-atom) and therefore exist as stereoisomers (enantiomers/mirror-images)
with D- and L- forms related to D and L-glyceraldehyde. The natural forms are D.
Monosaccharides can be drawn as open chain molecules but they exist largely as ring structures
in which the aldehyde (or ketone) group has reacted with an alcohol group on the same sugar
to form a hemiacetal (hemiketal) ring. The formation of a ring structure creates a new
asymmetric C-atom at C-1 of an aldose or C-2 of a ketose. This C-atom is known as the
anomeric C-atom and can have two forms: α or β. Enzymes are able to distinguish between
these two structures and will preferentially use one or the other.
The major hexose found in blood is glucose and it is always present (~5mM). In addition,
fructose and galactose may appear for short periods depending on the dietary intake of fruit and
dairy products. Excessive amounts of galactose and fructose in the blood are associated with a
number of clinical problems (e.g., Galactosaemia, Fructose intolerance) as are the persistently
high levels of glucose (≥8.0 mmol/L) seen in untreated diabetes.
Sugars have a number of important physico-chemical properties including:
o Hydrophilic-water soluble, attract water, do not readily cross cell membranes.
o Partially oxidized-need less oxygen than fatty acids for complete oxidation.
37
Disaccharides
Disaccharides are formed by the condensation of two monosaccharides with the elimination
of water and formation of an O-glycosidic bond. The major dietary disaccharides are sucrose
(glucose-fructose) and lactose (glucose-galactose). In addition, maltose (glucose-glucose) is
produced during the digestion of dietary starch. Disaccharides can be non-reducing if the
aldehyde or ketone groups of the two sugars are both involved in forming the glycosidic bond
(e.g., sucrose).
Polysaccharides
Polysaccharides are polymers of monosaccharide units linked by glycosidic bonds. Most

are homopolymers made by the polymerization of one type of monosaccharide.
Glycogen is a polymer of glucose found in animals. The glucose units joined together in -
1,4 and -1,6 glycosidic linkages (10:1) and it has a highly branched structure. It is the major
store of glucose in the human body and is synthesized in liver and skeletal muscle where it is
stored as granules.
Starch is a polymer of glucose found in plants. It consists of a mixture of amylose (α-1,4
linkages) and amylopectin (α-1,4 and -1,6 linkages). Starch can be hydrolyzed to release
glucose and maltose by digestive enzymes in the human gastrointestinal tract.
Cellulose is also a polymer of glucose found in plants where it has a structural role. The
glucose units are joined by β-1, 4 linkages to form long linear polymers. The healthy human
diet contains significant amounts of cellulose. However, the human gastrointestinal tract does
not produce enzymes that are able to hydrolyze β-1, 4 linkages and cellulose cannot be digested.
It thus forms a major component of the dietary fibre that is important for normal gastrointestinal
function.
Stage 1: Metabolism (Digestion and absorption) of dietary carbohydrates
Dietary polysaccharides (starch & glycogen) are hydrolysed by glycosidase enzymes to

release glucose, maltose and leave smaller polysaccharides (dextrins). The process begins in
the mouth with salivary amylase and continues in the duodenum with pancreatic amylase.
Digestion of maltose, dextrins and the dietary disaccharides lactose and sucrose occurs in the
duodenum and jejunum. The glycosidase enzymes involved are large glycoprotein complexes
that are attached to the brush border membranes of the epithelial cells lining these regions. The
major enzymes are maltase, lactase, sucrase, isomaltase, and trehalase; they release the
monosaccharides glucose, galactose and fructose. The activity of lactase is high in infants but
decreases in childhood in most populations except Northern Europeans. Low activity of lactase
is associated with a reduced ability to digest the lactose present in milk products and may
produce the clinical condition of lactose intolerance (Marks’, p 501-502).
Sugar absorption
Glucose, galactose and fructose are actively transported (i.e. against their concentration
gradient) into the absorptive cells lining the gut. Transport from the absorptive cells into the
blood and from the blood into tissues (i.e. down a concentration gradient) is by facilitated
38
diffusion and involves a family of glucose transport proteins (GLUT1- GLUT 5). The affinity
for glucose and relative activities of these glucose transport proteins differs between tissues and
reflect differences in the requirements of the tissues for glucose. Of particular importance is the
sensitivity of the glucose transport process in skeletal muscle and adipose tissue (GLUT 4) to
the presence of insulin, since high levels of insulin increase the uptake of glucose into these
tissues by increasing the number of glucose transport proteins in the plasma membrane.
Glucose requirements of tissues
All tissues can remove glucose, galactose and fructose from the blood. However, while all
tissues metabolize glucose, the liver is the major site of fructose and galactose metabolism.
Glucose is the major sugar in the blood and its concentration is normally held relatively
constant. This is because some tissues have an absolute requirement for glucose and the rate of
glucose uptake into these tissues is dependent on its concentration in the blood. The minimum
amount of glucose required by a healthy adult on a normal diet is ~180 g/day:
o ~ 40 gram is required by tissues which can only use glucose such as red blood cells,
white blood cells, kidney medulla, and lens of the eye.
o ~140 gram required by the central system and this normally prefers glucose.
o Variable amount is required by tissues for specialized functions e.g., synthesis of
triacylglycerols in adipose tissue requires glucose metabolism to provide glycerol
phosphate.
Stage 2: Metabolism of glucose in tissues (intracellular)

There are a number of pathways that glucose can enter in tissues. These include glycolysis,
pentose phosphate pathway, conversion to glycogen for storage and conversion to other sugars
such as galactose. The importance of these pathways varies in different tissues.
Glycolysis
Glycolysis is the central pathway in the catabolism of all sugars it is characterized by:
(1) It is carried out in the cytosol of all cells.
(2) The function of glycolysis is to produce energy (ATP) and provide cells with essential
metabolites, in particular trioses.
(3) Consists of 10 reactions, 3 of them are irreversible, the 1st, 3rd and 10th reactions.
They are catalyzed by allosteric enzymes, i.e., hexokinase (HK), phosphofructokinase
(PFK), and pyruvate kinase (PK). They are used to control the rate of the pathway.
The remaining 7 reactions are reversible.
(4) It can be taken place either aerobically or anaerobically.
o Aerobic glycolysis is carried out in all cells (except red blood cells) under conditions
of normal oxygen supply, as in the following equation:
Glucose + 2ADP + 2Pi + 2NAD+ + 2H+ → 2pyruvate + 2ATP + 2NADH
o Anaerobic glycolysis is carried out in red blood cells (no mitochondria), and cells
exposed to conditions of low oxygen supply (Hypoxia), e.g., contracted muscles
under vigorous exercise, septic shock and cancer cachexia, as in the following
equation:
Glucose + 2ADP + 2Pi → 2lactate + 2ATP + 2H2O
39
(5) Cellular uptake of glucose is enhanced by insulin in all cells except liver, brain, RBCs,
and pancreatic β-islet cells. Thus, the availability of glucose in the latter cells is
independent on insulin, while that of the former is dependent.
(6) Conversion of glucose to G-6-P (1st Rx) is achieved by the action of hexokinase (HK)
that found in all cells, and its isoenzyme, glucokinase (GK) which is present only in
liver. Km (the substrate concentration that exhibits half of maximal velocity) values of
the two enzymes are;
o Glucokinase (liver) = 10-2 M (Low affinity)
o Hexokinase (Brain) = 10-5 M (High affinity)
In the liver hexokinase is saturated under normal conditions, and acts to provide G-6-P at
constant rate to meet the need of the cells. Glucokinase has low affinity, not saturated, so its
activity increases when the load of glucose in the hepatocytes is high (postprandially). Thus,
the difference between the two enzymes is that HK acts to continue glycolysis, while GK is
involved in the decreasing of the blood glucose level after a meal.
(7) Phosphorylation of glucose has a number of important functions:

o Makes the sugar anionic (-ve charge)-prevents it crossing the plasma membrane
o Increases the reactivity of the sugar so that it can be metabolised by several pathways
including glycolysis, glycogen formation and pentose phosphate.
o Allows formation of compounds with high phosphoryl-group transfer potential that
can transfer their phosphate group to ADP to form ATP (substrate level
phosphorylation).
(8) The rate of the pathway is controlled by regulation of the activity of the allosteric
enzymes.
o HK is inhibited by the product G-6-P.
o PFK is inhibited by citrate and by normal cellular concentration of ATP (negative
allosteric effecter), this inhibition is relieved by 5-AMP (positive allosteric effecter). It
is also regulated hormonally in liver (insulin stimulates and glucagon inhibits). Reaction
3 is the first reaction unique to glycolysis. It is known as the committing step since it
commits glucose to metabolism via glycolysis.
o PK is regulated by covalent modification; thus, phosphorylation deactivates this
enzyme.
(9) NADH produced is converted back to NAD+ in the lactate dehydrogenase reaction (LDH)
in which pyruvate is reduced to lactate. This enables anaerobic glycolysis to continue to
generate the ATP needed for cell function.
CH3COCOOH + NADH + H+ CH3CHOHCOOH + NAD+
(10) In red blood cells, the first site of ATP formation may be bypassed. 1, 3-
bisphosphoglycerate is converted to 2, 3-BPG by BPG mutase. 2, 3-BPG can bind to
hemoglobin, decreasing its affinity for oxygen, and making it available to tissues in some
circumstances for example high altitude areas.
40
41
Significance of lactate production
Under normal physiological conditions ~50g of lactate are produced every day by tissues
such as red blood cells, skin, brain, skeletal muscle and the gastrointestinal tract. This lactate is
released into the circulation and transported to the liver and heart muscle where it is converted
back to pyruvate and oxidized to CO2 (heart muscle) or converted to glucose (liver). Under
these conditions, the rate of lactate production equals the rate of utilization and the plasma
concentration remains relatively constant (<1mM). Elevations of plasma lactate are seen in a
number of physiological and pathological conditions. Normally such elevations are only
significant if they are greater than 5mM since this exceeds the renal threshold for lactate and it
also begins to affect the buffering capacity of the plasma causing lactic acidosis. Situations in
which there may be a marked increase in plasma lactate due to increased production include
strenuous exercise (up to 10 g/min), hearty eating, shock and congestive heart disease. Increases
due to decreased utilization occur in liver disease, thiamine deficiency and during alcohol
metabolism.
42
Group work
Diet Analysis
Hopefully you have kept a record of what you have eaten and drunk for 3 days in the Food
Diary supplied in the Appendix of the Module Workbook.
a. Do you think your diet is nutritionally balanced? YES/NO
b. What changes could you make to ensure it is healthier?
c. What stops you from making healthy food choices?
d. Do you think there may be additional barriers for other population groups which influence
their food choices?
e. How could that affect their health and wellbeing in the long term?
43
Reproduced with permission from Food Standards Agency (LNDS) (also see Appendix)
Leicestershire Nutrition & Dietetic Service
f. How does your diet compare with the recommendations set by the FSA?
Almost 1/3 of food eaten each day should be fruit and vegetable (5 a day)
Almost 1/3 of food eaten each day should be bread, rice; potatoes and pasta (eat at each meal).
Ideally wholegrain varieties
Meat, fish, eggs, beans at 2 meals each day
Milk and dairy foods (suggest 3 servings each day)
Small amounts of food and drinks high in fat and sugar
44
g. The Eatwell Plate does not mention fluid. How much fluid is needed each day for good
hydration?
h. What fluids are considered as good sources of hydration?
i. If a patient has a Body mass Index (BMI) of 38 what foods/food groups on the Eatwell Plate
would you suggest they eat:
More of?
Less of?
j. Patients in hospital can appear to eat well. What factors would you consider /how would
you assess if they were at nutritional risk?
45
k. Nutrition screening tools are available and widely used in hospitals and primary care. The
Malnutrition Universal Screening Tool (MUST) developed by the British Association of
Enteral and Parenteral Nutrition (BAPEN) is the nationally recognized, evidenced based tool.
Using the MUST supplied in the Appendix, score the following patient for nutritional risk:
Mr. Hassan is 70 years old. His weight is measured as 61kg.

He thinks his height is about 5'10.
He says he always weighed about 11 stone until recently when he noticed his trousers were
getting loose.
He has lost his appetite since his wife died 4 months ago.
His dentures have become loose.
He has no problems with his skin and bowels and no nausea or sickness
Score =
What does this score mean?
Based on Mr Hassan's MUST score do you think:
- The Eatwell Plate is still appropriate YES/NO
- If not, why not?
- How would you suggest Mr. Hassan's nutritional intake is improved?
- Would these suggestions be as easy to achieve if in hospital, as at home?
46
Self-assessment
objectives for the Session.
a. Explain why cells need a continuous supply of energy and list the fuel molecules that can be
used by cells.
b. Explain the biological roles of ATP and creatine phosphate.
c. Define oxidation and explain, in outline, how fuel molecules are oxidized during catabolism.
d. List the major roles of the following tissues in whole body energy metabolism: CNS, heart
muscle, skeletal muscle, liver & adipose tissue.
e. Mr. D. a 56 year-old man was admitted to hospital for an exploratory abdominal operation.
While surgery was in =progress, he suffered a coronary thrombosis (blockage of one or more
of the coronary arteries), which led to cardiac arrest. Cardiac resuscitation managed to restart
his heart after ~2 min and the surgery was concluded. Subsequent recovery was uneventful
although there was evidence of cerebral dysfunction (e.g. loss of memory) and permanent
damage to an area of his myocardium (heart muscle). Explain, in outline, why cardiac arrest
affects the heart and central nervous system more rapidly than it affects skeletal muscle.
47
f. List the major carbohydrates found in a typical Eastern diet and describe how they are
digested.
g. Diarrhoea after a children's party.
Mrs Ahlam. a 30-year-old mother of two children has made a birthday party for her young
daughter. She usually ate very little dairy products or drank much milk but, on this occasion,
she ate the same food as the children, viz. ice cream, blancmange, cream cake and she drank a
milk-shake. Several hours after the party she developed severe stomach cramps and violent
diarrhoea that lasted for approximately 24 hours. None of the children or their parents were
affected. What was the likely cause of Mrs Ahlam's illness and how would you account for her
signs and symptoms? What advice would you give her with respect to the future?
h. How does glycogen differ from cellulose? Explain why humans can digest glycogen but not
cellulose.
i. Under anaerobic conditions, the pyruvate produced by glycolysis in skeletal muscle may be
reduced to lactate. What advantage is this to the muscle cells?
j. What are the possible fates of the lactate produced by skeletal muscle under anaerobic
conditions?
48
k. Define lactic acidosis and explain why it may occur.
l. Interpret the observation that the enzyme phosphofructokinase in skeletal muscle is inhibited
by high concentrations of ATP and activated by high concentrations of AMP.
m. Compare and contrast the functions of glycolysis in adipose tissue, skeletal muscle and red
blood cells.
n. List the end-products of glycolysis under aerobic and anaerobic conditions in red blood cells
and skeletal muscle.
49
Session Three
Carbohydrate Metabolism 2
Tricarboxylic Acid Cycle, Gluconeogenesis
Aims of the session

The aim of this session is that you should understand further aspects of carbohydrate
metabolism, the processes of the tricarboxylic acid cycle and gluconeogenesis within cells

08.00 - 09.00 Lecture: Carbohydrate metabolism 2
09:00 – 10:00 Lecture: TCA cycle and gluconeogenesis
10:30 – 01:30 Group Work: Case study: galactosaemia
Intended learning Outcomes:

After this session and your self-study, you should be able to:
o Explain why the pentose phosphate pathway is an important metabolic pathway in some
tissues.
o Describe the clinical condition of glucose 6-phosphate dehydrogenase deficiency and
explain the biochemical basis of the signs and symptoms.
o Explain the biochemical basis of the clinical condition of lactose intolerance and
galactosaemia.
o Explain the key role of pyruvate dehydrogenase in glucose metabolism.
o Describe the roles of tricarboxylic acid cycle (TCA cycle) in metabolism.
o Explain how the TCA cycle is regulated
o Explain why and how glucose produced from non-carbohydrate sources.
Directed study: You should read the case study on glucose 6-phosphate dehydrogenase
deficiency and prepare answers to the questions. Your answers will be reviewed during the
Group Work of Session 4.
Self-assessment: You should answer the self-assessment questions to ensure you can meet
Reading:
Mark's essential of medical biochemistry, Chapter 19, Chapter 22, Chapter 27.
Medical Biochemistry, Baynes and Dominiczak Chapter 13, 14, 21
50
Lecture notes
Carbohydrate metabolism 2
Pentose phosphate pathway (hexose monophosphate shunt)
Not all of the glucose 6-phosphate produced in cells enters glycolysis; some is metabolized
via the pentose phosphate pathway. This is an important pathway in tissues such as the liver,
red blood cells and adipose tissue.
The major functions of the pathway are to:
o Produce NADPH in the cytoplasm. NADPH has a number of functions including the
provision of reducing power for anabolic processes such as lipid synthesis that occur
in liver and adipose tissue. In red blood cells it has an important role in maintaining
free -SH groups on cysteine residues in certain proteins. In addition, it is involved in
various detoxification mechanisms that protect cells against toxic chemicals.
o Produce the C5-sugar ribose for the synthesis of nucleotides, the building blocks from
which DNA & RNA are made. The pathway therefore has a high activity in dividing
tissues (e.g., bone marrow). The pathway, like glycolysis is an oxidative pathway that
can be considered in terms of two phases. However, unlike glycolysis there is no ATP
generation and CO2 is produced.
In phase 1, glucose 6-phosphate is oxidized and decarboxylated (oxidative decarboxylation)

by the enzymes glucose 6-phosphate dehydrogenase and 6-phosphogluconate dehydrogenase
in reactions that requires NADP+:
Glucose-6phosphate + 2NADP → →→ C5-sugar phosphate + 2NADPH + 2H+ + CO2
In phase 2, a complex series of reactions converts any unused C5-sugar phosphates to

intermediates of glycolysis:
3C5- sugar phosphate →→→→ 2fructose-6-phosphate and glyceraldehyde-3-phosphate
Thus, the overall equation for the pathway is:
3 glucose-6-phosphates + 6 NADP+
3CO + 6NADPH + 6H+ + 2fructose-6-phosphate + glyceraldehyde 3-phosphate
The pathway is regulated by controlling the activity of glucose 6-phosphate dehydrogenase, the
first enzyme in the pathway. The activity of the enzyme is controlled by the NADP+/NADPH
ratio in the cell, NADPH inhibiting and NADP+ activating the enzyme.
51
Glucose 6-phosphate dehydrogenase deficiency (G6PD deficiency)
This is an X-linked gene defect found in some populations e.g. those originating from the
Mediterranean region and black USA males. The defect is caused by point mutations in the
gene coding for glucose 6-phosphate dehydrogenase that result in reduced activity of the
enzyme in tissues such as the red blood cells and low levels of NADPH. The structural integrity
and functional activity of key proteins in these cells depends on free -SH groups. However, -
SH groups tend to form disulphide bridges unless prevented by NADPH. In RBCs, reactive
oxygen species (superoxide and hydrogen peroxide) are formed normally during the process of
oxygen transport as in the following:
Hb-Fe+2 -O Hb-Fe+3 + O2.- (superoxide anion)

This reaction is spontaneous and it takes place 1% per hour. Superoxide anion is very
reactive and harmful to the cell due to the formation of free radicals; it is inactivated by
dismutation, by a reaction catalyzed by superoxide dimutase as in the following:
2O2.- + 2H+ → H2O2 + O2
Hydrogen peroxide can also form free radicals, so that it must be inactivated by the cellular
anti-oxidant reduced glutathione (GSH). The reaction is catalyzed by glutathione peroxidase as
in the following:
2GSH + H2O2 →G-S-S-G + 2H2O
52
You have to know that glutathione is a tripeptide, has the following structure in the reduced
and oxidized forms:
Regeneration of GSH must be carried out to maintain sufficient level for normal metabolism.
It is carried out by a supply of hydrogen atoms, provided by NADPH, in a reaction catalyzed
by glutathione reductase as in the following reaction:
G-S-S-G + 2NADPH 2GSH + 2NADP+
Thus, sufficient level of NADHP is crucial for normal metabolism of RBC. If G6PDH gene
is mutated the production of NADPH may be insufficient to maintain appropriate level of
NADPH leading to the accumulation of hydrogen peroxide in RBCs. The consequence is the
oxidation of haemoglobin and other proteins. Haemoglobin becomes cross-linked by disulphide
bonds to form insoluble aggregates called Heinz bodies.
This leads to premature destruction of the red blood cells and causes haemolysis. Acute
haemolytic episodes are precipitated by chemicals that reduce NADPH levels, making them
more fragile and susceptible to hemolysis with a decrease of their life span. The result is a
pathological problem called favism, characterized by hemolytic anemia. It is precipitated by
chemicals that increase the oxidant stress (e.g. sulphonamides, aspirin, NSAIDs and
antimalarials) or when an individual have eaten fava beans which contain glycosides (vicine &
isouramil).
53
Galactose metabolism
Dietary lactose is hydrolysed by the digestive enzyme lactase to release glucose and
galactose that are absorbed into the blood stream. Galactose is metabolised largely in the liver
(some in kidney and gastrointestinal tract) by soluble enzymes that catalyse the following
reactions:
The overall reaction is:

Galactose + ATP → glucose-6-phosphate + ADP
The epimerase reaction is reversible enabling galactose to be synthesized from glucose via
UDP-glucose. This is important during lactation when breast tissue is synthesizing large
amounts of lactose for milk production. There are a number of clinical conditions that affect
galactose metabolism including Lactose Intolerance and Galactosaemia.
In Galactosaemia individuals are unable to utilize galactose obtained from the diet because
of a lack of the kinase or transferase enzyme. The absence of the kinase is relatively rare and
is characterized by accumulation of galactose in tissues. The absence of the transferase is more
common and more serious as both galactose and galactose 1-phosphate accumulate in tissues.
Accumulation of galactose in tissues leads to its reduction to galactitol (aldehyde group reduced
to alcohol group) by the activity of the enzyme aldose reductase:
54
This reaction depletes some tissues of NADPH. In the eye the lens structure is damaged,
(cross linking of lens proteins by -S-S- bond formation) causing cataracts. In addition, there
may be nonenzymatic glycosylation of the lens proteins because of the high concentration of
galactose and this may contribute to the cataract formation. The accumulation of galactose and
galactitol in the eye may lead to raised intra-ocular pressure (glaucoma) which if untreated may
cause blindness. Accumulation of galactose 1-phosphate in tissues causes damage to the liver,
kidney and brain and may be related to the sequestration of Pi making it unavailable for ATP
synthesis.
Fructose metabolism
Dietary sucrose is hydrolysed by the digestive enzyme sucrase to release glucose and
fructose. These are absorbed into the blood stream. Fructose is metabolized largely in the liver
by soluble enzymes that catalyze its conversion to glyceraldehyde 3-phosphate an intermediate
of glycolysis.
Summary of stage 2 catabolism of sugars
Metabolism of pyruvate
Pyruvate does not enter stage 3 of catabolism directly but is first converted to acetyl~CoA
by the enzyme pyruvate dehydrogenase (PDH).
Pyruvate dehydrogenase
Pyruvate dehydrogenase (PDH) is a multi-enzyme complex that catalysis the overall

reaction:
CH3COCOOH + CoA + NAD+ CH3CO~CoA + CO2 + NADH + H+
55
The structural integration of a number of enzyme activities in one multi-enzyme complex

enables a complicated reaction to be performed in a controlled manner. The reaction requires
the cofactors FAD, thiamine pyrophosphate and lipoic acid all of which act catalytically in the
reaction. Thus, four B vitamins (pantothenic acid in CoA, niacin in NAD+, riboflavin in FAD
and thiamine) are involved and the reaction is therefore very sensitive to vitamin B deficiency.
The PDH reaction cannot be reversed in the cell. There are two major consequences of
this:
o The loss of CO2 from pyruvate is irreversible.
o Acetyl~CoA cannot be converted to pyruvate and therefore cannot be converted to
glucose by the process of gluconeogenesis (to be covered in Session 4).
Summary of stage 3 catabolism of sugars
The reaction is therefore subject to control mechanisms (Marks p305-306) that ensure:
o Acetyl~CoA from the β-oxidation of fatty acids rather than from glucose is used in stage
3 of catabolism (acetyl~CoA inhibits the enzyme allosterically).
o The reaction is sensitive to the energy status of the cell (ATP and NADH inhibit and
ADP activates the enzyme allosterically).
o The enzyme is activated when there is plenty of glucose to be catabolized (insulin
activates the enzyme by promoting its dephosphorylation).
56
Lecture notes
Tricarboxylic acid cycle and Gluconeogenesis
Stage 3 of catabolism, the TCA cycle (sometimes known as the citric acid cycle or Krebs
cycle) is a central pathway in the catabolism of sugars, fatty acids, ketone bodies, alcohol and
amino acids. It is an oxidative pathway that occurs in mitochondria and requires NAD+, FAD
and oxaloacetate. The main function of the pathway is to break the C-C bond in acetate (as
acetyl~CoA) and oxidize the C atoms to CO2. The H+ and e- removed from acetate are
transferred to NAD+ and FAD. It is of fundamental importance to the major energy requiring
tissues of the body and does not function in the absence of oxygen. There are no known genetic
defects in the pathway as they would be lethal. Reactions of TCA cycle are summarized in
figure 2.
The pathway consists of a cycle of reactions some of which are irreversible. The chemical
strategy of the pathway is to produce intermediates (C6 tricarboxylic acids and C5 keto-acids)
that readily lose CO2 producing C4 acids that are inter-convertible. The intermediates of the
cycle act catalytically in the oxidation of CH3COO- to 2CO2. There is no net synthesis of the
intermediates of the cycle by the reactions of the cycle alone. The overall equation for the
pathway is:
CH3CO~CoA + 3 NAD+ + FAD + GDP + Pi + 2 H2O
↓
2 CO2 + CoA + 3 NADH + 3 H+ + FADH2 + GTP
57
In addition to its major catabolic role in oxidizing CH2COO- to 2CO2, the TCA cycle has
anabolic (biosynthetic) functions of the intermediates that include:
• α-ketoglutarate, succinate, fumarate and malate are used for the synthesis of non-
essential amino acids.
• Succinate and oxaloacetate are used for the synthesis of haem and glucose.
• Citrate is used for the synthesis of fatty acids.
When TCA cycle intermediates are removed from the cycle and used for biosynthesis they
have to be replaced or the cycle will stop. Replacements can come from the breakdown of
amino acids that give rise to C5 and C4 intermediates. However, the major replacement comes
via the activity of pyruvate carboxylase.
Regulation of the TCA cycle
The oxidation of acetyl~CoA linked to the reduction of NAD+ and FAD by the TCA cycle
is essential for the generation of ATP in all tissues containing mitochondria (Stage 4 of
catabolism). The rate of ATP utilization is, therefore, the primary factor in driving the TCA
cycle. Two major signals feed information on the rate of utilization of ATP to the TCA cycle:
• ATP/ADP ratio
• NADH/NAD+ ratio.
One of the early irreversible steps of the TCA cycle (catalysed by isocitrate dehydrogenase)
is allosterically inhibited by isocitrate the high-energy signal activated by the low-energy signal
ADP
Gluconeogenesis
Even when carbohydrate is absent from the diet (e.g. during fasting & starvation) the central
nervous system and other glucose-dependent tissues need glucose. Initially this comes from the
breakdown of liver glycogen. However, the amount of glucose stored as liver glycogen is only
sufficient for 8-10 h of fasting and if fasting lasts more than 8-10 h the body has to produce
glucose by the process of gluconeogenesis. The major site of gluconeogenesis is the liver
although the kidney cortex can produce glucose during starvation.
Possible substrates for gluconeogenesis
The metabolism of glucose involves a number of intermediates that are common to

triacylglycerol and amino acid metabolism. It is therefore possible that some of these
intermediates could be used to synthesize glucose:
o Pyruvate, lactate and glycerol can be converted to glucose.
o Essential and non-essential (Glucogenic) amino acids whose metabolism involves
pyruvate or intermediates of the TCA cycle can be converted to glucose.
o Acetyl~CoA cannot be converted to glucose in man because PDH is irreversible.
58
Pathways involved in gluconeogenesis from pyruvate
The pathway of gluconeogenesis from pyruvate uses some of the steps of glycolysis (Figure
3). The overall process can be represented by the following equation:
2pyruvate + 4ATP + 2GTP + 2NAD → glucose + 2NAD + 4ADP + 2GDP + 6Pi + 2H+
Seven of the ten reactions of glycolysis are reversible and can be used in the synthesis of
glucose. The three irreversible steps (steps 1, 3 & 10) are by-passed.
Steps 1 & 3 are by-passed by thermodynamically spontaneous reactions catalysed by
phosphatases (glucose 6-phosphatase and fructose 1,6-bisphosphatase):
Step 10 is by-passed by two reactions driven by ATP and GTP hydrolysis and catalysed by
pyruvate carboxylase and phosphoenolpyruvate carboxykinase (PEPCK).
The last reaction provides the link between the TCA cycle and gluconeogenesis and enables
the products of amino acid catabolism that are intermediates of the TCA cycle to be used for
the synthesis of glucose.
Regulation of gluconeogenesis
Gluconeogenesis occurs as part of the response to stress situations (e.g. fasting, starvation,
prolonged exercise) and is largely under hormonal control. The major control sites are PEPCK
and Fructose 1,6-bisphosphatase. The activity of PEPCK is increased by glucagon and cortisol
and decreased by insulin (the hormones change the amount of enzyme). The activity of fructose
1,6- bisphosphatase is also increased by glucagon and decreased by insulin (the hormones affect
both the amount and activity of the enzyme). Thus, the insulin/glucagon ratio plays a major role
in determining the rate of gluconeogenesis. In the absence of adequate levels of biologically
effective insulin, such as occurs in diabetes, increased rates of gluconeogenesis contribute
significantly to the hyperglycaemia.
59
Fig 3: Gluconeogenesis
60
Group work
Galactosaemia
Susan was born to healthy parents after a normal delivery at the Alzhraà for maternity and
pediatrics Hospital in Najaf. She was breast-fed but on the second day she vomited several
times. The following day she developed diarrhoea and she lost weight. She continued to be
fretful, taking her feeds reluctantly and vomiting frequently. On the 5th day she was found to
be jaundiced and over the course of the next few days the jaundice deepened. Physical
examination revealed liver enlargement. Susan was put on a formula milk (based on cow's milk)
on which she seemed to improve, although vomiting and diarrhoea continued. On the 10th day
cataracts were noticed in the lenses of her eyes. The total sugar concentration in her blood was
raised, and the glucose was low (As shown below). Her urine gave a positive test for sugar,
which was shown to be galactose. The urine also contained amino acids and protein. A
diagnosis of Galactosaemia was made and Susan was put on a low-lactose diet on the 16th day.
Within two days the vomiting and diarrhoea stopped and the galactose disappeared from her
urine. She took her feeds well and began to put on weight. The jaundice faded and by the end
of the following month her liver had returned to a normal size. Thereafter, she continued to
make good progress, but her cataracts remained. The patient's blood sugar levels were:
Sugar Obtained concentration (mM) Reference value (mM)

Total sugar 8.5 4.0 – 6.0
Glucose 3.5 3.5 – 5.5
a. What is Galactosaemia?
b. On what evidence was the diagnosis of galactosaemia made?
c. What tissue is responsible for the major part of galactose metabolism in man?
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d. What 3 enzymes are involved in the initial stages of galactose metabolism?
e. Are these enzymes normally present in red blood cells?
f. Which of these enzymes could be missing in Susan?
g. How could you determine which enzyme is missing or defective in Susan?
h. Is galactose a normal constituent of urine?
i. How could you account for its presence in this patient's urine?
j. What are the metabolic consequences of an absence of galactose 1-P uridyl transferase?
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i. Galactitol was found in Susan's urine. What is galactitol and how is it formed?
l. Why do galactosaemic patients develop cataracts?
m. Are the metabolic consequences of an absence of galactokinase similar to those of an

absence of galactose 1-P uridyl transferase?
n. Why did this patient become jaundiced?
o. How would you treat a patient with galactosaemia?
p. Is there an alternate source of tissue galactose for patients on a galactose free diet?
q. Would a mother who is galactosaemic be able to produce lactose in her milk?
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Self-assessment
objectives for this Session.
a. Outline the important roles of pyruvate dehydrogenase in glucose metabolism.
b. List the functions of the TCA cycle.
c. Explain the consequences of a genetic defect that prevented the synthesis of one of the
enzymes of the TCA cycle.
d. What is gluconeogenesis and why is it necessary? List the hormones that stimulate the
process and those that inhibit it
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Session Four
Oxidative Phosphorylation, Oxidative Stress
Fuel Storage and Lipid Metabolism
Aims of the session

The aim of this session is that you should understand the processes of oxidative
phosphorylation that take place within cells and understand the ways in which energy is stored
in the body, including glycogen and lipids, the structure of lipids and their metabolism

08:00 – 09:00 Lecture: Oxidative phosphorylation, oxidative stress.
09:00 – 10:00 Lecture: Fuel storage and lipid metabolism
10:30 – 01:30 Group Work: glucose 6-phosphate dehydrogenase deficiency
Intended learning Outcomes

o Describe the key features of oxidative phosphorylation.
o Explain the processes of electron transport and ATP synthesis and how they are
coupled.
o Describe how, when and why uncoupling of these processes occur in some tissues.
o Compare the processes of oxidative phosphorylation and substrate level
phosphorylation.
o Describe the major energy stores in a 70 kg man.
o Describe, in outline, the reactions involved in glycogen synthesis and breakdown.
o Compare the functions of liver and muscle glycogen.
o Explain the clinical consequences of glycogen storage diseases.
o Describe the various classes of lipids.
o Explain why triacylglycerols can be used as efficient energy storage molecules in
adipose tissue.
o Describe how dietary triacylglycerols are processed for storage or to produce energy.
o Describe how fatty acid degradation differs from fatty acid synthesis.
o Describe the central role of acetyl~CoA in metabolism.
Directed study: You should read the case studies of hyperlipidaemia and
hypercholesterolaemia and prepare answers to the questions. Your answers will be reviewed
during the Group Work of Session 5.
Self-assessment: You should answer the self-assessment questions to ensure you can meet the
learning objectives for the Session.
Reading:
Marks' Essentials of Medical Biochemistry, chapter 16, chapter 17.
65
Lecture notes
Stage 4 of catabolism
Oxidative phosphorylation
The complete oxidation of glucose can be represented by the following equation:
C6H12O6 + 6O2 → 6 H2O ΔGo = -2,870 kJ/mole
By the end of stage 3 of catabolism the following have occurred:

o All the C-C bonds have been broken and the C-atoms oxidised to CO2.
o All the C-H bonds have been broken and the H-atoms (H+ + e-) transferred to NAD+
and FAD. Where has all the energy gone?
o ATP/GTP formation (2 in glycolysis and 2 in TCA cycle = 124 kJ/mole)
o Chemical bond energy of the e- in NADH and FADH2
NADH and FADH2 contain high-energy electrons that can be transferred to oxygen through
a series of carrier molecules with the release of large amounts of free energy:
This energy can be used to drive ATP synthesis in the final stage of catabolism (oxidative
phosphorylation). This occurs at the inner mitochondrial membrane and involves highly
organized multi-component systems. Two processes are involved:
o Electron transport: electrons in NADH and FAD2H are transferred through a series
of carrier molecules to oxygen with the step-wise release of free energy. The process
therefore requires oxygen.
o ATP synthesis: the free energy released in electron transport is used to drive ATP
synthesis from ADP + Pi.
66
Electron transport
The carrier molecules that transfer electrons to molecular oxygen are organized into a series
of four highly specialized protein complexes spanning the inner mitochondrial membrane.
Proteins found in the complexes include flavoproteins, iron-sulphur proteins and cytochromes
and each complex have its own unique set of proteins. These complexes are:
• Complex I (NADH-Q oxidoreductase): oxidizes NADH and transfers electrons to

coenzyme Q
• Coenzyme Q (Ubiquinone)
• Complex II (Succinate-Q reductase): oxidizes FADH2 and transfers electrons to
coenzyme Q
• Complex III (Q-cytochrome c oxidoreductase): passes the electrons to cytochrome c
• Complex IV (Cytochrome c oxidase): passes the electrons to O2
Electron transport system
Electrons are transferred from NADH (and FAD2H) sequentially through the series of
complexes to molecular oxygen with the release of free energy. Three of the complexes (I, III,
IV) in addition to transferring electrons, also act as proton translocating complexes. They use
the free energy (derived from electron transport) to move protons from the inside to the outside
of the inner mitochondrial membrane. The membrane itself is impermeable to protons and as
electron transport proceeds the proton concentration on the outside of the inner membrane
increases. The proton translocating complexes therefore transform the chemical bond energy
of the electrons into an electro-chemical potential difference of protons. This is known as the
proton motive force (p.m.f). The greater the chemical bond energy of the electrons, the more
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protons that can be translocated and the greater the p.m.f. The electrons in NADH have more
energy that the electrons in FADH2 and as a consequence NADH uses all three proton
translocating complexes while FADH2 uses only two. The process can only normally occur in
the presence of oxygen since this act as the terminal electron acceptor.
ATP synthesis
ATP hydrolysis results in the release of energy:
ATP + H2O ADP ΔGo = -31 kJ/mole
Thus, for ATP synthesis from ADP and Pi +31 kJ/mole would be required to drive the
reaction. This energy is derived from the proton gradient (p.m.f) that has been produced across
the inner mitochondrial membrane by electron transport. Protons can normally only re-enter the
mitochondrial matrix via the ATP synthase complex, driving the synthesis of ATP from ADP
and Pi.
2H+outside +ADP +Pi → 2H+inside +ATP
The greater the p.m.f. the more ATP is synthesized and this is expressed as the ATP/O ratio
or P/O ratio. Thus, the oxidation of 2 moles of NADH drives the synthesis of 5 moles of ATP
(P/O = 2.5) and the oxidation of 2 moles FAD2H drives the synthesis of 3 moles ATP (P/O =
1.5). The overall efficiency of oxidative phosphorylation in terms of energy conservation as
ATP is ~35% for NADH (220 kJ/mole available and 77.5 kJ conserved as 2.5 moles ATP) and
~31% for FAD2H (152 kJ available and 46.5 kJ conserved as 1.5 mole ATP). The energy not
conserved appears as heat and helps in maintaining the body temperature at ~37oC. (N.B. The
ATP-synthase is also known as the F1F0-ATPase as it can also catalyse the reverse reaction)
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Coupling between electron transport (ET) and ATP synthesis
Normally ET and ATP synthesis are tightly coupled and controlled such that one does not
occur without the other. The mitochondrial concentration of ATP plays an important role in
regulating both processes. When [ATP] is high:
o The [ADP] is low and the ATP synthase stops (lack of substrate).
o This prevents the transport of protons back into the mitochondria.
o The [H+] outside increases to a level that prevents more protons being pumped.
o In the absence of proton pumping electron transport stops. The reverse occurs when
[ATP] is low.
Uncouplers
Some substances (e.g. dinitrophenol, dinitrocresol) increase the permeability of the inner
mitochondrial membrane to protons. This enables protons pumped out of the mitochondria by
ET to re-enter the mitochondrial matrix without driving ATP synthesis i.e., the two processes
are uncoupled and the potential energy of the p.m.f is dissipated as heat. Under these conditions
ET continues, ATP synthesis does not occur and heat is generated. Proton leak is
physiologically important and accounts for 20-25% of the basal metabolic rate.
Uncoupling proteins
Specific proteins, called uncoupling proteins (UCP), have been identified whose function is
to uncouple the electron transport chain from ATP production to produce heat. Five different
uncoupling proteins have so far been identified: UCP1-5 and of these UCP 1-3 seem to be the
most important. They are located on the inner mitochondrial membrane and allow a leak of
protons across the membrane, reducing the p.m.f and inhibiting ATP synthesis. UCP1
(previously known as thermogenin) is expressed in brown adipose tissue and is involved in non-
shivering thermogenesis, which enables mammals to survive in cold environments. In response
to cold, noradrenaline is released from the sympathetic nervous system and stimulates lipolysis
releasing fatty acids to provide fuel for oxidation in brown adipose tissue.
As a result of β-oxidation of the fatty acids NADH and FADH2 are formed, driving ET and
increasing the p.m.f. However, noradrenaline also activates UCP1 allowing the protons to re-
enter the mitochondrial matrix without driving ATP synthesis, which dissipates the p.m.f as
heat. UCP2 is quite widely distributed in the body and research has suggested that it could be
linked to diabetes, obesity, metabolic syndrome and heart failure. UCP3 has been found in
skeletal muscle, brown adipose tissue and the heart and it appears to be involved in modifying
fatty acid metabolism and in protecting against reactive oxygen species damage. The UCPs are
important targets for future pharmacological agents.
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Inhibitors of electron transport
ET is inhibited under anaerobic conditions and by a number of substances including carbon

monoxide and various poisons (cyanide, rotenone, antimycin). Under these conditions NADH
& FAD2H cannot be oxidized by electron transport. As a consequence there is no energy to
drive the pumping of protons and a p.m.f cannot be created. Without the p.m.f. ATP cannot be
synthesised and no heat is generated. Irreversible cell damage rapidly occurs.
Oxidative stress
Relatively large amounts of energy can be obtained by using oxygen; however, there is a cost
to this. During oxidative phosphorylation, reactive oxygen species (highly reactive molecules)
are also produced as a by-product. Mitochondria produce superoxide radicals (O2- ) which
gives rise to most reactive oxygen species (ROS). Superoxide radicals can be converted to
hydrogen peroxide (H2O2) and then to water, which deactivates them. However, some
superoxide radicals react with nitric oxide to form peroxynitrite (ONOO-) and hydroxyl radicals
( OH) can also produce. These highly reactive agents can cause damage to cells, particularly to
membranes; fortunately, cells usually have an abundant supply of antioxidants which can react
with ROS to deactivate them.
The main antioxidants in cells are glutathione (a tripeptide) and NADPH, but the antioxidant
vitamins C and E are also important in the diet. The balance between ROS production and
antioxidants is important, and oxidative stress is now known to have a role in a wide variety of
disease states. Some cells, such as neutrophils, can produce an oxidative burst, in which they
deliberately release large amount of ROS to destroy nearby bacteria, this is a feature of some
types of inflammatory disease and will be covered in more detail in the Mechanisms of Disease
Module.
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Lecture notes
Fuel storage & lipid metabolism
Glucose storage (glycogen metabolism)
In spite of its intermittent availability from the diet some tissues require a continuous supply
of glucose. Initially this requirement is met by storing glucose (as glycogen) when it is available
following a meal and releasing it from storage between meals. If the period between meals is
long enough to deplete the stored glycogen (8-12 hrs.) then glucose has to be synthesised by
the process of gluconeogenesis (to be covered in Session 5).
Glycogen is a highly branched polymer of glucose residues linked together by glycosidic

bonds of two types, α1-4 and α1-6 present in the ratio of ~10.1. The α1-6 bonds are the branch
points. The highly branched structure provides many sites to which glucose residues can be
added or removed allowing rapid synthesis or degradation of glycogen. Glycogen is a large
molecule (Mol Wt 106 108) that is stored in granules in liver and skeletal muscle.
The large size of the glycogen molecule means that many glucose molecules can be stored
with minimal osmotic effect in the storage tissue. However, there is a limit to the amount of
glycogen that can be stored in tissues as it is a highly polar molecule that attracts a lot of water.
In addition, there is no specialized storage tissue. Thus, it has to be stored in tissues that have
other important functions.
The liver can store up to ~100g glycogen while skeletal muscle can store up to ~300g
glycogen. Abnormal storage of glycogen (excessive or inadequate) is seen in a number of
clinical conditions known collectively as the glycogen storage diseases.
Glycogen synthesis (glycogenesis)
The pathway of glycogen synthesis from glucose involves a number of steps:
1) Glucose + ATP → glucose-6-phosphate + ADP catalysed by hexokinase (glucokinase

in liver)
2) Glucose-6-phosphate ↔ glucose-1-phosphate catalyzed by phosphoglucomutase
3) Glucose-1-phosphate + UTP + H2O→ UDP-glucose + 2Pi
UTP is structurally similar and energetically equivalent to ATP. UDP-glucose can be

considered as a highly activated form of glucose. It is an important intermediate in the synthesis
of a number of sugar containing molecules (e.g. lactose and glycogen) and in the inter-
conversion of glucose and galactose.
4) Glycogen (n residues) + UDP-glucose → glycogen (n+1 residue) + UDP

This irreversible reaction is catalysed by two enzymes, glycogen synthase and branching
enzyme. Glycogen synthase links glucose residues in series to a glycogen primer by α1-4
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glycosidic bonds. At appropriate points (after every ~10 units) branching enzyme links a
glucose residue by an α1-6 glycosidic bond introducing a branch point.
Glycogen degradation (glycogenolysis)
Glycogen is degraded in skeletal muscle in response to exercise and in the liver in response
to fasting of as part of the stress response (“fright, fight or flight response”).
The pathway is not a reversal of the synthetic pathway. This is a characteristic feature of
many degradative and biosynthetic pathways that allows greater metabolic flexibility and
independent control. The complete degradation of glycogen can be represented by the equation:
Glycogen (n residues) + nPi → 0.9n glucose-6-phosphate + 0.1n glucose
However, glycogen is never degraded completely as a small amount of primer is always

preserved. The degradative pathway consists of the following steps:
(1) Glycogen (n residues) + Pi → glucose-1phosphate + glycogen (n-1 residues)

This reaction is catalysed by the enzyme glycogen phosphorylase that attacks the α1-4
bonds. The bonds are subjected to phosphorolysis rather than hydrolysis with the result
that glucose residues are released as glucose 1-phosphate rather than free glucose.
Glycogen phosphorylase does not attack the α1-6 branch points and this requires the
activity of a de-branching enzyme. De-branching enzyme produces free glucose.
(2) Glucose-1-phosphate ↔ glucose-6-phosphate catalysed by phosphoglucomutase
In muscle, the glucose 6-phosphate enters glycolysis and is used to provide energy for
the exercising muscle. Thus, muscle glycogen represents a store of glucose 6-phosphate
that can only be used by the muscle cells. In liver during fasting or during stress the
glucose 6-phosphate is converted to glucose by the enzyme glucose 6-phosphatase (this
enzyme is absent from muscle)
(3) glucose-6-phosphate + H2O → glucose + Pi catalyzed by glucose 6-phosphatase.
The glucose is released into the blood stream and transported to other tissues. Thus,
liver glycogen represents a store of glucose that can be made available to all tissues of
the body.
Regulation of glycogen metabolism
Glycogen metabolism is regulated by controlling the activities of enzymes catalyzing

irreversible reactions in the biosynthetic and degradative pathways (glycogen synthase and
glycogen phosphorylase). These enzymes are subject to allosteric control (AMP activates
phosphorylase) and control by covalent modification (reversible phosphorylation) in response
to changes in hormone levels. In general, the enzymes are controlled reciprocally i.e., when one
is activated, the other is inhibited. Glycogen synthase is inhibited by phosphorylation and
activated by de-phosphorylation while glycogen phosphorylase is activated by phosphorylation
and inhibited by de-phosphorylation. Glucagon and adrenaline increase phosphorylation of both
enzymes while insulin promotes their dephosphorylation.
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Glycogen storage diseases
A number of inherited disorders of glycogen metabolism have been identified. They all
result from an abnormality in one or other of the enzymes of glycogen metabolism. The clinical
picture and severity of the problem depends on which enzyme or tissue is affected.
The major features are:
(1) Increase of decrease amount of glycogen which may cause:
o Tissue damage if excessive storage.
o Fasting hypoglycaemia (low blood glucose).
o Poor exercise tolerance.
(2) Glycogen structure may abnormal.
(3) Usually, liver and or muscle affected.
Overview of glycogen metabolism
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Lipid metabolism
Lipids are a structurally diverse group of important compounds that are generally insoluble
in water (hydrophobic) but are soluble in organic solvents. There is no general formula but most
only contain C, H and O (phospholipids also contain P and N). They are more reduced than
carbohydrates (i.e., they contain less O and more H per C-atom).
Classes of lipids
It is possible to consider the lipids found in the body under three headings:
1- Fatty acid derivatives:
• Fatty acid- fuel molecules
• Triacylglycerols- fuel storage and insulation
• Phospholipids- components of membranes and plasma lipoproteins
• Eicosanoids- local mediators
2- Hydroxy-methyl-glutaric acid derivatives (C6 compound):

• Cholesterol (C27)- membranes and steroid hormone synthesis
• Cholesterol esters- cholesterol storage
• Bile acids and salts (C24)- lipid digestion
3. Vitamins
• A, D, E and K
Triacylglycerols
Triacylglycerols are the major dietary and storage lipid in the body. They consist of three
fatty acids (usually long chain where n=16) esterified to glycerol:
Triacylglycerols are hydrophobic and are stored in an anhydrous form in a highly specialized
storage tissue (adipose tissue). They function largely as a store of fuel molecules (fatty acids
and glycerol) for prolonged aerobic exercise, stress situations such as starvation and during
pregnancy. Storage is under hormonal control being promoted by insulin and reduced by
glucagon, adrenaline, cortisol, growth hormone and thyroxine.
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Energy storage in man
Type of fuel Weight Energy content in:

(1) Healthy 70kg man
Type of fuel Weight (kg) Energy content (kJ)
Glycogen 0.4 4000
Muscle protein 6 100000
(2) Obese 135 kg man
Glycogen 0.4 4000
Muscle protein 6 100000
Stage 1 (metabolism of triacylglycerols)
The major dietary lipids are triacylglycerols (butter, ghee, margarine, vegetable oils). These
are hydrolyzed by pancreatic lipase in the small intestine to release glycerol and fatty acids.
This is a complex process that requires bile salts and a protein factor called colipase.
Glycerol metabolism
Glycerol derived from the hydrolysis of dietary triacylglycerols enters the blood stream and
is transported to the liver where it is metabolized:
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Fatty acids
The most common fatty acids in the body are long-chain molecules that contain an even
number of C atoms: CH3(CH2)nCOOH (n = 14 to18). They are hydrophobic and highly
reduced molecules, properties that make them ideal for energy storage. They may be saturated
or unsaturated (contain C=C double bonds). The saturated fatty acids are non-essential
components of the diet as they can be synthesized from carbohydrates and certain amino acids.
Over 50% of the fatty acids in the body are unsaturated and contain between 1 and 4 C=C
double bonds. Certain polyunsaturated fatty acids (>1 double bond) are essential components
of the diet as they cannot be synthesised in the body. Arachidonic acid (C20:4) is an important
polyunsaturated fatty acid as it is the starting point for the synthesis of the eicosanoids.
Stage 2 (catabolism of fatty acids)
When the body is subjected to stress situations (aerobic exercise, starvation, lactation)
adipose tissue triacylglycerols are hydrolysed by the enzyme hormone-sensitive lipase to
release fatty acids and glycerol that diffuse from the tissue. This process is known as lipolysis.
It is activated by adrenaline, glucagon, growth hormone, cortisol and thyroxine and inhibited
by insulin.
The fatty acids are carried to tissues via the blood stream bound non-covalently to albumin.
The albumin-bound fatty acids are variously called non-esterified fatty acids (NEFA) or free
fatty acids (FFA). The glycerol is transported in the blood to the liver where it may be oxidised,
converted to glucose or used in the synthesis of triacylglycerols.
Many tissues including liver, heart muscle and skeletal muscle can use fatty acids as a source
of energy. The process by which fatty acids are oxidised to release energy is known as -
oxidation and it occurs in mitochondria. Thus, cells such as red blood cells that do not possess
mitochondria cannot oxidize fatty acids. In addition, the process does not occur in the cells of
the central nervous system (brain and spinal cord) because fatty acids do not readily cross the
blood-brain barrier.
Fatty acid activation
In order for fatty acids to be oxidised they have to be activated. This is achieved by linking
to coenzyme A (See Marks p109-111). Coenzyme A (CoA) is a complex molecule that contains
the vitamin pantothenic acid and a free SH group. Fatty acids are linked to the coenzyme via
the S-atom forming a high energy of hydrolysis bond thereby producing the activated fatty acid.
The reaction for linking fatty acids to coenzyme A requires ATP and is catalysed by fatty acyl
CoA synthase:
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Fatty acid transport into mitochondria
The activation of fatty acids occurs outside the mitochondrion and the activated fatty acids
do not readily cross the inner mitochondrial membrane for oxidation. This is overcome by a
special transport system that uses carnitine to shuttle the fatty acid across the inner
mitochondrial membrane. This system plays an important role in regulating the rate of fatty
acid oxidation by controlling their entry into mitochondria.
Transport of the activated fatty acids into mitochondria is inhibited by malonyl-CoA, an
intermediate in the synthesis of fatty acids. This inhibition is important as it prevents fatty acids
newly synthesized in the cytoplasm, from being immediately transported into the mitochondria
and oxidized. A number of patients have been discovered with a defective mitochondrial fatty
acid transport system. They suffer from poor exercise tolerance and have unusually large
amounts of triacylglycerols in their muscle cells.
Β-oxidation of fatty acids
The oxidation of fatty acids occurs via a sequence of reactions (β-oxidation pathway) that
oxidizes the fatty acid and removes a C2 unit (acetate). The shortened fatty acid is cycled
through the reaction sequence repeatedly removing a C2 unit each turn of the cycle until only
two carbon atoms remain.
The overall reaction for the β-oxidation of stearic acid (C-18) is:
The reaction sequence requires mitochondrial NAD+ and FAD and cannot occur in the
absence of oxygen since this is required for stage 4 of catabolism to re-oxidise the NADH and
FAD2H formed. There is no direct synthesis of ATP by the pathway. All the intermediates in
the pathway are linked to coenzyme A and the C-atoms of the fatty acid are converted to acetyl-
coA.
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Acetyl~CoA
Acetyl-coA is produced by the catabolism of fatty acids, sugars, alcohol and certain amino
acids and can be oxidised via stage 3 of catabolism. It is also an important intermediate in lipid
biosynthesis. The major site of lipid synthesis in the body is the liver (some in adipose tissue)
and most lipids (not polyunsaturated fatty acids) can be synthesized.
Fatty acid synthesis (lipogenesis)
Fatty acids (e.g. palmitic acid, CH3(CH2)16COOH) are synthesized from acetyl~CoA
(derived from the catabolism of carbohydrate, amino acids) at the expense of ATP and NADPH.
The pathway occurs in the cytoplasm and can be represented by the overall equation:
NADPH is produced in the cytoplasm by the pentose phosphate pathway. Acetyl-coA comes
from the mitochondria in combination with oxaloacetate as citrate. The citrate is cleaved in the
cytoplasm to release Acetyl~CoA and oxaloacetate.
Most of the steps of the pathway are carried out by a multi-enzyme complex known as the
fatty acid synthase complex. The fatty acids are built up sequentially from Acetyl~CoA by a
cycle of reactions that adds C2 per turn of the cycle to the growing fatty acid. The reactions
therefore appear to act in the reverse of those in the β- oxidation pathway. However, in spite of
this apparent similarity the two pathways are quite distinct.
The C2 units are added growing fatty acid chain as malonyl~CoA (a C3 compound) with the
subsequent loss of CO2. Malonyl~CoA is produced from acetyl~CoA by the enzyme
acetyl~CoA carboxylase in a reaction that requires biotin:
CH3CO~CoA + CO2 ATP → CH2(COOH)CO~CoA + ADP + Pi
78
Acetyl~CoA carboxylase is not a component of the fatty acid synthase complex. It plays an
important role in controlling the rate of fatty acid synthesis. The enzyme is subject to allosteric
regulation (citrate activates and AMP inhibits) and regulation by covalent modification of
protein structure (reversible phosphorylation/ dephosphorylation). Insulin activates the enzyme
by promoting its dephosphorylation while glucagon and adrenaline inhibit the enzyme by
promoting its phosphorylation.
Conversion to fatty acids and esterification to triacylglycerols for storage in adipose tissue
is the fate of most of the dietary carbohydrate and protein consumed in excess of requirements.
These processes are important clinically as excessive lipid synthesis and storage is the cause of
obesity and associated problems such as type 2 diabetes and atherosclerosis. The process is
stimulated by insulin and inhibited by the anti-insulin hormones glucagon and adrenaline.
Comparison of fatty acid synthesis and fatty acid oxidation
Both processes consist of a cycle of reactions that either increase or decrease the length of
the fatty acid carbon chain by C2 per turn of the cycle. However, fatty acid synthesis is not
simply a reverse of fatty acid degradation and it occurs via a totally different pathway. The fact
that degradative (catabolic) and biosynthetic (anabolic) pathways occur by partially different
routes (glycolysis/gluconeogenesis) or totally-different AZSWSQ1routes (fatty acid
oxidation/fatty acid synthesis) is a characteristic feature of metabolism. It allows:
o Greater flexibility (substrates and intermediates can be different)
o Better control (can be controlled independently or co-ordinately).
o Thermodynamically irreversible step can be-passed.
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Group work
Glucose 6-phosphate dehydrogenase deficiency
A 6-year-old child brought to you by his parents in the emergency room complained of
severe pallor, weakness and back pain with persistent vomiting. On taking history, he was well
and had no complain until the day before his presentation where he & his family were invited
to take a lunch of rice & fava bean. On examination, he was found to be weak, feverish with
yellow sclerae. Analysis of a sample of his blood in the hematology laboratory gave the
following data:
The red cells, on microscopic examination, were found to contain precipitates of a dark
material (Heinz bodies). Over the next few days the blood picture returned to normal, apart
from an increased number returned to 10% of the normal activity (1.3 U/g )The symptoms
vanished and the of reticulocytes. However, the patient's red cell glucose 6-phosphate
dehydrogenase activity only patient was discharged. The diagnosis was Favism. It is due to
glucose 6-phosphate dehydrogenase deficiency.
a. What is glucose 6-phosphate dehydrogenase?
b. Why is it important to cellular function?
c. What does an enzyme activity of 13 U/g tissues mean?
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d. The normal activities of glucose 6-phosphate dehydrogenase in different tissues (U/g) are:
o Red blood cells 13
o Liver 1
o Adipose tissue 1.5
o Skeletal muscle 0.01
o Brain 0.2
How do you account for these differences?
e. What evidence is there of anemia in the patient?
f. What biochemical evidence is there of jaundice in the patient?
g. Is it likely that in this patient the anaemia and jaundice are related?
h. Can you give him aspirin for the treatment of the fever. Why?
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i. What could cause an absence of glucose 6-phosphate dehydrogenase from the patient's red
blood cells?
j. Would you expect to find glucose 6-phosphate dehydrogenase activity absent from other
tissues?
k. How do you account for the observation that some glucose 6-phosphate dehydrogenase
activity returned to the patient's red blood cells ?
l. propose an explanation for the presence of Heinz bodies in the patient's erythrocytes.
m. Where are the areas of highest prevalence of this disorder?
n. What do you think about the diet that should be prevented?
o. What do you think about sex involvement of this disorder?
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p. What do you think if his mother &/ or father suffered from the same disorder (Regarding the
severity of the disease)?
q. Are these patients prone to splenomegaly? Why?
r. What do you think about PR (pulse rate) & BP (blood pressure)?
Self-assessment
You should answer these self-assessment questions to ensure you can meet the learning
a. Describe the key features of electron transport and explain how the proton motive force
(p.m.f) is produced.
b. Describe the relationship between electron transport and ATP synthesis. Explain how this
relationship is altered during thermogenesis in brown adipose tissue mitochondria.
c. Compare and contrast the processes of oxidative phosphorylation and substrate level
phosphorylation.
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d. Explain why cyanide is toxic to cells.
e. The anaerobic oxidation of glucose to lactate yields only 2 moles ATP/mole glucose, whereas
the aerobic oxidation to CO and H O yields 32 moles ATP/mole glucose. Does this mean that
the latter process is energetically much more efficient than the former? Explain your answer.
f. Case study: Pesticide poisoning
Shalaàn an agricultural worker, was employed by a farmer to spray 400 acres of wheat with a
pesticide containing an aromatic weak acid, dinitrocresol (DNC). He failed to wear any
protective clothing. After several days work, Bill Shalaàn fell ill with a very high temperature
and profuse sweating. He was admitted to hospital, but in spite of strenuous attempts to decrease
his body temperature, he fell into a coma and died. Autopsy showed a striking absence of
subcutaneous fat. How would you explain these symptoms?
g. Compare and contrast the functions of liver and skeletal muscle glycogen.
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h. Compare and contrast triacylglycerols and glycogen as energy storage materials in man.
i. What are the major energy stores in a 70kg man and when are they used?
j. Describe, in outline, the processes that enable the triacylglycerols stored in adipose tissue to
be used by skeletal muscle cells.
k. List the products that can be synthesized from acetyl~CoA and explain why it cannot be
converted to glucose in man.
l. Explain why the process of fatty acid synthesis (lipogenesis) is not simply a reversal of the
process of fatty acid degradation -oxidation)
85
Session five
Lipid Metabolism and Transport
Protein and Nitrogen Metabolism
Aims of the session

The aim of this session is that you should understand how lipids are transported around the
body in the blood stream; the clinical problems associated with lipid transport and have an
overview of nitrogen metabolism in the body.
Structure of the session:

0.8:00 – 09:00 Lecture: Lipid metabolism and transport
09:00 – 10:00 Lecture: Protein and nitrogen metabolism
10:30 – 01:30 Group Work: Case study: hyperlipidaemia, hypercholesterolaemia

o Explain how, when and why ketone bodies are formed.
o Describe how lipids are transported in the blood.
o Explain how tissues obtain the lipids they require from lipoproteins.
o Explain how disturbances to the transport of lipids can lead to clinical problems.
o Analyse simple problems that involve disturbances to lipid transport.
o Explain how hyperlipoproteinaemias may be treated.
o Describe how amino acids are catabolised in the body.
o Explain the clinical consequences of a defect in phenylalanine metabolism.
o Explain the clinical relevance of measuring creatinine in blood and urine.
o Describe how ammonia is metabolised in the body.
Directed study: You should read the case studies on PKU and amino acid metabolism and
prepare answers to the questions. Your answers will be reviewed in the Group Work in Session
6.
Suggested reading:
Mark's essential of medical biochemistry, chapter 30, chapter 31, chapter 20
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Lecture notes
Lipid metabolism and transport
Ketone bodies
There are three ketone bodies produced in the body:

• Acetoacetate = CH3COCH2COO-
• Acetone = CH COCH,
• β-hydroxybutyrate = CH CHOHCH COO-
Acetoacetate and -hydroxybutyrate are synthesized in the liver from acetyl~CoA. Acetone
arises from the spontaneous (non-enzymatic) decarboxylation of acetoacetate. Normally the
concentration of ketone bodies in the circulation is low (<1 mM) but this can increase in
starvation (2-10mM = physiological ketosis) and in untreated type 1 diabetes (>10mM =
pathological ketosis).
The ketone bodies are water-soluble molecules, a property that allows high plasma
concentrations and their excretion in the urine (ketonuria). Acetoacetate and -
hydroxybutyrate are relatively strong organic acids and when present in high concentrations in
the plasma they may cause acidosis (ketoacidosis). Acetone is volatile and may be excreted via
the lungs. The characteristic smell of acetone (nail varnish remover) can often be smelt on the
breath of untreated type 1 diabetics. Ketone bodies are synthesized in liver mitochondria by the
following pathway:
87
The activities of the lyase and reductase enzymes are reciprocally controlled by the
insulin/glucagon ratio. When the ratio falls the lyase is activated, the reductase inhibited and
ketone body formation is activated. When the ratio increases the lyase is inhibited, the reductase
activated and cholesterol synthesis occurs. The synthesis of ketone bodies requires both of the
following:
o Fatty acids to be available for oxidation in the liver following excessive lipolysis
in adipose tissue this supplies the substrate.
o The plasma insulin/glucagon ratio to be low, usually due to a fall in plasma
insulin this activates the lyase and inhibits the reductase.
Ketone bodies are important fuel molecules that can be used by all tissues containing
mitochondria including the central nervous system. The rate of utilisation is proportional to the
plasma concentration. They are converted to acetyl~CoA and this is subsequently oxidised via
stage 3 of catabolism.
Lipid transport
Various classes of lipids including triacylglycerols, fatty acids, cholesterol, cholesterol

esters and phospholipids are normally found in blood. They may have come from the diet or
have been synthesised in the body and are being transported to tissues for storage and/or
utilisation. They are insoluble in water and must therefore be carried in the plasma in association
with protein.
Most of the lipid (~98%) is carried as highly specialised non-covalent assemblies known as
lipoprotein particles. The remaining 2% (mostly fatty acids) are carried bound non-covalently
to albumin. These albumin bound fatty acids are fatty acids released from adipose tissue during
lipolysis and are used as a fuel by tissues such as muscle.
Albumin has a limited capacity to transport fatty acids and as a consequence blood fatty
acids levels do not normally exceed ~3mM. Plasma lipoproteins are of great significance in
medicine since disorders in their metabolism are associated with a number of important diseases
including atherosclerosis and its commonest manifestation coronary artery disease.
Plasma lipoprotein particles
These are multi-molecular complexes that contain variable amounts of different lipids
(phospholipids, cholesterol, triacylglycerols and cholesterol esters) in non-covalent (mostly
hydrophobic) association with specific proteins. Their primary function is to transport water-
insoluble lipid molecules in the bloodstream. Several classes of lipoproteins are found which
differ from each other in the lipid being transported, the origins of the lipid and its destination.
The protein components are specific proteins (apoproteins) that have functional as well as
structural roles. Structurally, the apoproteins are involved in packaging non-water soluble lipid
molecules into soluble form as multi-molecular particles. They are able to do this effectively
because they contain hydrophobic regions that interact with lipid molecules and hydrophilic
regions that interact with water.
88
Functionally, apoprotein molecules may be involved in the activation of enzymes or in the

recognition of cell surface receptors. The particular apoprotein composition of a lipoprotein
particle determines its function.
Lipoprotein structure
All mature lipoproteins found in normal human plasma are spherical particles that consist of
a surface coat (shell) and a hydrophobic core. The surface coat contains the phospholipids,
cholesterol and apoproteins. The hydrophobic core contains triacylglycerols and cholesterol
esters.
Lipoproteins particles are only stable if they maintain their spherical shape and this is
dependent on the ratio of core to surface lipids. Thus, as the lipid from the hydrophobic core is
removed and taken up by tissues, the surface coat must also be reduced. Many components of
the lipoprotein surface coat are free to transfer to different particles and to cell membranes.
However, core components can only be removed by special proteins such as lipases and transfer
proteins.
Classes of plasma lipoproteins found in man
Various classes of lipoproteins can be identified which differ from each other both in the
relative amounts of the different types of lipids they contain and in their apoprotein
composition. These differences give the particles different physical properties such as net
electrical charge, size, molecular weight and density and enable the lipoprotein classes to be
separated from each other by electrophoresis or by ultracentrifugation.
Using these techniques four classes of mature lipoproteins can be identified: Chylomicrons,
Very Low Density Lipoproteins (VLDL), Low Density Lipoproteins (LDL), High Density
Lipoproteins (HDL). In addition, two classes of remnant lipoproteins and can be identified:
Chylomicron remnants and remnants of VLDL (Intermediate Density Lipoproteins). These are
formed as a result of the removal of lipids (mostly triacylglycerols) from chylomicrons and
VLDL.
Functions of the plasma lipoproteins
Each of the various classes of plasma lipoprotein has its own distinct transport function
determined largely by its apoprotein composition:
89
Chylomicrons
The transport of dietary lipid absorbed from the intestine to tissues such as adipose tissue
involves the class of lipid transport proteins known as chylomicrons. Dietary triacylglycerols
cannot be absorbed directly and are hydrolysed in the small intestine by the enzyme pancreatic
lipase that releases fatty acids and glycerol. The fatty acids enter the epithelial cells of the small
intestine. There they are reesterified back to triacylglycerols using glycerol phosphate produced
from glucose metabolism in the epithelial cells. The triacylglycerols are then packaged with
other dietary lipids (e.g. cholesterol, fat soluble vitamins) into chylomicrons. The chylomicrons
are released from the epithelial cells into the blood stream via the lymphatic system and are
carried to tissues, such as adipose tissue, which have the extracellular enzyme lipoprotein lipase.
This enzyme hydrolyses the triacylglycerols to release the fatty acids that enter the cell where
they are converted to triacylglycerols for storage.
Dyslipoproteinaemias
Dyslipoproteinaemia refers to any defect in the metabolism of the plasma lipoproteins. It

may be primary (familial inborn error of lipoprotein metabolism) or secondary (acquired) as a
result of diet, drugs or an underlying disease such as diabetes. Raised levels of one or more of
the plasma lipoproteins are found in the hyperlipoproteinaemias.
Classification of Hyperlipoproteinaemias
Different types of hyperlipoproteinaemia are recognized and because they each have a
different risk of coronary artery disease, have different causes and respond to different
treatments, it is important to have a system for identifying and classifying them. The most
widely used system is that devised by Fredrickson (also called the WHO system). It is based on
measurement of the fasting plasma concentrations of glucose (to check for fasting sample
and/or diabetes), total cholesterol and triacylglycerols and examination of the results of plasma
lipoprotein separation by electrophoresis. Using this system six different types can be
recognized:
o Type I - chylomicrons in fasting plasma. No link with coronary artery disease.
Caused by defective lipoprotein lipase.
o Type IIa - raised LDL. Associated with coronary artery disease that may be severe.
Caused by defective LDL receptor.
o Type IIb - raised LDL & VLDL. Associated with coronary artery disease.
Defect unknown.
o Type III - raised IDL and chylomicron remnants. Associated with coronary artery
disease. Caused by defective apoprotein (Apo. E).
o Type IV - raised VLDL. Associated with coronary artery disease. Defect
unknown.
o Type V - raised chylomicrons and VLDL in fasting plasma. Associated with
coronary artery disease. Cause unknown
90
Treatment of Hyperlipoproteinaemia
Diet and lifestyle modification (e.g. increased exercise) should be considered as the first
approach to the treatment of hyperlipoproteinaemia. The aims are to reduce/eliminate
cholesterol from the diet and reduce the intake of triacylglycerols especially those containing
saturated fatty acids. In some patient's diet and lifestyle modification does not appear to achieve
the desired results and drug therapy may be necessary.
The statins (e.g. simvastatin) are a group of drugs that may be effective in lowering plasma
cholesterol levels by reducing the synthesis of cholesterol in tissues. The liver can dispose of
cholesterol by converting it to bile salts that are secreted in the bile. In addition, a small amount
of cholesterol is secreted directly in the bile.
The bile salt sequestrants (e.g. cholestyramine) lower plasma cholesterol by increasing its
disposal from the body. They act by binding to bile salts in the GI tract preventing them from
being reabsorbed into the hepatic-portal circulation and promoting their loss in the feces
Enzymes of lipoprotein metabolism
Lipoprotein Lipase: is the enzyme responsible for removing the core triacylglycerols from
lipoprotein particles such as chylomicrons and VLDLs. It is found attached to the inner surface
of capillaries in tissues such as adipose tissue and muscle. Insulin increases the synthesis of the
enzyme by tissues. The enzyme hydrolyses triacylglycerols in lipoprotein particles, releasing
fatty acids and glycerol. The fatty acids are then taken up by tissues and the glycerol is
transported to the liver.
Lecithin: Cholesterol Acyltransferase (LCAT): The removal of core lipids from lipoprotein
particles makes them unstable as the ratio of surface to core lipids increases. Stability can be
restored if some of the surface lipid is converted to core lipid. This is achieved by the enzyme
LCAT which is important both in the formation of lipoprotein particles and in maintaining their
structure. The enzyme converts cholesterol to cholesterol ester using fatty acid derived from
lecithin (phophatidylcholine). Deficiency of the enzyme results in unstable lipoproteins of
abnormal structure and a general failure in the lipid transport processes. Lipid deposits occur in
many tissues and atherosclerosis is a serious problem.
LDL metabolism
Tissues obtain the triacylglycerols they require from chylomicrons and VLDLs using the
extracellular enzyme lipoprotein lipase and these lipoprotein particles remain outside the cell.
In contrast, tissues obtain the cholesterol they need from LDLs by the process of receptor-
medicated endocytosis. In this process the LDL particles are taken up by the cell and the
cholesterol released inside the cell. With few exceptions (erythrocytes) all cells are able to
synthesize cholesterol from acetyl CoA and could satisfy their requirements by biosynthesis.
However, in practice all cells appear to prefer to take up pre-formed cholesterol circulating in
plasma lipoproteins. This allows the whole body cholesterol content to be closely controlled.
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Cells requiring cholesterol synthesize specific LDL receptors that are exposed on the cell
surface. The LDL receptors recognize and bind to specific apoproteins (Apo B100) on the
surface of the LDL particles. The LDL receptor with its bound LDL particle is then taken into
the cell by endocytosis and subjected to lysosomal digestion. In this process cholesterol esters
are converted to free cholesterol that is released within the cell. This cholesterol can be stored
(as cholesterol esters) or used by the cell. In addition, it inhibits the synthesis of cholesterol by
the cell and reduces the synthesis and exposure of LDL receptors. These actions normally
prevent the cell accumulating too much cholesterol. Familial hypercholesterolaemia (Type IIa
hyperlipoproteinaemia) is a condition in which there may be an absence (homozygous) or
deficiency (heterozygous) of functional LDL receptors. The condition is characterized by
elevated levels of LDL and cholesterol in the plasma. Homozygotes develop extensive
atherosclerosis early in life and heterozygotes develop the condition later in life.
Lecture notes
Protein, amino acid and nitrogen metabolism
Protein is an essential component of the diet since it supplies the body with amino acids,
some of which cannot be synthesised in the body (the essential amino acids). Lack of adequate
protein in the diet is a major cause of illness in developing countries.
Stage 1 (catabolism of protein)
As for other components of the diet, Stage 1 of the metabolism of protein occurs in the
gastrointestinal tract, where a variety of enzymes (proteases and peptidases) hydrolyse peptide
bonds to release free amino acids. The amino acids are absorbed into the circulation and are
used by tissues for:
o Protein synthesis.
o Synthesis of various nitrogen containing compounds (e.g. purines, creatine, and haem).
Insulin and growth hormone stimulate the uptake of amino acids into tissues such as
skeletal muscle, adipose tissue and liver and their incorporation into protein (protein
synthesis). Cortisol has the opposite effect on skeletal muscle promoting the breakdown
of muscle proteins (proteolysis) and release of amino acids.
In a typical western diet more protein is eaten than is needed to supply the essential amino
acids and as a result more amino acids are available in the circulation than tissues require.
These excess amino acids are not stored in the body but are broken down in stage 2 of
catabolism.
Stage 2 (catabolism of amino acids)
Each amino acid found in protein has its own pathway of catabolism and thus there are over
20 different pathways. However, many of these pathways share common features and all end
up converting the amino acid to one or more of a group of molecules that are important organic
92
precursor molecules. An early step in the catabolism of an amino acid is the removal of the
amino group (-NH ). This is converted to urea (CO(NH ) ) and excreted from the body in the
urine. The remaining C-skeletons of the amino acids are converted to one or more of the
following: pyruvate, oxaloacetate, fumarate, - ketoglutarate, succinate, and acetyl~CoA.
Amino acids that produce acetyl~CoA (e.g. leucine, lysine) are described as ketogenic as
acetyl~CoA can be used for the synthesis of ketone bodies. Amino acids that give rise to the
other products are described as glucogenic as they can be used for glucose synthesis by
gluconeogenesis. Some amino acids are both ketogenic and glucogenic (isoleucine, threonine,
phenylalanine, tyrosine and tryptophan).
Products at the end of stage 2 of catabolism
Stage 2 of the catabolism of sugars, fatty acids, glycerol and amino acids produces the
following compounds under aerobic conditions:
o Glucose, galactose, fructose pyruvate acetyl~CoA
o Glycerol pyruvate acetyl~CoA
o Fatty acids and ketone bodies acetyl~CoA
o Amino acids pyruvate ( acetyl~CoA), acetyl~CoA,
oxaloacetate, -ketoglutarate, fumarate and succinate
All of these products can enter stage 3 of catabolism, the tricarboxylic acid cycle (TCA
cycle) a mitochondrial pathway.
Nitrogen metabolism
The term Nitrogen metabolism covers the metabolic processes that relate to the metabolism
of all nitrogen-containing compounds (N-cpds) in the body. The metabolism of individual N-
cpds alters in a variety of diseases and the measurement of particular N-cpds in blood and urine
can be useful in the diagnosis of specific diseases.
N-compounds in the body
The total amount of nitrogen in the body (70kg male) is 2.0 kg ( 3% of the body weight)
and it is found mostly in the high molecular weight molecules such as proteins (the major N-
compounds in the body containing over 90% of the nitrogen), DNA & RNA. In addition, there
are several low molecular weight N-containing molecules which are present in small amounts
but which have important functions. These include: amino acids, purines & pyrimidines,
hormones, neurotransmitters, porphyrins, creatine, and carnitine.
93
Overview of whole body nitrogen metabolism (healthy 70kg man)
Body proteins (2.0kg N) Loss of skin, hair (2g N)
Dietary protein Amino acid pool (16g N) N-compounds (60g N)
(16g N)
N-waste products in urine
(14g N)
Protein metabolism
Protein synthesis: All of the proteins synthesized in the body have specific functions, and the
body does not synthesize a specific protein simply to store excess amino acids.
Protein turnover: All body proteins undergo continuous breakdown & resynthesis i.e. they
turnover, the rate of turnover depend on the protein and varies during growth (fast) and ageing
(slows). The average half-life of a body protein is ~80 days. The total protein turnover in a
healthy adult is 300-400g per day and of this, 100-150g are muscle proteins & digestive
enzymes. Normally the rate of protein breakdown equals the rate of resynthesis. Protein
turnover is not a random process and mechanisms exist for identifying proteins that are to be
degraded.
Nitrogen balance (N-balance): Most nitrogen (N) enters the body as protein (>90%). and most
N leaves the body as urea (~85%), creatinine (5%), ammonia (3%) and uric acid in the urine
(some in sweat and faeces). In addition, there is some direct loss of protein (skin, hair, nails etc)
from the body.
In healthy adults there is a steady state in which the amount of N taken into the body equals
the amount of N lost from the body and the individual is said to be in N-balance. During periods
of active growth, pregnancy, tissue repair and convalescence N intake is greater than N loss
(positive N-balance). There are many situations in which N intake is less than N loss (negative
N-balance) including starvation, malnutrition and trauma.
Amino acid metabolism
Essential Amino Acids: The following amino acids are essential for an adult and cannot be
synthesized in the body: lysine, isoleucine, leucine, threonine, valine, tryptophan,
phenylalanine & methionine. Small quantities of histidine and arginine can be synthesised in
the body and a dietary supply normally only becomes necessary during periods of active growth
such as during pregnancy. Tyrosine can be synthesised in the body from phenylalanine and it
94
may become essential if the diet is low in phenylalanine. Similarly cysteine can be synthesised
from methionine in the body and may become essential if the diet is low in methionine.
Amino acid pool: The amino acid pool is the total amount of free amino acids in the body
(intracellular and extracellular) and is 100g in a 70Kg male. The normal fasting concentration
of amino acids in the blood is ~3mM. Four non-essential amino acids make up 50% of the
pool (glutamine, alanine, proline and glycine).
Amino acid reutilization: Approximately 75% of the amino acids released during protein
breakdown are reutilised for protein synthesis. The other 25% are either oxidised to release
energy or used in the synthesis of other N-compounds. A regular and adequate supply of protein
in the diet is required to replace the amino acids that are not reutilised.
Amino acid synthesis: The body can only synthesize some of the amino acids it requires at a
rate sufficient to satisfy the needs of the body (the non-essential amino acids) the remainder
have to be supplied in the diet (the essential amino acids). The carbon atoms for the non-
essential amino acids come from intermediates of glycolysis (C3), the pentose phosphate
pathway (C4 & C5) and the Krebs cycle (C4 & C5). The amino group comes from other amino
acids by the process of transamination or from ammonia.
Amino acid functions. The main functions of amino acids are protein synthesis (requires all
20 amino acids) and the synthesis of other N-compounds (requires specific amino acids). Those
supplied in excess of the requirements for these processes are not stored but are converted to
intermediates of carbohydrate and lipid metabolism or oxidised to provide energy. Also, it is
now known that two important signaling molecules are synthesised from amino acids in the
body: nitric oxide from L-arginine and hydrogen sulphide from L-cysteine.
Synthesis of N-compounds: Some amino acids are used in the synthesis of other N-
compounds. For example tryptophan is used in the synthesis of 5-hydroxytryptamine (5-HT), a
neurotransmitter, and histidine is used in the synthesis of histamine, a local mediator. Glycine
and tyrosine are unusual in playing a role in the synthesis of several N-compounds. Thus,
tyrosine is used in the synthesis of melanin, thyroid hormones & catecholamines while glycine
is used in the synthesis of purines, gluthathione, porphyrins and creatine.
Amino acid breakdown: Amino acids available in excess of those needed for protein and N
compound synthesis cannot be stored or excreted and are therefore broken down into smaller
molecules. Many tissues are involved but the liver is the major site of breakdown of most amino
acids. Each amino acid has its own pathway of breakdown but the pathways share common
features:
o The C-atoms are converted to intermediates of carbohydrate and lipid metabolism.
o They usually start with removal of the NH -group (transamination or deamination).
o The N-atoms are usually converted to urea.
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Fate of the C-atoms of amino acids
All the C-atoms are converted to one or more of the following:

o pyruvate, oxaloacetate, fumarate, -ketoglutarate, succinate
o acetyl CoA, acetoacetyl CoA
Fourteen amino acids are converted to one or more of the products in (i) and are called
glucogenic (they can be used to synthesize glucose or glycogen). Leucine and lysine are
converted to intermediates in (ii) and are called ketogenic (they can be used to synthesize fatty
acids or ketone bodies). Isoleucine, tyrosine, phenylalanine & tryptophan are both glucogenic
and ketogenic. Normally the products of amino acid degradation are oxidized to CO and H O
and the energy released used by the cell. However, in starvation and diabetes the products can
be used to produce glucose and ketone bodies.
Fate of the N-atoms of amino acids: The amino groups of amino acids are initially transferred
to other molecules (transamination) or removed (deamination).
Transamination: This is the major mechanism for the removal of the NH2-group from amino
acids. The enzymes involved are called aminotransferases (transaminases) and they are specific
for individual amino acids or groups of structurally similar amino acids. The reaction of an
aminotransferase is:
Most transaminases use -ketoglutarate as the keto acid2 and this is converted to glutamate.
When oxaloacetate is used as keto acid2 it is converted to aspartate an important intermediate
in the synthesis of urea. The hormone cortisol stimulates transaminase synthesis in the liver.
Two transaminases are clinical important (alanine aminotransferase and aspartate
aminotransferase) as they are measured in the serum of patients to assess liver function.
Unfortunately they are known by a number of different names:
Alanine aminotransferase (ALT) = glutamate-pyruvate transaminase (GPT):
Alanine + -ketoglutarate pyruvate + glutamate
Aspartate aminotransferase (AST) = glutamate-oxaloacetate transaminase (GOT):

Aspartate + -ketoglutarate oxaloacetate + glutamate
Deamination: Several enzymes of varying specificity are found in the liver and kidney which
react with amino acids to remove the NH2-group as free NH3 (NH +): L&D-amino acid
96
oxidases are low specificity enzymes that convert amino acids to keto acids and NH . Human
liver cells have a high activity of D-amino acid oxidase. D-amino acids are found in plant and
bacterial cell and therefore enter the body through the diet. They must not be used for protein
synthesis as the proteins would be structurally abnormal and non-functional. The enzyme
converts them to keto acids that are not optically active.
Glutaminase is a high specificity enzyme that converts glutamine to glutamate + NH .
Glutamate dehydrogenase is a high specificity enzyme that catalysis the reaction:
Glutamate + NAD+ + H O -ketoglutarate + NH + + NADH + H+
This reaction is important in amino acid metabolism by the liver as it is involved in both the
disposal of amino acids (glutamate -ketoglutarate +NH +) and the synthesis of non-
essential amino acids ( -ketoglutarate glutamate). The direction of the reaction is
determined by the relative concentrations of the substrates and products.
Disorders of amino acid metabolism
Over 50 inherited disorders of amino acid metabolism have been discovered each one
resulting from a specific enzyme defect. There may be a total loss of enzyme activity but usually
there is only a partial loss. The disorders usually only have clinical consequences when the
affected enzyme is involved in amino acid breakdown. This is because sufficient amino acids
are normally supplied in the diet to overcome any defect in their synthesis. However, a defect
in breakdown allows the amino acid and/or products of its breakdown to accumulate and these
may be toxic themselves and/or may be metabolized to toxic products. The toxicity may
produce mental retardation and developmental abnormalities. Treatment usually involves
restricting the amount of a particular amino acid in the diet by using a special diet. This must
be done early in life. There are number of metabolic disorders which affect the metabolism of
phenylalanine and tyrosine including alkaptonuria, phenylketonuria and albinism.
Phenylketonuria (PKU)
It is an inherited metabolic disorder in which the urine contains large amounts of

phenylketones produced from phenylalanine. The first step in the metabolism of phenylanine
is its oxidation to tyrosine by the enzyme phenylalanine hydroxylase. This enzyme is defective
in most cases of PKU. As a result of the deficiency, phenylalanine accumulates in tissues and
blood. It is metabolised by other pathways to produce various products including
phenylpyruvate that is excreted in the urine. The condition is diagnosed by the detection of
phenylketones in the urine or by the measurement of the blood phenylalanine concentration.
This is normally less than 0.1mM but in phenylketonuria can exceed 1.0 mM. The condition is
treated by a special diet that is low in phenylalanine. The untreated condition is associated with
an inhibition of brain development. This is because phenylpyruvate inhibits pyruvate uptake
into mitochondria and interferes with energy metabolism in the brain. Affected individuals must
therefore be identified shortly after birth and fed an appropriate diet. Many countries (including
the UK) have screening programmes for all new born babies.
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Homocystinuria
It is a rare inherited autosomal recessive defect in methionine metabolism, in which Type 1

is caused by a deficiency in the cystathionine -synthase (CBS) enzyme. The CBS enzyme
normally converts homocysteine to cystathionine, which is further converted to cysteine. If CBS
is deficient then the levels of homocysteine increase in the blood and some of the homocysteine
can be converted to methionine. The condition is usually detected by elevated levels of
homocysteine and methionine in plasma and the presence of homocystine (the oxidised form
of homocysteine) in the urine.
Chronic elevated plasma levels of homocysteine cause disorders of connective tissue,

muscle, CNS and the cardiovascular system, although the mechanisms are not fully understood.
In children the symptoms of homocystinuria are very similar to Marfan's syndrome and it can
be easily misdiagnosed. Research has shown that elevated levels of homocysteine in plasma are
a risk factor for cardiovascular disease, although the mechanisms involved have not been fully
elucidated. Interest in the CBS enzyme has increased recently as it can also metabolise cysteine
to produce hydrogen sulphide, which is a signalling molecule in the body.
Ammonia metabolism
Most (98.5%) of the ammonia in the body (pH 7.4) is in the form of the ammonium ion:
+
NH + H O NH + OH-
Many tissues produce ammonia and it is also absorbed from the gut. However, ammonia is
toxic to cells. It is therefore normally rapidly detoxified and removed from the body. The
peripheral blood concentration is normally kept very low (25 M).
Toxicity of ammonia: The central nervous system is very sensitive to ammonia and high levels
of ammonia in the blood (hyperammonaemia) are associated with blurred vision, tremors,
slurred speech, coma and eventually death. The molecular basis of the toxic effect of ammonia
may involve its reaction with -ketoglutarate to form glutamate in mitochondria via glutamate
dehydrogenase. This effectively removes -ketoglutarate from the TCA cycle which slows,
disrupting the energy supply to brain cells. In addition, it may affect the pH inside cells of the
CNS and interfere with neurotransmitter synthesis and release.
Ammonia detoxification: The liver plays an important role in ammonia detoxification and
hyperammonaemia is seen in liver disease. Ammonia can be detoxified either by being used in
the synthesis of N-compounds such as glutamine or by conversion to urea and excretion from
the body. In addition, ammonia can be excreted directly from the body in the urine.
Glutamine synthesis: The normal blood concentration of glutamine (0.5mM) is higher than
that of any other amino acid and it increases further after a protein-rich meal. Glutamine is non-
toxic and is synthesised from ammonia and glutamate via the enzyme glutamine synthetase.
98
+
NH + Glutamate + ATP Glutamine + ADP + Pi
This reaction is used by certain cells in an attempt to reduce the toxicity of ammonia. The
glutamine is released from the cell and transported to the liver and kidney where it is hydrolysed
by glutaminase releasing the ammonia which is disposed of in the urine (kidney) or converted
to urea (liver).
+
Glutamine NH + Glutamate
Urea synthesis: Urea is very soluble in water and can therefore be excreted in the urine. It is
nontoxic, metabolically inert and has a high nitrogen-content (47%) and is therefore a very
effective way of disposing of unwanted nitrogen. Urea is synthesised in the liver by the urea
cycle (a series of 5 enzymes) and transported via the blood to the kidneys for excretion in urine.
The overall reactions of the cycle are:
HCO - + NH +
+ aspartate + 3ATP CO(NH ) + fumarate + 2ADP + AMP + 4Pi
The NH groups of urea come from NH + and aspartate. NH + comes from the actions of
enzymes in the liver that deaminate amino acids releasing NH and from NH produced by gut
bacteria that enters the liver via the portal circulation. Aspartate is formed from oxaloacetate by
transamination.
Regulation of urea synthesis: The enzymes of the cycle are not subjected to feed-back
inhibition by the end product of the cycle as the function of the cycle is to dispose of ammonia
as urea. However, the enzymes of the cycle are inducible; a high protein diet induces the
enzymes while a low protein diet or starvation represses enzymes. Since starving individuals
have a very low activity of the enzymes of the cycle it is important that treatment involves the
gradual re-introduction of protein. Too much protein too soon will lead to hyperammonaemia
as excess amino acids are degraded.
Inherited diseases of the urea cycle: Defects in each one of the five enzymes of the urea cycle
have been discovered. The complete loss of an enzyme is always fatal but the partial loss may
not be fatal and such defects occur with a frequency of 1 in 30,000 live births. All defects
cause:
o Hyperammonaemia (high blood NH + concentration)
o Accumulation and/or excretion of a particular urea cycle intermediate(s)
The clinical picture depends on the extent of the defect and the amount of protein eaten and
includes vomiting, lethargy & irritability. There is usually mental retardation. In severe cases
there may be seizures, coma and eventually death. Treatment usually consists of low protein
diets and diets in which the keto acids of the essential amino acids are used to replace the amino
acids themselves. The keto acids are converted to amino acids using some of the NH + thereby
lowering its concentration in the tissues.
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Hyperammonaemia: may also arise as a secondary consequence of liver disease such as

cirrhosis where the liver's ability to remove NH3 from the portal blood is impaired.
Metabolic fate of urea: Urea diffuses from the liver cells to the blood and is carried to the
kidney where it is filtered and excreted in the urine. A small amount of urea may diffuse across
the intestinal wall and enter the intestine. Here bacteria may break it down releasing ammonia
that can be reabsorbed. In kidney failure where the concentration of urea in the blood is high,
the production of ammonia from urea by gut bacteria can contribute to the hyperammonaemia.
Overview of ammonia metabolism
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Group work
Case 1. Hyperlipidaemia
The patient is a 15-year-old female who had been admitted to the pediatric ward of the Hospital
at mid-day with suspected appendicitis after severe abdominal pain throughout the night. A
long history of abdominal pain had been ascribed to a grumbling appendix. A blood specimen,
taken from the child on admission, had the appearance of cream of tomato soup and after
centrifugation a creamy layer was found at the top of the sample. The child's mother indicated
that her daughter had not eaten for at least 15 hours but that she had attended a birthday party
the previous evening. The party had been held at Macdonald's and her daughter had eaten burger
and chips followed by ice cream and had drunk a milk-shake. The child's plasma triglycerides
and cholesterol were elevated (hyperlipidaemia) and electrophoresis of her plasma lipoproteins
indicated the presence of large amounts of chylomicrons. The lipoprotein lipase activity in her
plasma was low. The child was prescribed a special low-fat diet with increased amounts of
carbohydrate and protein to provide appropriate energy intake. The hyperlipidaemia regressed,
the abdominal pain subsided and after few days she was discharged. Her subsequent
development was reasonably normal, although there were episodes of violent abdominal pain
and hyperlipidaemia apparently related to excessive consumption of fat.
a. Provide an explanation for the creamy appearance of the patient's plasma.
b. Are chylomicrons normally present in a plasma sample taken from a patient who has not
eaten for 15 hours? Explain your answer.
c. What is the cause of the patient's high level of chylomicrons?
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d. What possible causes could there be for the patient's low plasma lipoprotein activity?
e. Why was the patient's plasma cholesterol elevated?
f. What are the potential problems of a low-fat diet?
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Case 2. Hypercholesterolaemia
A 37-year-old man was found to have hypercholesterolaemia during a health-screening

programme organised by his employers. A dietary history indicated that he consumed
considerable amounts of fatty food derived from animal sources. His fasting plasma cholesterol
concentration on two separate occasions was found to be 8.5mmol.l-1. His blood glucose was
within the normal range and thyroid function tests were normal. Electrophoresis of his plasma
lipoproteins revealed increased amounts of low density lipoproteins (LDL). He was prescribed
a low animal fat diet and various changes to his lifestyle were recommended (increased
exercise, no smoking and decreased alcohol consumption). However, after 3 months of
following these dietary and lifestyle recommendations, his fasting plasma cholesterol had only
decreased to 7.7 mmol/L. Since there was a family history of early heart disease he was treated
with simvastatin (a HMG~CoA reductase inhibitor). Over the next three months his is plasma
cholesterol fell to 5 mmol/L, a value that was considered acceptable for this patient. He was
advised to continue with his dietary and life-style changes.
a. Why was the patient initially prescribed a diet low in animal fat?
b. Why are life-style modifications considered to be an important component of the treatment

in this case?
c. Why does a cholesterol-free diet not necessarily reduce the plasma cholesterol concentration?
d. What is the significance of high plasma levels of low density lipoproteins (LDL)?
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e. What are the possible health benefits of a reduction in plasma cholesterol from 8.5 to 5.0
mmol/L in this patient?
f. How does simvastatin reduce plasma cholesterol concentrations?
Self-assessment
a. List the three ketone bodies produced in man and explain why they are only produced under
certain conditions.
b. Explain how lipids are transported around the body.
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c. Explain how tissues obtain the lipids they need from lipoproteins.
d. Explain why individuals with a defect in the enzyme lecithin-cholesterol acyltransferase

produce unstable lipoproteins of abnormal structure. What are the clinical consequences of this
defect?
e. A 32-year old male came to see you in a general practice surgery. He was concerned that his
father had died at the age of 50 from a heart attack and he wanted his blood cholesterol checked.
You arrange for a fasting blood sample to be taken and sent to the Clinical Chemistry Lab for
analysis. The laboratory reports the following results:
Total serum cholesterol = 12 mM (reference values = <5.2mM)
Serum triacylglycerol = 1.0mM (reference values = 0.5-2.0mM)
Serum lipoprotein profile = increased amounts of Low Density Lipoprotein particles (LDL)
1-What other analysis should you have requested and why?
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2-What is hyperlipoproteinaemia?
3-What type of hyperlipoproteinaemia is this patient likely to be suffering from?
4-What classes of lipoprotein are present in the serum from a fasting blood sample taken from
a normal individual and what are their functions?
5-List two signs or symptoms of the very high blood cholesterol that you might expect to find
in this patient?
6-Outline the pathways by which tissues obtain the cholesterol they need.
7-Outline the treatment options for this patient.
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f. Explain how some amino acids can be converted to glucose (glucogenic), some can be
converted to ketone bodies (ketogenic) and others can be converted to both glucose and ketone
bodies (glucogenic & ketogenic).
g. Describe in general terms how amino acids are degraded in the body and list the major
products of their degradation.
g. Describe in general terms how amino acids are degraded in the body and list the major
products of their degradation.
h. Describe the processes that produce ammonia in the body.
i. Explain why blood ammonia levels are normally kept low and describe the processes
involved.
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j. The patient was a 7-month old baby boy. He had developed normally until he was weaned at
6 months. Following the introduction of a high protein diet he had become irritable, lethargic
and less alert and had begun to vomit. He was admitted to hospital where he had episodes of
screaming, listlessness and ataxia (uncontrolled limb movements) especially after a protein rich
meal. His urine was persistently alkaline and contained a lower urea concentration than normal.
His blood NH + and glutamine concentrations were increased but fell to normal when his
protein intake was reduced. He was put on a special low-protein diet and his subsequent
development was normal.
Explain the biochemical basis of this patient's signs and symptoms.
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Session Six
Control of Energy Metabolism

Drug Metabolism
Aims of the session

The aim of this session is that you should have an overview of the ways in which energy
metabolism as a whole is controlled and the pathways of drug metabolism in the body.
Structure of the Session

08:00 – 09:00 Lecture: Control of energy metabolism
09:00 – 10:00 Lecture: Drug metabolism
10:30 – 01:30 Group work: PKU, amino acid metabolism

o Describe the major metabolic fuels and their sources in the normal individual.
o Describe how the blood glucose concentration is controlled and explain why this is
necessary.
o Compare and contrast the effects of insulin and glucagon on nutrient storage and
mobilization.
o Describe the metabolic responses to feeding and fasting and explain how they are
controlled.
o Describe the metabolic responses to starvation and explain how they are controlled.
Compare and contrast phase I and phase II of drug metabolism
o Discuss the importance of the cytochrome P450 system
o Explain variation in drug metabolism in the population
o Describe the specific examples of the metabolism of alcohol and paracetamol
Directed study: You should read the case studies on hypoglycaemia and glycogen storage
diseases. Your answers will be reviewed during the Group Work in Session 7.
Self-assessment: You should answer the self-assessment questions to ensure that you can
meet the learning objectives for the Session.
Reading:
Marks' Essential of Medical Biochemistry, Chapter 26.

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Lecture notes
Control of energy metabolism
All cells need a continuous supply of fuel to support their metabolism. A number of fuels
are potentially available either in the blood or from storage tissues. Hormonal control is a major
factor in determining the availability of fuel molecules in the blood and alterations in hormone
concentrations may have dramatic effects on blood fuel concentrations. The hormone insulin
lowers fuel concentrations in the blood while glucagon, adrenaline, growth hormone and
cortisol increase their concentrations. Since the effects of glucagon, adrenaline, growth
hormone and cortisol oppose those of insulin they are collectively known as the anti-insulin
hormones.
Glucose can be used by all cells and is the preferred fuel. However, there is very little free
glucose in the body. About 12g is present in solution in the body fluids and this would support
the metabolism of the CNS for ~2hr. More glucose (~300g) is stored as glycogen, principally
in liver and muscle. Only the glucose stored in the liver (~100 g) can be made available to
tissues such as the CNS. Many cells, but, not red blood cells or those in the central nervous
system can also use fatty acids as fuels. These are derived from triacylglycerol stored in adipose
tissue. In a typical 70kg individual there is 10-15kg of fat, enough to supply the body's fuel
needs for about two months. This makes up about 80% of the total fuel reserve in the body and
is substantially greater in the obese. Fatty acids can be converted to ketone bodies in the liver
to be used as fuel by tissues including the CNS when glucose is critically short during a period
of starvation. Some of the protein in muscle (~6kg) can be broken down (proteolysis) to amino
acids that can also be used to provide fuel in times of shortage, either by conversion to glucose
and ketone bodies or by direct oxidation. This fuel reserve corresponds to about two weeks
supply of fuel at normal rates of metabolism.
The central nervous system: The main problem in the control of fuel reserves is to ensure that
the CNS receives an adequate supply of glucose, in the face of apparently dangerously small
glucose stores. Glucose has to be available at all times as metabolism in the CNS (~140g/24hr)
and other glucose-dependent tissues (~40g/24hr) proceeds at a relatively constant rate
throughout the day. Since the rate of glucose uptake by the CNS is related to the blood glucose
concentration, the problem reduces to maintaining the blood glucose concentration within a
particular range. In a healthy individual, blood glucose concentration is maintained in the range
4.0-6.0mM. The blood glucose concentration is controlled via the endocrine system by
regulating the rates of entry of glucose into the blood and removal from it.
Hypoglycaemia: A reduction in blood glucose to 3.0mM or lower is known as hypoglycaemia.

The acute effects of hypoglycaemia can include: trembling, weakness, tiredness, headache,
sweating, and sickness, tingling around the lips, palpitations, and changes in mood (angry/bad
temper), slurred speech, and a staggering walk. They can be confused with intoxication.
Hypoglycaemia may rapidly lead to unconsciousness and death if untreated as the CNS is
starved of glucose.
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Hyperglycaemia: Elevation of the fasting blood glucose above 7.0 mM is known as

hyperglycaemia. The chronic effects of hyperglycaemia are generally insidious and reduce both
the quality and duration of life. Many systems of the body including the nervous, cardiovascular
and renal systems may be affected. Glucose appears in the urine; because all that is filtered by
the kidney cannot be recovered (the renal threshold for glucose is exceeded). More water is lost
in the urine as a result of the osmotic effect of the glucose ('polyuria') and so increased thirst
follows (polydipsia). Hyperglycaemia is also associated with abnormal metabolism of glucose
to products that may be harmful to cells. There is increased non-enzymatic glycosylation of
plasma proteins such as lipoproteins that leads to disturbances in their function (Session 8).
Feeding/fasting cycle
Individuals who eat regular meals experience a regular cycle of metabolic changes:
Effects of feeding: The absorption of glucose, amino acids and lipids from the gut raises their
blood concentration. These increases stimulate the endocrine pancreas to release insulin. Insulin
has the following actions:
o Increases glucose uptake and utilization by muscle and adipose tissue.
o Promotes storage of glucose as glycogen in liver and muscle.
o Promotes amino acid uptake and protein synthesis in liver and muscle.
o Promotes lipogenesis and storage of fatty acids as triacylglycerols in adipose
tissue.
Effects of fasting: As the blood glucose concentration falls insulin secretion is depressed. This
reduces the uptake of glucose by adipose tissue and muscle. The falling blood glucose
concentration also stimulates glucagon secretion i.e. insulin/anti-insulin ratio . This stimulates:
o Glycogenolysis in the liver to maintain blood glucose for the brain and other glucose
dependent tissues
o Lipolysis in adipose tissue to provide fatty acids for use by tissues
o Gluconeogenesis to maintain supplies of glucose for the brain
Should fasting proceed beyond 10hr the changes associated with starvation begin.
Starvation
Though it is relatively rare for individuals to eat no food at all for long periods, sustained
poor nutrition is very common worldwide. Diets poor in different components have a variety
of effects, but we will be concerned here solely with the consequences of inadequate intake of
energy in a previously well-nourished individual.
The initial response to starvation is merely a prolonged version of the normal fasting (inter-
meal) response. At first blood glucose falls, but is maintained at an adequate level (3.5mM) by
the actions of glucagon, which stimulates the breakdown of hepatic glycogen. As these stores
last only a few hours, the continuing reduction of blood glucose stimulates the pituitary to
release ACTH, and consequently blood cortisol is elevated. This hormone, amongst other
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effects, acts to maintain blood glucose by stimulating gluconeogenesis, and at the same time
making gluconeogenic substrates available (mainly alanine and glycerol) by stimulating the
breakdown of protein and fat. In addition to cortisol, glucagon also stimulates gluconeogenesis
and the actions of both hormones involve increasing the amounts and activities of key enzymes
of the gluconeogenic pathway in liver cells as well as increasing the availability of
gluconeogenic substrates.
Lipolysis occurs at a high rate, because of the fall in plasma insulin and rise in lipolytic
hormones such as glucagon, cortisol and growth hormone. Free fatty acids in blood rise to about
2mM, from a normal value in the fed individual of ~0.3mM. The continuing action of cortisol
stimulates fat breakdown, and as the reduction in insulin, reinforced by the anti- insulin effects
of cortisol, prevents most cells from using glucose, the fatty acids so produced are preferentially
metabolised. Glycerol then provides an important substrate for gluconeogenesis, reducing the
need for breakdown of proteins.
Under the influence of the change in the insulin/anti-insulin ratio, fatty acids are also
oxidized in the liver to produce ketone bodies, which can replace glucose as a fuel for the brain.
This further reduces the need for gluconeogenesis in the liver, and further spares body protein.
Ketone concentrations rise from 0.01mM in the fed state to 2- mM after three days of starvation
and 6-7mM after 1-2 weeks (physiological ketosis). As adaptation to starvation proceeds two
factors become important:
o The brain becomes able to use ketones as fuel, reducing its glucose requirement from
140g/day to 40g/day.
o The kidneys begin to contribute to gluconeogenesis.
The brain's use of ketone bodies reduces the need for breakdown of protein for
gluconeogenesis so that after 4-5 weeks starvation gluconeogenesis has fallen to ~30% of that
seen in the during the early period of starvation. Urinary nitrogen excretion initially about
12g/day (mostly urea) eventually falls to about 4g/day (approx. equal amounts of urea and NH
+
).
The reduction in urea synthesis during starvation leads to a marked decrease in the amount
and activities of the enzymes involved in the process in liver cells. This has important
implications for re-feeding a starved individual, where the temptation to give large amounts of
protein and/or amino acids, in the early stages, must be resisted and the protein content of the
diet increased gradually.
Once all of the body's fat stores are depleted, the system must revert the use of protein as a
major fuel, and as this is rapidly used up, death follows shortly. Death results from a number of
causes related to loss of muscle mass including serious respiratory infections due to loss of
respiratory muscle.
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Lecture notes
Drug metabolism
Pharmacology, the study of drug action, can be divided into two areas: pharmacodynamics
(how drugs work) and pharmacokinetics (the fate of drugs in the body). The term
pharmacokinetics' is derived from two Greek words 'pharmaco' pertaining to drugs and 'kinetics'
meaning movement. So it can be thought of as the study of the movement of drugs and their
metabolites through the body. A more scientific definition would be 'the study of the time
course of drugs and their metabolites in the body'. It is important not to confuse
pharmacokinetics with pharmacodynamics. An easy way to remember the difference is that
' pharmacodynamics is what the drug does to the body, whereas pharmacokinetics is what the
body does to the drug'.
The pharmacological effects of a drug depend on its free concentration at its site of action;
in other words, the pharmacodynamics of a drug depends on its pharmacokinetics. Essentially
pharmacokinetics covers the:
• Absorption,
• Distribution,
• Metabolism, and
• Elimination
of a drug (abbreviated to ADME)
Drug Metabolism
As soon as a drug enters the body it will begin to be metabolized. Most drugs are foreign to
the body and could have toxic effects, so they are deactivated and eliminated by metabolism. It
is an interesting question whether the necessary enzyme systems have evolved or whether these
exogenous compounds are simply metabolized by the existing enzymes for endogenous
metabolism. Most drugs are lipid-soluble and therefore it is inefficient to excrete them
unchanged in aqueous urine via the kidneys. The problem is that the lipid-soluble molecules
are reabsorbed from the urine into the blood in the renal tubules. Typically only 1% of the total
amount of drug in the body may be excreted in an unchanged state. Therefore drug molecules
are altered during metabolism to make them more water soluble, so that the metabolites can be
efficiently excreted via the urine. This usually occurs in two stages, termed phase I and phase
II metabolism. During metabolism the drug is usually deactivated, as the metabolites are usually
pharmacologically inactive, although this is not always the case. Some drugs are given as
prodrugs which are metabolized to the active form.
Phase I Metabolism
Most drug molecules are stable and relatively un-reactive, so in phase I a reactive group is
exposed on the parent molecule or added to the molecule. This generates a reactive intermediate
which can then be conjugated, in phase II, with a water-soluble molecule to form a water-
soluble complex. The most common chemical reactions in phase I are oxidation, reduction and
hydrolysis. The process requires a complex enzyme system called the cytochrome P450 (CYP)
system and a high-energy cofactor, nicotinamide adenine diphosphate (NADPH). Some drugs
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already have a reactive group on their molecule, so they can bypass phase I and go straight into
phase II metabolism. Morphine is a good example of a drug for which this occurs.
Phase II Metabolism
In phase II metabolism, the reactive intermediate from phase I is conjugated with a polar
molecule to form a water-soluble complex. The process is also known as conjugation.
Glucuronic acid is the most common conjugate, as it is a freely available by-product of cell
metabolism. Drugs can also be commonly conjugated with sulphate ions and glutathione. Phase
II metabolism requires specific enzymes and a high-energy cofactor, uridine diphosphate
glucuronic acid (UDPGA).
Sites of Metabolism
By far the major site of drug metabolism in the body is the liver, as the hepatocytes contain
all of the necessary enzymes. However, some other sites are important for some drugs, for
example the lungs, the kidneys, the gastrointestinal tract and the plasma.
Variation in Drug Metabolism in the population

Genetic Factors
Humans are a very heterogeneous species and each individual is genetically distinct. We all
differ slightly in the level of expression of metabolic enzymes. So, if the same dose of drug is
given to a sample of the population then it will be metabolized at slightly different rates in each
individual. Therefore drug effects can vary from person to person. There are about 50 different
haem-containing enzymes in the cytochrome P450 system (CYP) and there are polymorphisms
in the human population. The isoform CYP3 A4 is the most important, accounting for about
55% of drug metabolism, some individuals may lack the gene which codes for a crucial enzyme
and this can have a large effect on drug metabolism. For example, some people are described
as slow acetylators, because they lack the main enzyme responsible for the acetylation reaction
in phase II. This has a profound effect on the rate of metabolism of drugs requiring this pathway.
Some individuals have relatively low levels of pseudocholinesterase enzymes in the plasma,
which affects their ability to metabolise drugs containing an ester bond, such as
suxamethonium, a muscle relaxant used during anaesthesia. This emerging area of
pharmacogenetics is very important and has become more relevant since the sequencing of the
human genome.
Environmental Influences
Enzyme levels in the body are not fixed, but vary continuously and can be influenced by
external factors. If two drugs are given together to a patient then the metabolism of one drug
may affect the metabolism of the other drug. Enzyme inhibition or induction can occur. There
have been recent reports that some types of pesticides can cause enzyme induction in the liver.
Ethanol, nicotine and barbiturates are well known enzyme inducers.
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First pass effect

Substances absorbed from the lumen of the ileum enter the venous blood which drains into
the hepatic portal vein and is transported directly to the liver. Unfortunately, the liver is the
main site of drug metabolism as it contains all of the necessary enzyme systems, so any drug
absorbed from the ileum may be extensively metabolized during this first pass through the liver
- the first pass effect. For example, in the case of paracetamol, 90% of an oral dose is usually
metabolised via the first pass effect. This is one reason why quite large oral doses (1 g.) of
paracetamol are required.
Example of drug metabolism: metabolism of alcohol

Metabolic response to alcohol
Most of the alcohol (> 90%) that enters the body is metabolized, the remainder (< 10%)
being excreted passively in the urine and on the breath. The major site of alcohol metabolism
in the body is the liver. Most of the alcohol is oxidized by alcohol dehydrogenase (a low
specificity enzyme) to acetaldehyde and this is further oxidised to acetate by aldehyde
dehydrogenase. The acetate is converted to acetyl~CoA.
Acetaldehyde is extremely toxic to cells and its toxicity is normally kept to a minimum
because aldehyde dehydrogenase has a very low Km for acetaldehyde (10-7mol/L) and removes
it as soon as it is formed. However, when the consumption of alcohol is prolonged and
excessive, sufficient acetaldehyde can accumulate to cause liver damage. In addition, the
decrease in the NAD+/NADH ratio and the increased availability of acetyl~CoA, as a result of
alcohol catabolism, have significant effects on liver metabolism.
Effects of decrease in NAD+/NADH ratio on liver cell metabolism

The increased levels of NADH in the liver caused by alcohol oxidation means that NAD+
levels are inadequate for fatty acid oxidation, conversion of lactate to pyruvate and metabolism
of glycerol. The decreased utilization of lactate by liver cells leads to its accumulation in the
blood and may cause lactic acidosis. Increased levels of lactate reduce the kidney's ability to
excrete uric acid and as uric acid levels increase, crystals of urate may accumulate in tissues
producing the painful condition of gout. The low NAD+ level combined with the inability of
the liver cells to use lactate and glycerol means that gluconeogenesis cannot be activated and
fasting hypoglycaemia may become a serious problem. The poor dietary habits of the alcoholic
may also contribute to the hypoglycaemia as liver glycogen levels tend to be low.
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Effects of increased availability of acetyl~CoA

The increased availability of acetyl~CoA to liver cells, at a time when it cannot be oxidized
because of the low NAD+/NADH ratio, leads to increased synthesis of fatty acids and ketone
bodies. The newly synthesized fatty acids are converted to triacylglycerols. These cannot be
transported from the liver cells because of the lack of lipoprotein synthesis and they therefore
contribute to the fatty liver. In some cases, the production of ketone bodies is sufficient to cause
keto-acidosis.
Effects of damage to liver cells caused by toxic effects of acetaldehyde
Damaged liver cells have leaky plasma membranes that result in the loss of enzymes from
the cells. These enzymes include transaminases and gamma glutamyl transpeptidase and their
appearance in the blood is used diagnostically as an indicator of liver cell damage (liver function
tests).
Damaged liver cells do not perform their normal functions as well as undamaged liver cells
and this may produce a variety of signs and symptoms. A reduction in the capacity of liver cells
to take up and conjugate bilirubin leads to hyperbilirubinaemia that may produce jaundice. A
reduction in the capacity to produce urea may lead to hyperammonaemia and increased levels
of glutamine. Reduced protein synthesis in liver leads to decreased synthesis of albumin,
clotting factors and lipoproteins. Low serum albumin may produce oedema and decreased
amounts of clotting factors lead to an increase in blood clotting time. A failure to produce
adequate amounts of lipoproteins means that lipids synthesized in the liver (the major site of
lipogenesis) cannot be transported from the liver instead they accumulate and cause fatty liver.
Indirect effects of excessive alcohol consumption
The cost of alcoholic beverages and their effects on the central nervous system are such that
excessive consumption is generally associated with poor dietary habit. There are likely to be
vitamin and mineral deficiencies and there may also be inadequate protein and carbohydrate
intake.
Direct effect of alcohol on gastrointestinal tract

High concentrations of alcohol damage the cells lining the GI tract and produce a variety of
GI tract disturbances that may compound the effects of a poor diet. There is often loss of
appetite, diarrhea and impaired absorption of certain nutrients such as vitamin K, folic acid,
pyridoxine and thiamine. The signs and symptoms of specific vitamin deficiencies are often
seen in alcoholics. Neurological symptoms associated with deficiencies of thiamine or
pyridoxine and haematological problems (e.g. anaemia) associated with folic acid deficiency
are common in alcoholics. Thiamine deficiency can lead to the Wernicke-Korsakoff syndrome
with mental confusion and unsteady gait.
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Treatment of Alcohol Dependence
Disulfiram is a drug which can be used as an adjunct in the treatment of chronic alcohol
dependence. It is an inhibitor of the aldehyde dehydrogenase enzyme:
If the patient drinks alcohol then acetaldehyde will accumulate in the blood causing
symptoms of a hangover, such as nausea. With additional support it can be effective in treating
alcohol dependence.
Example of drug metabolism: metabolism of paracetamol

Paracetamol is a widely available antipyretic drug, which is safe if used at the normal dosage
specified. At therapeutic levels paracetamol is metabolised by phase II conjugation with
glucuronide or sulphate, however if a toxic dose is ingested then these pathways become
quickly saturated. Under these conditions paracetamol undergoes phase I metabolism,
producing a toxic metabolite, N-acetylp- benzo-quinone imine (NAPQI). This metabolite is
itself toxic to hepatocytes, but it also undergoes phase II conjugation with glutathione, so it
depletes the cells of glutathione, which is an important antioxidant. This causes destruction of
liver cells and liver failure occurs over a period of several days.
117
Group Work
Case 1. Phenylketonuria (PKU)
The patient was a two-week-old baby girl who had been discharged from the Hospital 2 days
after a normal delivery to healthy parents. One week after discharge, as part of the routine
screening of all newborn, the community midwife had visited the baby at home and taken a
small sample of the baby's blood from a heel-prick.. The blood sample was processed and had
indicated the presence of phenylketones. As a result of this positive result the baby's mother
was asked to bring her daughter to the paediatric department for further tests. At this time the
baby's serum phenylalanine concentration was found to be 2.0 mmol/L (reference values 0.05
to 0.1 mmol/L) and her serum tyrosine was 0.1 mmol/L (reference values 0.05 to 0.1 mmol/L).
Her urine was positive for phenylketones (phenylpyruvate). A diagnosis of Phenylketonuria
(PKU) was made.
a. What enzymatic reaction is likely to be defective in the patient with PKU?
b. Why does PKU cause an increase in serum phenylalanine and the production of
phenylpyruvate?
c. What are the clinical consequences of PKU, and why should it be detected as early as
possible?
d. What is the treatment for patients with PKU?
e. Will a patient with PKU require a dietary source of tyrosine? Explain your answer.
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Case 2: Homocystinuria
At the age of 7 Nawaàr was initially diagnosed as having Marfan's syndrome, with
developmental delay. Later tests at 10 years of age showed a high concentration of an amino
acid in his urine and blood levels of amino acids were measured as shown below. At the age of
30 he presented with chest pain which was diagnosed as angina and was successfully treated.
a. What was the amino acid found at high concentration in his urine?
b. Comment on the blood test results.
c. Briefly explain the biochemical basis of this condition.
119
d. Why do the signs and symptoms of homocystinuria initially resemble Marfan's syndrome?
e. Why is homocystinuria associated with increased risk of early onset cardiovascular disease?
f. How can homocystinuria be treated?
120
Self-assessment
You should answer these self-assessment questions to ensure you can meet the learning
a. Explain why the blood glucose concentration in man is normally held relatively constant
and describe how this is achieved.
b. Describe and account for the signs and symptoms of hypoglycaemia.
c. Outline the metabolic responses to feeding and fasting and describe how they are
controlled.
d. Outline the metabolic responses to starvation and describe how they are controlled.
121
e. Compare and contrast the effects of insulin and glucagon on nutrient storage and
mobilisation.
f. List the most common reactions involved in phase I of drug metabolism
g. List the most common reactions involved in phase II of drug metabolism
h. Briefly explain why the rate at which patients metabolize drugs can vary.
i. Briefly explain how the metabolism of alcohol can cause damage to the liver
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Session Seven
Review
Aims of the session

The aim of this session is to provide an opportunity to review the contents of the six
modules you have studied.

09:00 - 10:00 Review
10:30 – 01:30 Review
Module staff will be available to answer any last-minute queries arising from your revision
of the module.

On completion of this module, you should be able to:
o List the essential components of the human diet and explain why they are essential.
o Calculate Body Mass Index and describe the factors involved in the long-term
regulation of body weight
o Define homeostasis and discuss control systems in the body
o Explain how the energy required for cellular activity is derived from the food eaten
o Describe the general features and clinical relevance of the metabolic pathways by which
carbohydrates, lipids, amino acids and alcohol are oxidised and may be synthesised
from appropriate precursors.
o Outline the pathways involved in drug metabolism
o Describe the metabolic problems of anaerobic conditions and explain their clinical
consequences
o Describe in outline how glucose and lipids are transported and stored in the body and
explain the clinical consequences of defects in these pathways
o Describe how and why ketone bodies are produced and explain the clinical importance
of these molecules
o Analyse simple clinical case histories involving disturbances to metabolism such as
marasmus, kwashiorkor, obesity, galactosaemia, glucose 6-phosphate dehydrogenase
deficiency, hypercholesterolaemia, phenylketonuria, homocystinuria, glycogen storage
diseases, and hypoglycaemia
o List the major metabolic activities of the following: central nervous system, liver, heart
muscle, skeletal muscle, adipose tissue, red blood cells.
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Session Eight
Introduction to endocrinology and the endocrine pancreas

Aims of the session
The aim of this session is that you should understand the control of the endocrine system,
the function of the endocrine pancreas and how metabolism is controlled by the endocrine
system.

08:00 - 09:00 Lecture: Introduction to Endocrinology
09:00-10:00 Lecture: Hormones of the Endocrine Pancreas and the Control of Metabolism.
10:30 – 01:30 Group Work: case- hypoglycaemia and glycogen storage diseases
Intended learning Outcomes: By the end of this session you should be able to:
o Define the term 'hormone' and list the features of communication processes involving
hormones.
o List the classes of chemical substances which can act as hormones.
o Describe how hormones are transported and act upon target cells
o Explain, in general terms, the ways in which hormone secretion may be controlled
o Describe the actions of insulin and glucagon
o Describe how the ultrastructure of the -cell relates to the synthesis and storage of insulin.
o Explain the roles of insulin and glucagon in the control of metabolism
Directed study: Session 8 will cover diabetes mellitus. In order to prepare yourself for this
session you should read the notes on diabetes and try to answer the questions in the case studies.
Self-assessment:
You should answer the self-assessment questions to ensure that you can meet the learning
Suggested Reading:
Marks Essentials of Medical Biochemistry, p121-127, 304-311
Ganong's Review of Medical Physiology Chapter 18, 21
Medical Physiology Boron and Boulpaep Chapter 47, 51
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Lecture notes
Introduction to endocrinology
Organisms function because cells can communicate with one another. Communication
usually involves the production of chemicals by one cell or group of cells that travel by various
means to other cells and change their activity. Chemical messengers that travel via the
bloodstream are known as hormones. They are normally present in the blood at very low
concentrations (10-10 - - 9M) and may be bound to carrier proteins. Hormones are secreted by
endocrine glands. The cells upon which hormones act are known as target cells. It is usually
a change in the concentration of the hormone that produces a response in a target cell.
Hormones may be classified by chemical type.

o Polypeptide hormones (largest group) - short or long chain(s) of amino acids, e.g.
insulin, glucagon, growth hormone, placental lactogen
o Glycoprotein hormones - large protein molecules, (often made up of sub-units) with
carbohydrate side chain e.g. the 'anterior pituitary hormones' - luteinizing hormone
(LH), follicle stimulating hormone (FSH), thyroid stimulating hormone (TSH)
o Amino acid derivatives - small molecules synthesised from amino acids e.g. adrenaline
(a catecholamine) and the thyroid hormones - thyroxine, tri-iodothyronine
o Steroids - all derived from cholesterol e.g. cortisol, aldosterone, testosterone, oestrogen.
Endocrine glands are found throughout the body. Mostly they are discrete structures (e.g.
the thyroid, adrenals or gonads), but in some cases they are collections of cells scattered
throughout another organ (e.g. cells secreting insulin & glucagon are found as small groups of
cells in the pancreas).
The endocrine glands that produce the polypeptide hormones and catecholamines normally
store their hormonal products within the cell in discrete storage vesicles prior to secretion. The
steroid producing tissues do not normally store hormones but store their precursor, cholesterol,
as cholesterol esters in the form of lipid droplets. The thyroid gland is an interesting exception
to these two general types of endocrine tissue in that it stores its hormonal products outside the
cell in the form of a protein colloid.
Polypeptide hormones, glycoprotein hormones and adrenaline are relatively hydrophilic and
are transported in the bloodstream dissolved in the plasma. Steroid hormones and thyroid
hormones are relatively hydrophobic (lipophilic) and need specialized transport proteins.
Hormones only work effectively if their secretion is controlled so that the desired
physiological effect on target cells is achieved. Generally speaking, the effect that a hormone
has on a target cell depends upon its concentration in the blood stream. Often however,
lipophilic hormones (steroids and thyroid hormones) bind specifically or non-specifically to
proteins in the blood, and in this case it is the concentration of unbound or free hormone that
matters. For example, the total concentration of thyroid hormones in the blood is normally 60-
160 nM. However, ~75% of this is normally bound specifically to thyronine binding globulin
(TBG) and ~25% is bound non-specifically to other proteins such as albumin. Thus, the
concentration of free and therefore biologically active thyroid hormones in the blood is
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normally less than 1% of the total concentration and is in the range of 15-30 pM. Changes in
the binding of hormones to proteins in the blood can have complicated effects on the
responsiveness of target tissues.
If the physiologically effective concentration of the hormone in the blood is too low, the
subject will suffer hormone deficiency, which will usually produce a number of effects. For
example, if there is greatly reduced secretion of growth hormone a hormone from the anterior
pituitary gland, a child will fail to grow properly.
If the physiologically effective concentration of the hormone is too high, then the signs and
symptoms of excess will occur. For example, in Acromegaly there is excess secretion of growth
hormone, which, in the adult produces characteristic changes in the shape of the face and body
and other metabolic effects.
Hormones are constantly lost from the circulation as they are excreted or broken down, so
the secretion rate must be adjusted to maintain an appropriate blood concentration. The rate of
secretion of a hormone is usually controlled by negative feedback. In such a system, the rate of
secretion of the hormone is affected by either the blood concentration directly, or more
commonly by some consequence of blood concentration. If the blood concentration is 'correct'
then hormone secretion slows. As soon as the concentration or the effect of the hormone falls
below a critical level, hormone secretion increases, until the correct level is achieved again.
Example: The pancreatic -cells secrete insulin. This acts on liver, muscle and adipose tissue
to remove glucose from the blood. The -cells are directly sensitive to blood glucose
concentration. If it rises above 5 mM i.e., following a meal, insulin is secreted and so the blood
glucose concentration falls until it reaches the normal level again when insulin secretion is
switched off. This is an exact analogy to the operation of a thermostat in a heating system.
In many cases, however, the secretion of one hormone is controlled by another. This second
hormone is known as a trophic hormone. Trophic hormones are mostly secreted by the
anterior pituitary gland found just below the brain. For example the secretion of cortisol from
the cortex of the adrenal gland is controlled by adrenocorticotrophic hormone (ACTH), secreted
from the anterior pituitary.
The anterior pituitary secretes six main hormones:

o Thyroid Stimulating Hormone, Thyrotrophin (TSH) - affects thyroid gland
o Adrenocorticotrophic Hormone, Corticotrophin (ACTH) - affects adrenal gland
o Growth Hormone, Somatotrophin (GH) - affects metabolism
o Luteinizing Hormone (LH) - affects ovary and testis function
o Follicle Stimulating Hormone (FSH) - affects ovary and testis function
o Prolactin - affects breast development and milk production
TSH, ACTH, LH and FSH are all trophic hormones that control the hormone production of
other endocrine glands. The secretion of the trophic hormones must itself be controlled. In some
cases the concentration of the hormone they control affects the secretion by negative feedback
- an example is TSH. When the concentration of thyroid hormone in the blood gets too high
less TSH is secreted, so thyroid hormone production falls. Conversely if thyroid hormone
concentration is too low, then more TSH is secreted, so more thyroid hormone is produced.
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In addition, however, some factors change the setting of the 'thermostat' to produce
controlled changes in hormone concentration. These substances act on the anterior pituitary
cells, and are known as Releasing or Inhibiting Hormones (depending on whether they turn
the 'thermostat' up or down). Releasing and Inhibiting Hormones come from nerve cells in a
part of the brain close to the pituitary gland, known as the hypothalamus, and travel to the
gland via specialised blood vessels known as the hypophyseal portal vessels. This allows the
brain to control hormone secretion, and explains, for example how the secretion of hormones
can change during stress.
Examples of releasing or inhibiting hormones include:
o Thyrotrophin Releasing Hormone (TRH) - stimulates TSH release.
o Corticotrophin Releasing Hormone (CRH) -stimulates ACTH release
o Somatotrophin Releasing Hormone (SRH) - stimulates GH release
o Somatostatin - inhibits GH release
To change the activity of a target cell, hormones must interact chemically with the target
cell. The first stage in this interaction is the binding of the hormone to specific, high affinity
receptors on or in the cell. The location of the receptor in the target cell depends upon the
chemical nature of the hormone. Hormones that can cross cell membranes (i.e. are lipophilic)
bind to receptors inside cells (cytoplasmic and/or nuclear). Hormones that cannot readily cross
cell membranes (i.e. are hydrophilic) bind to receptors on the cell surface. The binding of the
hormone to a receptor triggers changes in the target cells, which may be in the activity of
enzymes or other proteins or in the expression of genes. Where hormones bind to receptors on
the cell surface, a second messenger is often released within the cell, which goes on to
influence the cell's activities. Examples of second messengers include cyclic AMP (cAMP) “ a
low energy signal” produced from ATP, cyclic GMP (cGMP), calcium ions (Ca+2), inositol
trisphosphate (IP3) and diacylglycerol (DAG).
Target tissues usually respond rapidly (seconds-minutes) to hormones that work by altering
the activity of functional proteins (e.g. enzymes, membrane transport proteins) involved in the
response mechanism. In contrast, the response of target tissues to hormones that work by
changing the rate of gene expression occurs over a longer time period (minutes-hours) and may
even occur after the hormone concentration has returned to normal. Some hormones appear to
have one major target tissue (e.g. the major effects of Thyroid Stimulating Hormone are on the
thyroid gland) while others have a number of important target tissues (e.g. insulin has important
actions on liver, muscle and adipose tissue).
Inactivation of hormones occurs in the liver and kidney and sometimes in target tissues.
Steroid hormones are inactivated by a relatively small change in chemical structure that
increases their water solubility enabling them to be excreted from the body in the urine or via
the bile. Protein hormones undergo more extensive chemical changes and are degraded to amino
acids that are reused for protein synthesis.
Hormones play important roles in regulating growth, development and reproduction. They
are also involved in nutrient and electrolyte homeostasis and in the body`s response to stress,
trauma and external stimuli. Abnormalities of the endocrine system cause a number of
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important clinical problems including thyroid disease, diabetes, Cushing`s disease, Addison`s
disease, infertility for example.
Disorders of the endocrine system that produce clinical consequences can result from a number
of causes. These include:
o There may be changes in the endocrine tissue that leads to over or under secretion of
hormones or production of structurally abnormal and less effective hormones
o The responsiveness of endocrine tissues may be altered by the presence, in the
circulation, of abnormal proteins such as antibodies
o The physiologically effective concentration of the hormone in the circulation may be
reduced because of binding to circulating proteins
o There may be changes in the responsiveness of target tissues to hormones resulting from
changes to receptors and/or post-receptor events
Lecture notes
The endocrine pancreas
The pancreas has both endocrine and exocrine functions that are reflected in its histological
structure. The endocrine functions of the pancreas are performed by the Islets of Langerhans.
These are small (~0.25 mm diameter) spherical structures which contain ~6,000 cells and are
found scattered throughout the exocrine tissue. The normal adult pancreas weighs 200-300g
and contains ~1 million islets which represent only 1-2% of the weight of the organ.
A typical islet contains a number of cell types that produce different polypeptide hormones.
The major cell types are the β -cells (~75%) that produces insulin and the α- cells (~20%) that
produce glucagon. Both these cell types store their hormonal products intracellularly in
membrane-limited vesicles (storage granules) prior to secretion and each cell may contain up
to 13,000 storage vesicles. In addition, they have ultra-structural features characteristic of
tissues that synthesize proteins for export, such as extensive rough endoplasmic reticulum, a
well-defined Golgi apparatus, many mitochondria and a well-defined system of microtubules
and microfilaments.
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Insulin
Structure: Insulin is an unusual polypeptide hormone as it contains two polypeptide chains (A
and B chains) linked covalently by two disulphide bridges. In addition to the disulphide bridges
that link the two chains together, there is a third disulphide bridge in the A chain. The presence
of two polypeptide chains and three disulphide bridges affect the way the molecule is
synthesised as the disulphide bridges have to connect the correct cysteine residues to ensure the
biological activity of the molecule.
Synthesis: Insulin is synthesised as pre-proinsulin (a single-chain polypeptide of 109 amino

acids) on ribosomes associated with the rough endoplasmic reticulum. The pre-part (23 amino
acids) is a signal peptide that ensures the newly synthesised protein enters the cisternal space
of the endoplasmic reticulum. The signal peptide is removed once the molecule enters the
endoplasmic reticulum. The remaining proinsulin (86 amino acid, single-chain polypeptide)
folds to ensure that there is correct alignment of the cysteine residues and the correct disulphide
bonds form.
Proinsulin is transported from the endoplasmic reticulum to the Golgi apparatus and
packaged into storage vesicles. Proteolysis in the storage vesicles removes a connecting peptide
(C-peptide) of 31 amino acids together with four basic amino acids (3 arginine and 1 lysine)
from near the middle of the chain. This breaks the single chain into two chains that are held
together by disulphide bridges i.e. the mature insulin molecule. The storage vesicles contain the
products of proteolysis i.e. insulin and C-peptide in equimolar amounts and a small amount of
unchanged proinsulin. The entire contents of the storage granules are released during secretion.
As C-peptide is released with insulin, its level in plasma is a useful marker of endogenous
insulin release. Measurement of plasma C-peptide levels in patients receiving insulin can
be used to monitor any endogenous insulin secretion.
Transport: Insulin is stored in the -cell storage granules as a crystalline zinc-insulin complex.
When released it dissolves in the plasma and circulates as a free hormone (i.e. not bound to a
transport protein).
Target tissues: The major target tissues for insulin action are liver, skeletal muscle and adipose
tissue. In addition, insulin is required for the normal growth and development of most tissues
of the body. Insulin interacts with receptors on the surface of its target cells.
Actions: Insulin has a wide range of effects on its target tissues and affects carbohydrate, lipid
and amino acid metabolism. These effects are largely anabolic and are related to insulin's major
function of clearing absorbed nutrients from the blood following a meal. Most of the effects
occur rapidly (sec/hr) in response to an increase in the concentration of insulin in the circulation
and are produced by changes in the activities of pre-existing functional proteins such as
enzymes and transport molecules in target tissues. In addition, insulin has long-term (hr/days)
effects on cell growth and division that relate to its ability to stimulate the synthesis of new
protein molecules and to stimulate DNA replication.
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The major actions of insulin on carbohydrate, lipid and amino acid metabolism are:
o Increase glucose transport into adipose tissue & skeletal muscle.
o Increase glycogenesis and decrease glycogenolysis in liver & muscle.
o Decrease gluconeogenesis in liver.
o Increase glycolysis in liver & adipose tissue
o Decrease lipolysis in adipose tissue.
o Increase lipogenesis and esterification of fatty acids in liver & adipose tissue.
o Increase lipogenesis and esterification of fatty acids in liver & adipose tissue.
o Increase lipoprotein lipase activity in the capillary bed of tissues such as adipose
tissue.
o Increase amino acid uptake and protein synthesis in liver, muscle & adipose tissue.
o Decrease proteolysis in liver, skeletal muscle & heart muscle
Control of Insulin Secretion: Insulin is the major hormone that acts to lower the blood glucose
concentration and its secretion must be controlled to ensure that the glucose concentration stays
within the normal physiological range under a variety of situations. Thus, insulin secretion is
controlled by a number of factors that ensure that the rate of secretion is appropriate for the
prevailing conditions. These factors include metabolites (glucose, amino acids, fatty acids), GI
tract hormones (gastrin, secretin, cholecystokinin) and neurotransmitters (adrenaline,
noradrenaline, acetyl choline). The metabolic signals, GI tract hormones and acetyl choline all
stimulate secretion, while adrenaline and noradrenaline inhibit secretion.
Glucagon
Structure and synthesis: Glucagon is a single chain polypeptide hormone. The molecule lacks
disulphide bridges and has a flexible 3D structure that takes up its active conformation on
binding to its receptor on the surface of target cells. It is synthesised as a larger precursor
molecule (pre-proglucagon) that undergoes post-translational processing to produce the
biologically active molecule.
Action: The major actions of glucagon are:

o Increase glycogenolysis and decrease glycogenesis in liver
o Increase gluconeogenesis in liver.
o Increase ketogenesis in liver.
o Increase lipolysis in adipose tissue
Mechanism of action: The mechanism of action of glucagon has been defined and will be
covered in detail in the MGD and Membranes and Receptors Modules. Glucagon binds to a
specific glucagon receptor in the cell membrane, which is a type of receptor termed a G protein-
coupled receptor (GPCR). Binding to the receptor activates the enzyme adenylate cyclase,
which increases cyclic AMP (cAMP) intracellularly. High levels of cAMP activate protein
kinase A (PKA), which phosphorylates and thereby activates a number of important enzymes
in target cells.
Secretion: The major factor that increases the rate of secretion is a decrease in the blood glucose
concentration.
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Group work
Case study 1 - hypoglycaemia
The patient is a 5 year-old girl with a history of multiple hospitalisations for hypoglycaemia
and metabolic acidosis on fasting. On first admission to the hospital, the patient (age 6 months)
was noted to be alert and of normal height and weight. Fasting hypoglycaemia and metabolic
acidosis were readily elicited by an 8 hr overnight fast. The intravenous infusion of a glucose
solution resulted in rapid and complete recovery and she was discharged without a specific
diagnosis. Over the next few years the patient was admitted several times for hypoglycaemia
and metabolic acidosis on fasting and it was during the most recent admission that a specific
diagnosis was made.
Evaluation of the clinical problem

The evaluation of this patient`s hypoglycaemia and metabolic acidosis upon fasting
demonstrates a method of clinical investigation based upon basic biochemical concepts and
methods. One may investigate the metabolic acidosis or the hypoglycaemia first. The
hypoglycaemia was investigated first.
a. What is hypoglycaemia and what are its clinical signs?
b. What is metabolic acidosis?
c. Why investigate the hypoglycaemia before investigating the acidosis?
d. What are the causes of hypoglycaemia?
e. How would you proceed to investigate the biochemical basis of the patient`s hypoglycemia?
Answer this question before turning the page.
131
Clinical Investigation of Fasting Hypoglycaemia
Fasting hypoglycaemia is caused, either by an abnormality in one of the pathways of

carbohydrate metabolism or by a defect in the control of these pathways. Either too much
glucose is being used or too little glucose is being produced.
An endocrine basis for the patient`s problem was excluded on the basis of measurements of
plasma insulin, glucagon, cortisol and growth hormone concentrations, all of which were within
their reference ranges. A reasonable approach to establishing the nature and location of the
patient`s metabolic defect is first to follow the changes in blood metabolites during fasting and
then to look at the changes in blood metabolites following the ingestion of various substances
that can normally be metabolised.
Response to Fasting
After several days on a normal diet, the child was fasted after a large 8pm meal and blood
samples taken at four hourly intervals for analysis of various metabolites. The results of these
analyses were given in below
Effect of fasting on blood metabolite concentrations
f. Which results above reflect an abnormal response to fasting?
g. What evidence is there in Table 1 that glycogen metabolism in the patient is probably normal?
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Evaluation of glucose utilization
The next step was to administer glucose (1g glucose/kg body weight) orally after an eight
hour overnight fast and measure the concentration of glucose in the blood at the time of
administration and at 30 min intervals thereafter. This is procedure is known as a glucose
tolerance test (GTT) and the results of the test are given in below Oral glucose tolerance test
results
The results reflect those of a normal glucose tolerance test with a peak value for glucose at
~1h and a return to the initial value by 2h. One can conclude from this data that the utilization
and storage of glucose by the patient`s tissues is normal and that the fasting hypoglycaemia is
probably due to a defect in gluconeogenesis.
h. What is the reasoning behind the conclusion that glucose utilisation and storage by the patient
is normal?
i. Describe the results you would expect for glucose tolerance tests if glucose utilisation were abnormally
slow or fast.
133
Evaluation of gluconeogenesis
The ability of the patient`s liver to produce glucose can be tested by giving the patient
various gluconeogenic substrates orally (1g/Kg body weight), after an eight hour overnight fast,
and determining whether they are converted to glucose by measuring the blood glucose
concentration. The results of these studies are given in below.
Blood glucose concentrations after oral galactose, fructose and glycerol
Normally, after eight hours of fasting gluconeogenesis becomes active and any compound
that could be converted to glucose would normally increase the blood glucose concentration.
There would be an initial increase in glucose concentration and then a return to normal values
as the glucose is utilised. The response to galactose is normal while the responses to fructose
and glycerol are abnormal and suggest that they are not converted to glucose.
j. What do these results tell you about the location of any defect in the pathway of
gluconeogenesis?
Liver biopsy
A liver biopsy was performed and the tissue was subjected to histological examination and
enzyme assays. Enzyme assays revealed normal activities of the enzymes of glycogen
metabolism and glycolysis and a deficiency of one of the enzymes involved in
gluconeogenesis.
k. What is your specific diagnosis?
l. How would you treat the patient?
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Case Study 2
Husham was born after a normal pregnancy. His mother noticed his large, protuberant abdomen
soon after birth. During his early development he had frequent bouts of sweating, pallor and
generalized weakness, which were relieved by feeding. When he was 1 y old he was examined
in hospital. His blood glucose, after a 6-hour fast was found to be 2mM (normal range 3.5-
5.5mM) and his blood fatty acids 1.6mM (Reference values 0.3-0.9). Liver biopsy showed
extensive deposition of glycogen which had a normal structure.
a. Which tissues are involved in the storage of glycogen?
b. Why was Husham`s abdomen protuberant?
c. How do you account for Husham`s bouts of sweating, pallor and generalised weakness?
d. What enzymes are involved in glycogen mobilization from the liver (glycogenolysis)? Does
skeletal muscle have the same enzymes?
135
e. Which enzyme is normally rate limiting for glycogenolysis?
f. How could you account for Husham`s fasting hypoglycaemia?
g. Which enzyme of glycogen metabolism is likely to be missing or defective in Husham?

Explain your answer.
h. How could you account for the raised fasting blood fatty acid concentration?
Self-assessment
a. Describe the key features of the endocrine system.
b. Describe how the chemical structures of hormones determine how they are transported and
the way they interact with their target tissues.
c. Describe how hormone secretion may be controlled and explain why this is necessary.
136
d. Outline the major ultrastructural features of the -cell that relate to the synthesis, storage and
secretion of insulin.
e. Explain why insulin & C-peptide are secreted from the -cell in equimolar amounts.
f. List the major metabolic actions of insulin and glucagon.
g. Describe the metabolic basis of insulin's action in lowering the blood glucose concentration.
h. List the factors that affect insulin secretion and explain their physiological
significance.
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Session Nine
Diabetes mellitus
Control of appetite, metabolic syndrome
Aims of the session

The aim of this session is that you should understand the underlying disease mechanism in
diabetes mellitus and understand the mechanisms and consequences of the control of appetite
08:00 – 09:00 Lecture: Clinical presentation: Diabetes mellitus, Consultant Physician

09:00 – 10:00 Lecture: Control of appetite, metabolic syndrome
10:30 – 01:30 Group work: You will review the case studies of diabetes
Intended learning outcomes: By the end of this session you should be able to:
• Describe the condition of Diabetes Mellitus.
• List the main differences between Type 1 and Type 2 Diabetes.
• Describe and explain the typical pattern of presentation of Type 1 and Type 2 Diabetes.
• Explain the sequence of events leading to ketoacidosis in the uncontrolled diabetic.
• Explain the causes and consequences of hypoglycaemia and hyperglycaemia.
• Describe, in broad outline, the principles of management of diabetes.
• Explain the principle and practice of measuring glycosylation of haemoglobin as an
index of blood glucose control in the diabetic.
• List the common long term side effects of diabetes, including: cardiovascular problems,
diabetic eye disease, diabetic kidney disease, diabetic neuropathy and the diabetic foot.
• Describe in outline the control of appetite
• Discuss the hormones involved in the control of appetite
• Discuss metabolic syndrome and its consequences
• Explain the Developmental Origins of Health and Disease theory and epigenetics
Suggested reading:
Marks Essentials of Medical Biochemistry, p299-311, 351-359
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Lecture notes
Diabetes mellitus
Diabetes Mellitus is a group of metabolic disorders characterized by chronic
hyperglycaemia (elevated blood glucose concentration), due to insulin deficiency, insulin
resistance, or both. There are two major types of the disease, clearly distinguished by their
epidemiology and probable causation, but not always so easily separated clinically:
Type 1 diabetes:
o Commonest type in the young.

o Characterized by the progressive loss of all or most of the pancreatic -cells.
o Is rapidly fatal if not treated.
o Must be treated with insulin.
Type 2 diabetes:
o Affects a large number of usually older individuals.

o Characterized by the slow progressive loss of -cells but with disorders of insulin
secretion and tissue resistance to insulin.
o May be present for a long time before diagnosis.
o May not initially need treatment with insulin but all do eventually
Staging of diabetes
Both type 1 and type 2 diabetes can be staged in terms of progression of the disease. In type
1, people can be found with the relevant HLA markers and auto-antibodies but without glucose
or insulin abnormalities. Subsequently they may develop impaired glucose tolerance, then
diabetes (sometimes initially amenable to dietary control), before finally becoming totally
insulin dependent.
In type 2, people can be found with insulin resistance, and then as insulin production fails
they develop impaired glucose tolerance. Finally they will develop diabetes that will be initially
managed with diet, then tablets, and then insulin; if the process continues long enough for them
to lose all insulin production.
Size of the problem

Approximately 2.6 million people in the UK have diabetes (2009 figure), the majority
(~90%) with type 2 disease. A further million are believed to be undiagnosed and numbers are
predicted to increase to over 4 million by 2025.
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Type 1 diabetes
About 15 people per 100,000 of the population each year are diagnosed with Type 1
diabetes. More present in the teenage years but the age related rate is otherwise similar up to
old age. There are substantially different rates between different countries. It is likely that a
genetic predisposition to the disease interacts with an environmental trigger to produce immune
activation. This leads to the production of killer lymphocytes and macrophages and antibodies
that attack and progressively destroy β-cells (an auto-immune process). The genetic
predisposition is associated with the genetic markers HLA DR3 and HLA DR4. There is a
strong seasonal variation, suggesting a link with a viral infection acting as a trigger to a rapid
deterioration.
The classic picture of type 1diabetes is a lean, young person with a recent history of viral
infection who presents a triad of symptoms:
1. Polyuria: excess urine production. In the nephron of a healthy individual all of the
glucose filtered from the blood is reabsorbed at the end of the proximal most section of
the nephron the proximal tubule. The reabsorption in this part of the kidney is isosmotic.
In diabetes mellitus where large quantities of glucose in the blood are filtered by the
kidney not all of this glucose is reabsorbed. The extra glucose remains in the nephron
tubule. This places an extra osmotic load on the nephron, and means that less water is
reabsorbed to maintain the isosmotic character of this section of the nephron. This extra
water then remains with the glucose in the nephron tubule and is excreted as copious
urine.
2. Thirst (polydipsia drinking a lot): due to excess water loss and the osmotic effects of
glucose on the thirst centres.
3. Weight loss: as fat and protein are metabolized by tissues because insulin is absent.
Diabetes is easily diagnosed by measurement of plasma glucose levels. Blood glucose is

elevated because of the lack of insulin. The lack of insulin causes decreased uptake of glucose
into adipose tissue and skeletal muscle, decreased storage of glucose as glycogen in muscle
and liver and increased gluconeogenesis in liver. The high blood glucose will lead to the
appearance of glucose in the urine (glycosuria). If not dealt with urgently, these individuals
will progress to a life-threatening crisis (diabetic ketoacidosis).
The high rates of -oxidation of fats in the liver coupled to the low insulin/anti-insulin ratio
leads to the production of huge amounts of ketone bodies, such as acetoacetate, acetone and -
hydroxybutyrate. Acetone, which is volatile may be breathed out, and can be smelt on the
patient's breath. As this ketosis develops, the H+ associated with the ketones produce a
metabolic acidosis- keto-acidosis. The features of keto-acidosis are prostration,
hyperventilation, nausea, vomiting, dehydration and abdominal pain. Keto-acidosis is a
very dangerous condition. It is most important to test for ketones - conveniently in the urine -
when assessing diabetes control.
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Type 2 diabetes
Unlike type 1, type 2 diabetes is relatively common in all populations enjoying an affluent
life-style. The estimated prevalence in the UK is about 2%. Typically, the patients are older
and often, though not invariably, overweight. The disease has often been present for some time,
maybe years, before diagnosis. Whilst there is good evidence for a genetic predisposition to
type 2 diabetes, there is recent evolving evidence of the involvement of the immune system.
At diagnosis patients retain about 50% of their β-cells, however as the number of these cells
falls, ultimately to none at all, patients develop disorders of insulin secretion or insulin
resistance, so blood glucose is raised.
Patients may present with the classical triad of symptoms, but are more likely to present
with a variety of symptoms such as lack of energy, persistent infections, particularly thrush
infections of the genitalia, or infections of the feet, slow healing minor skin damage, or visual
problems.
Diagnosis of diabetes
Diabetes is diagnosed, in the presence of symptoms (i.e. polyuria, polydipsia and

unexplained weight loss) plus:
o A random venous plasma glucose concentration 11.1 mmol/L or
o A fasting plasma glucose concentration 7.0 mmol/L (whole blood 6.1 mmol/L) or
o Plasma glucose concentration 11.1 mmol/L 2 hours after 75g anhydrous glucose in an
oral glucose tolerance test (OGTT).
With no symptoms diagnosis should not be based on a single glucose determination but
requires confirmatory venous plasma glucose determination. At least one additional glucose
test result on another day with a value in the diabetic range is essential, either fasting, from a
random sample or from the two-hour post glucose load. If the fasting or random values are not
diagnostic the 2-hr value should be used. A diagnosis of diabetes has important legal and
medical implications for the patient and it is therefore essential to be secure in the diagnosis
and the plasma glucose measurement must be undertaken by an appropriate laboratory. A
diagnosis should never be made on the basis of glycosuria or a stick reading of a finger-prick
blood glucose alone, although such tests may be useful for screening purposes.
Management of Diabetes
Type 1 diabetes cannot be cured, and must be managed for the rest of the patient's life.
Insulin is used to treat Type 1 diabetics and some cases of Type 2 diabetes. It must be injected.
It comes in a variety of forms with different time courses of action, and may be injected by a
number of devices. Patients must be educated to treat themselves at appropriate times with
appropriate doses and formulations so as to mimic as closely as possible the behavior of
pancreatic islets in controlling blood glucose. On occasion, particularly if the patient has an
infection, or has suffered some trauma, insulin dosage needs to be increased, or there is a risk
of diabetic ketoacidosis. The social and psychological implications are huge, and the degree of
control achieved by patients can be very variable. Appropriate dietary management and regular
exercise are vital components of the treatment regime.
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The management of blood glucose requires frequent blood glucose measurement. A small
amount of blood from a finger prick is sufficient to measure blood glucose using a BM stick
and reader. These devices are only accurate if used carefully. There is always a risk that blood
glucose will fall too low ("hypoglycaemia"). Both patients and their associates need to be aware
of the signs and symptoms of hypoglycaemia, which can occasionally be fatal unless treated
with glucose, either by mouth or by infusion.
Type 2 diabetes can sometimes be managed by diet or by "oral hypoglycaemic" drugs such
as sulphonylureas that increase insulin release from the remaining -cells, and reduce insulin
resistance and particularly metformin that reduces gluconeogenesis. As with type 1 diabetes
appropriate dietary management and regular exercise are vital components of the treatment
regime.
Prevention of type 2 diabetes

Studies in the USA, Finland and China have shown that control of diet and exercise can
significantly reduce the chances of an individual getting type 2 diabetes. Participants in the
USA studies who were randomly assigned to lifestyle intervention (diet and exercise) reduced
their risk of getting type 2 diabetes by 58% compared to the control group. In participants who
were aged 60 years and over, the reduction was 71%.
Metabolic consequences of persistent hyperglycaemia

Persistent hyperglycaemia is associated, in some tissues, with the abnormal metabolism of
glucose to products that may be harmful to cells. This is because the uptake of glucose into
cells of tissues such as peripheral nerves, the eye and the kidney does not require insulin and
is determined by the extracellular glucose concentration. Thus, during hyperglycaemia the
intracellular concentration of glucose in these tissues increases and glucose is metabolised via
the enzyme aldose reductase which catalyses the reaction:
Glucose + NADPH + H+ Sorbitol + NADP+
This reaction depletes cellular NADPH and leads to increased disulphide bond formation in
cellular proteins, altering their structure and function. In addition, the accumulation of sorbitol
causes osmotic damage to cells.
Persistent hyperglycaemia is also associated with the increased non-enzymatic

glycosylation of plasma proteins (e.g. lipoproteins) that leads to disturbances in their function.
In this process glucose reacts with free amino groups in proteins to form stable covalent
linkages. The extent of glycosylation depends on the glucose concentration and the half-life of
the protein. Glycosylation changes the net charge on the protein and the 3-D structure of the
protein and therefore affects the function of the protein.
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Glycosylated haemoglobin (HbA1c)

Glucose in the blood will react with the terminal valine of the haemoglobin molecule to
produce glycosylated haemoglobin (HbA1c). The percentage of haemoglobin that is
glycosylated is a good indicator of how effective blood glucose control has been. As red blood
cells normally spend about 3 months in the circulation the % HbA1c is related to the average
blood glucose concentration over the preceding 2-3 months. In normal healthy individuals 4-
6% of haemoglobin is glycosylated and in poorly controlled diabetics this value can increase
above 10%.
Clinical complications of Diabetes

Long-term diabetics suffer a number of microvascular and macrovascular complications,
made worse in individuals whose blood glucose is poorly controlled.
Macrovascular complications include:
(1) Increased risk of stroke
(2) Increased risk of myocardial infarction
(3) Poor circulation to the periphery (particularly the feet)
Microvascular complications include:

(1) Diabetic eye disease: Visual problems can arise from changes in the lens due to
osmotic effects of glucose (glaucoma), and possibly cataracts, but the more important
problem is diabetic retinopathy - damage to blood vessels in the retina which can lead
to blindness. Damaged blood vessels may leak and form protein exudates on the retina
or they can rupture and cause bleeding in to the eye. In addition, new vessels may form
(proliferative retinopathy). These vessels are very weak and can easily bleed.
(2) Diabetic kidney disease (nephropathy): The kidney is affected by damage to the
glomeruli, poor blood supply because of changes in kidney blood vessels, or damage
from infections of the urinary tract which are more common in diabetics. An early sign
of nephropathy is an increase in the amount of protein in the urine (microalbuminuria).
(3) Diabetic neuropathy: Diabetes damages peripheral nerves in a number of ways

producing a variety of effects, including changes of or a loss of sensation, and changes
due to alteration in the function of the autonomic nervous system.
(4) Diabetic feet: Poor blood supply, damage to nerves, and increased risk of infection all
conspire to make the feet of diabetics particularly vulnerable. In the past loss of feet
through gangrene was not uncommon. Care is needed to keep feet in good condition.
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Lecture notes
Control of Appetite, metabolic syndrome, developmental origins of adult disease

Energy intake/energy output balance
You have already covered on the module the energy intake/energy output balance and why
this is important. As you learned in the first part of the module energy is derived from the
oxidation of carbohydrates and fatty acids, usually, but how is the intake of food controlled?
There is a “satiety” centre in the hypothalamus which controls the timing and amount of food
intake. Research has shown that the control of appetite is very complex, involving many
hormones and sensing of energy sources in the blood. Only the main hormones and mechanisms
will be covered, to provide an overview.
Control of appetite
The appetite centre is located in the arcuate nucleus in the hypothalamus. This nucleus is a
group of neurons consisting of two types: primary neurons that sense metabolite levels and
respond to hormones, and secondary neurons which synthesise input from primary neurons and
co-ordinate a response via the vagus nerve. Primary neurons can be further sub-divided into
excitatory and inhibitory. The excitatory neurons stimulate appetite via the release of two
peptides: neuropeptide Y (NPY) and agouti-related peptide (AgRP). The inhibitory neurons
suppress appetite by releasing pro-opiomelanocortin (POMC). POMC is a polypeptide
prohormone which can be enzymatically cleaved to produce several peptide hormones: β-
endorphin, adrenocorticotrophin hormone (ACTH), α-melanocyte stimulating hormone (α-
MSH). Of these, α-MSH acting on melanocortin 4 receptors is involved in suppressing appetite.
Regions of the brainstem are also involved in the control of appetite.
There is also a reward system in the brain which is involved with the control of feeding. So,
in response to the stomach being filled with food, there is a release of POMC in the brain which
suppresses appetite, but also the β-endorphin derived from this produces feelings of euphoria
and tiredness. You may have experienced this after a large meal!
For the system to work there needs to be feedback from the body to the hypothalamus, and
this is provided by several hormones, some of which have only recently been discovered.
Ghrelin is a peptide hormone released from the wall of the empty stomach, which activates the
stimulatory neurons in the arcuate nucleus, stimulating appetite. Stretch of the stomach wall
caused by food intake inhibits ghrelin release. PYY is a peptide hormone released from the wall
of the small intestine which acts in opposition to ghrelin by suppressing the appetite. One of the
most important recent discoveries in endocrinology is that of a new hormone, leptin, in 1994.
Leptin is a peptide hormone released into the blood by adipocytes in fat stores in the body. The
level of leptin in the blood has been found to correlate with the amount of adipose tissue in the
body. Leptin acts by stimulating inhibitory neurons and inhibiting stimulatory neurons in the
arcuate nucleus to suppress appetite. Thus, leptin acts as a feedback mechanism from the body’s
fat stores to control the level of intake of food.
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A lack of leptin production or insensitivity to leptin has been associated with obesity. It has
been shown that leptin induces the expression of uncoupling proteins in mitochondria, which
leads to the production of heat rather than ATP. Leptin is the target of much research and it has
been used clinically to treat obese patients lacking the hormone.
Insulin is another important hormone involved in the short term and long-term regulation of
body weight. Insulin suppresses appetite via the same mechanism as leptin; however, leptin
seems to be more important in this role than insulin. Insulin resistance is associated with obesity
and often leads to type 2 diabetes. Another new peptide hormone, amylin, was found to be
secreted with insulin from the β-cells of the Islets of Langerhans in 1987. Amylin is still being
investigated, but it is known to suppress appetite, decrease glucagon secretion and slow gastric
emptying. An analogue of amylin, Pramlintide, is undergoing trials as a hypoglycaemic agent
in early type 2 diabetes. Neurons in the arcuate nucleus are also able to sense the level of glucose
and fatty acids in the blood. The following diagram provides a useful summary of the
mechanisms involved in the control of appetite:
Research on the system of control of appetite has revealed new hormones and receptor
targets for the development of novel therapeutic agents.
Metabolic Syndrome
A recent estimate suggested that over 1 billion people are overweight and over 300 million
are obese, mostly in the developed world (WHO). Approximately 80% of obese adults have
morbidity arising from the obesity. This has been described as an epidemic of obesity and the
cause of it is not fully understood. It is thought to be partly due to a lack of exercise and partly
due to the availability of highly calorific processed foods. Also there appears to be a 60-84%
genetic component as obesity has been found to be heritable. One early concept was of a „thrifty
phenotype , in which individuals are genetically predisposed to store energy more efficiently
during times of plenty to increase the odds of survival during subsequent famine. Now that
human society has changed in the developed world there is a constant supply of food leading to
chronic obesity.
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A more recent idea is that of metabolic syndrome. Metabolic syndrome arose from the
observation of a common pattern of symptoms in obese people. It is defined as a group of
symptoms including insulin resistance, dyslipidaemia, glucose intolerance and hypertension
associated with central adiposity. The co-occurrence in the same individual of a number of
cardiovascular risk factors such as dyslipidaemia and hypertension, usually in association with
overweight or obesity and a sedentary life style is known as the “metabolic syndrome” (BMJ
2003;327:61-2). These abnormalities may be related to insulin resistance as they are commonly
found in type 2 diabetics. The major factors that predispose to insulin resistance are obesity and
a sedentary life-style. Insulin resistance in turn, is associated with the development of a
dyslipidaemic profile (VLDL, LDL & HDL) that is highly atherogenic. It is also associated
with an increased risk of hypertension.
The WHO criteria for metabolic syndrome are
➢ central obesity with a waist: hip ratio above 0.9 for men and 0.85 for women and/or
➢ a body mass index (BMI) above 30 kg/m2,
➢ blood pressure above 140/90 mmHg,
➢ triglycerides above 1.7 mmol/L,
➢ HDL cholesterol <0.9 mmol/L in men and <1 mmol/L in women,
➢ glucose fasting or 2 h after a glucose load above 7.8 mmol/L and glucose uptake during
hyperinsulinaemic euglycaemic clamp in lowest quartile for population.
Metabolic syndrome is increasingly prevalent in developed countries. Studies in Europe,

North America and Australia have found the prevalence of the metabolic syndrome to be
between 12% and 25%. An estimate of the current global prevalence of metabolic syndrome is
approximately 16%. Metabolic syndrome is present in approximately 80% of people with type
2 diabetes. Metabolic syndrome increases the risk of type 2 diabetes 5-fold and heart disease
by approximately 3-fold. The syndrome is increasing in prevalence worldwide as a consequence
of increasing obesity prevalence. Metabolic syndrome is likely to have a marked impact on the
prevalence of cardiovascular disease and type 2 diabetes worldwide in the next two decades
Metabolic syndrome is strongly associated with obesity particularly if fat is stored around
the abdomen. The influence of obesity on the incidence of the metabolic syndrome has also
been observed in children and obesity is now an important cause of type 2 diabetes occurring
in children. Some ethnic groups have a higher predisposition to central obesity than others, for
example, the amount of central obesity is greater among South Asians than Europeans and is
greater among Europeans than African-Caribbeans. Central fat accumulation is strongly
associated with insulin resistance. In diagnosing metabolic syndrome, BMI does not allow for
large muscle bulk and it is known that central fat around the abdomen not just total body fat
collection is associated with insulin resistance, fatty liver and other symptoms in metabolic
syndrome. Therefore, BMI is not an ideal measurement of central fat
(http://www.metabolicsyndrome.org.uk/). Metabolic syndrome is controversial and it has not
been universally accepted in the medical profession, although it is gaining ground in terms of
acceptance.
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Developmental Origins of Health and Disease (DOHD)
This area had its origins in the early 1990s when it was first known as the `Barker
Hypothesis`. David Barker was an epidemiologist working at the University of Southampton
who conducted a health survey on a large cohort of middle-aged men. Fortunately, this cohort
had very detailed medical records, including their birth weight. When he analyzed the data set
he found that the strongest correlation with incidence of adult disease was with birth weight,
surprisingly. The correlation with birth weight was much stronger than with smoking, for
example. Many similar studies have been conducted and they repeatedly show that the
incidence of adult diseases such as coronary heart disease, hypertension and type 2 diabetes is
related to low birth weight.
Subsequently, it has also been shown that these chronic conditions are related to placenta
weight, at birth. This suggested that the experience of the fetus in utero during development
somehow determines the future health of the individual. This was a revolutionary idea at the
time.
In the next phase of research the term `fetal programming` was coined. It was discovered
that biochemical adaptation took place in the fetus according to the supply of nutrients via the
placenta and that these adaptations were `programmed in` for adult life. These adaptations
predisposed the individual to developing chronic conditions in adult life. Further research
showed that the programming involved the switching on and off of genes at critical times during
fetal development. One puzzling feature was that low birth weight could apparently be passed
down several generations, so mothers who had a low birth weight themselves tended to give
birth to low birth weight infants. An explanation for this has been provided by epigenetics
(literally àbove genetics`). The following definition for epigenetics has recently been agreed:
‘an epigenetic trait is a stably inherited phenotype resulting from changes in a chromosome
without alterations in the DNA sequence’.
Thus, it is possible for adaptations in the phenotype to be passed down several generations,
without changes in the DNA. The mechanism appears to involve methylation of DNA at crucial
positions. In rodents, changes in DNA methylation at specific nucleotides and also changes in
histone structure causing suppression of gene transcription targeting the promoter region of
specific genes have been identified. Research in this area may lead to better understanding of
the origin of certain disease states.
147
Group work
Case 1
Sameer is 14 years old. He lives with both parents and a younger sister in a comfortable
home. He enjoys sports, particularly football, and is generally considered to be a well-balanced
individual. A few months ago he suffered a "flu-like" illness, but he has apparently recovered
well.
Sameer has noticed:
➢ His prowess on the football field has declined, he finds it difficult to run, and gets the
feeling that his body is not as solid as it used to be.
➢ Over the last three weeks he has had to ask permission to leave the class during lessons
in order to visit the toilet, and seems to be producing more urine than usual.
➢ He has had to ask for extra money to take to school in order to buy drinks and yet still
seems to be thirsty.
Sameer comes to you to report his concerns.
a. What questions will you ask him, and what examinations and tests will you perform?
Try to write them here before turning the page.
Your questioning will have revealed:
• Although he does not weigh himself very often Sameer feels that he has lost weight.
• His consumption of fluids has increased dramatically.
• He has to get up at night in order to pass large volumes of urine.
Your examination of Sameer would reveal:
• A lean young man of wasted appearance and reduced muscle bulk.

• Pulse more or less normal, respiration normal.
• A normal heart and chest examination.
• Possibly a faint but characteristic smell of acetone on his breath.
You would
• Collect a sample of urine and test it for the presence of Glucose and Ketones using a
multistick dip-stick test.
• Take a blood sample for accurate determination of plasma glucose concentration, and
make an initial blood glucose estimation from peripheral site (e.g. finger) using a BM
stick. This will give you values of:
Urine (multistick) Glucose = > 5%
Ketones = ++
Blood (BM stick) Glucose = 20 mmol/L
148
The symptoms, appearance and presence of glucose and ketones in urine and the glucose
concentration in peripheral blood should persuade you to make an emergency referral, the same
day by telephone, so that Sameer is seen by a consultant and treated rapidly.
b. What do you think is wrong with Sameer?
c. Why does he require immediate referral? What will happen to Sameer if he is not treated
rapidly?
d. Describe the sequence of events if Sameer is not treated rapidly and explain the metabolic
basis of these events.
e. How, in principle, might you expect his treatment to proceed?
f. Why do you think poor adherence to treatment regimens is common in type 1 diabetes?
g. In the long term, what other problems might Sameer face?
h. Consider how common the symptoms of thirst and polyuria are in the general population.
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Case 2
Heyam is 49 years of age, happily married to an accountant with two children both in their
early teenage years. She is a teacher of English language. Recently she has felt tired and
irritable, and seems to have lost a lot of her enthusiasm for life. She has presented at your clinic.
Heyam has noticed: Her family is complaining that she is unusually irritable for no apparent
reason. She has felt more 'down or low' in mood recently. She has been troubled by recurring
thrush infections of her genitalia. She is undergoing the menopause, but then so are all her
friends. A recent cut on her finger is not healing well. She feels her problems are of no
consequence and probably menopausal.
Your questions reveal:
Normal menopausal progress. She has recently noticed a reduction in energy and has given
up out of school activities. Recent weight loss and despite sensible eating she remains
overweight (BMI = 29). She is inclined to feel depressed for no obvious reason. Heyam
wonders whether she might benefit from hormonal replacement therapy (HRT) for the
menopause.
Your examination reveals:
Normal pulse and respiration, BP = 140/90 mmHg.

Weight loss. Infected cut to finger.
You proceed to:
Take a sample of urine, which is tested for sugar, ketones, and protein. Results: Sugar positive
(1+), ketones negative & protein negative.
You proceed to:
Take a random blood sample (i.e. without the patient fasting) and arrange for a fasting blood
sample to be taken for analysis of, Haemoglobin A1c (HbA1c), plasma glucose, cholesterol
(LDL & HDL), urea and electrolytes (i.e. sodium and potassium).
Results: Fasting plasma glucose = 11 mmol/L, urea & electrolytes = normal, cholesterol =
slight elevation, haemoglobin A1c = 10%
Heyam has Type 2 diabetes mellitus. Unlike Sameer, her situation is not immediately life
threatening, but is nevertheless serious, as she may have had the condition for some time, and
may already be suffering its long-term effects.
a. What is the difference between Type 1 and Type 2 diabetes? Why is Heyam 's case not
so urgent as that of James?
150
b. What is the significance of Heyam`s Haemoglobin A1c value of 10%?
c. How, in principle would you expect Heyam`s treatment to proceed?
d. How in principle will her care be monitored? (Don't forget to consider her physical,
emotional and psychological care).
e. Discuss the need for care with interpretation of biochemical variables. (Hint: think about
the blood sample going to the laboratory, assays performed and the reporting of results)
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Self-assessment
a. What is diabetes mellitus?
b. Describe the typical signs and symptoms of untreated type 1 diabetes mellitus.
c. How does type 2 diabetes mellitus differ from type 1diabetes mellitus?
d. Explain why ketoacidosis develops in untreated type 1 diabetes mellitus.
e. Explain how diabetes can be managed.
f. Describe the long-term clinical consequences of persistent hyperglycaemia.
g. What is haemoglobin A1c (HbA1c)? Explain how it can be used as an index of glycaemic
control.
h. List five of the signs and symptoms you might expect to find in a 10 year old male who
had the following test results on a fasting blood sample:
Plasma glucose 10 (reference values = 3.9-6.1 mmol/L)

Serum insulin 5 (reference values = 35-145 pmol/L)
Explain why these signs and symptoms occur?
152
i. List five of the signs and symptoms you might expect to find in a 60 year-old male who had
the following test results on a fasting blood sample:
Plasma glucose 8 (Reference values = 3.9-6.1mmol/L)

Serum insulin 250 (Reference values = 35-145 pmol/L)
Blood Haemoglobin A1c = 10% (reference values = 3.8-6.4%)
j. What are the important components of the management of this patient?
k. Explain why hyperglycaemia occurs in untreated type 1 diabetes.
l. Why is appetite controlled in humans?
m. What would be the clinical effect of failure of the appetite control mechanism?
n. Outline the mechanism of control of appetite.
o. Define metabolic syndrome
p. Explain why epigenetics is different to genetic mutation.
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Session Ten
The thyroid gland

Aims of the session
The aim of this session is that you should understand the function of the thyroid gland, the
actions of the thyroid hormones and the consequences of disturbance to normal function

08:00 – 09:00 Lecture: The Thyroid Hormones
09:00 – 10:00 Lecture: Clinical presentation: Disturbances to thyroid function
10:30 – 01:30 Group work: Clinical case studies. You should use the information from the
lecture and your reading to answer the questions on the clinical consequences of disturbances
to thyroid function
Intended learning outcomes: At the end of this session you should be able to:
o Describe the location and structure of the thyroid gland.
o Describe the chemical structure of the thyroid hormones and the mechanisms of their
production, storage and secretion.
o Describe how the activity of the thyroid gland is controlled.
o Describe the effects of thyroid hormones on cells and the body as a whole.
o Describe the consequences of over- and under-secretion of thyroid hormones.
o Analyse simple case histories involving disorders of thyroid secretion.
Self-assessment: You should answer the self-assessment questions to ensure that you
can meet the learning objectives for the Session.
Suggested Reading:
Marks Essentials of Medical Biochemistry, p191-192
Medical Physiology Boron and Boulpaep Chapter 49
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Lecture notes
Structure and function of the thyroid gland
Location of the thyroid: The gland is in the neck in front of the lower larynx and upper trachea.
The gland is usually only visible or palpable when enlarged (then called a goiter). Two nerves
lie in close proximity to the gland - the recurrent laryngeal and the external branch of the
superior laryngeal. During thyroid surgery these nerves are at risk and must be avoided as they
supply the larynx and are involved in speech. The thyroid is highly vascularized with three
arteries supplying it and three veins draining it (superior, middle and inferior thyroid arteries
and veins).
Structure of the thyroid: The gland has a butterfly shape with two lateral lobes joined by a
central isthmus. The size varies but is usually 2-3cm across and it weights 15-20g making it
one of the largest endocrine glands in the body. Two major cell types are found in the gland,
follicular cells and parafollicular (C-cells). The follicular cells are arranged in numerous
functional units called follicles separated by connective tissue. The parafollicular cells are
found in the connective tissue. The follicles are spherical and are lined with epithelial
(follicular) cells surrounding a central space (lumen) containing protein.
Hormones produced in the thyroid: The thyroid gland produces 3 hormones, thyroxine (T4)
and tri-idothyronine (T3) produced in the follicular cells and calcitonin produced in the
parafollicular cells. T3 & T4 are small molecules derived from the amino acid tyrosine with the
addition of atoms of iodine. Calcitonin is a polypeptide hormone involved in calcium
metabolism.
Synthesis: The basic steps in the synthesis of T3 & T4 in the thyroid follicles are:
o Transport of iodide into the epithelial cells against a concentration gradient.
o Synthesis of a tyrosine rich protein (thyroglobulin) in the epithelial cells.
o Secretion (exocytosis) of thyroglobulin into the lumen of the follicle
o Oxidation of iodide to produce an iodinating species.
o Iodination of the side chains of tyrosine residues in thyroglobulin to form MIT
(mono-iodotyrosine) and DIT (di-iodotyrosine).
o Coupling of DIT with MIT or DIT to form T3 & T4 respectively within the
thyroglobulin. T3 & T4 residues are produced in the ratio of ~1:10
Storage: T3 & T4 are stored extracellularly in the lumen of the follicles as part of the
thyroglobulin molecules. The amounts normally stored are considerable (T3 = ~0.4 moles, T4
= ~6 moles) and would last for several months at normal rates of secretion.
Secretion: Thyroglobulin is taken into the epithelial cells from the lumen of the follicles by the
process of endocytosis. Here proteolytic cleavage of the thyroglobulin occurs to release T3 &
T4 and these diffuse from the epithelial cells into the circulation.
155
Control of thyroid hormone secretion: The synthesis and secretion of T3 & T4 are under the
control of the hypothalamus and anterior pituitary gland. The hypothalamic factor is
Thyrotrophin-Releasing Hormone (TRH). This is a tri-peptide released from cells in the
dorsomedial nucleus of the hypothalamus under the influence of the circulating levels of T3 &
T4 (negative feedback), stress (increases release) and temperature (fall in temp increases
release). The TRH travels in the hypothalamic/pituitary portal system to stimulate the secretion
of Thyroid Stimulating Hormone (TSH) from the thyrotrophs in the anterior pituitary. TSH
travels in the blood to affect the follicular cells of the thyroid gland.
Thyroid Stimulating Hormone is a glycoprotein consisting of two non-covalently linked

subunits ( -subunits). TSH is released in low-amplitude pulses following a diurnal rhythm
with higher levels attained during the night and decreasing in the early hours of the morning.
Actions of TSH: TSH interacts with receptors on the surface of the follicle cells and stimulates
all aspects of the synthesis and secretion of T3 & T4. In addition, TSH has trophic effects on
the gland that result in increased vascularity, increase in size and number of the follicle cells.
These trophic effects can result in an enlarged thyroid (goitre) that may or may not be
overactive.
Transport of T3 & T4: T3 & T4 are hydrophobic molecules and are transported in the blood
bound to proteins (thyronine binding globulin, pre-albumin and albumin). Only a small amount
(<1%) of T3 & T4 is free in solution and it is this free hormone that is biologically active. T3
has a slightly lower affinity for the transport proteins than T4 and hence a greater percentage is
free and its half-life in the circulation is therefore shorter (2 days compared to 8 days for T4).
Oestrogens increase the synthesis of TBG during pregnancy and this produces a fall in the
amount of T3 & T4 in the circulation as more is bound. The fall in free T3 &T4 removes the
inhibitory feedback on the pituitary and hypothalamus. More TRH and TSH are produced and
the thyroid gland secretes more T3 & T4. As a result the amount of free T3 & T4 returns to
normal but the total amount in the blood is increased.
Major physiological actions of T3 & T4: T3 & T4 have general effects on the metabolic
activity of most tissues and more specific effects on particular tissues. In general, the response
of target tissues occurs slowly and may take day s/weeks to manifest themselves.
T3 & T4 increase the metabolic rate of many tissues, stimulate glucose uptake and
metabolism, stimulate mobilisation and oxidation of fatty acids and stimulate protein
metabolism. Their metabolic effects are generally catabolic and lead to an increase in BMR,
heat production and increased oxygen consumption.
T3 & T4 are important for normal growth and development. Their effects on physical growth
are in part related to their metabolic effects on tissues but they do also have specific effects on
certain tissues. Thus, they directly affect bone mineralization an important component of
physical growth and increase the synthesis of heart muscle protein.
156
The central nervous system is particularly sensitive to T3 & T4 especially during

development as they are required for the development of the cellular processes of nerve cells,
hyperplasia of cortical neurons and myelination of nerve fibres. In the absence of thyroid
hormones from birth to puberty the child remains mentally and physically retarded (cretinism).
If the deficiency is not corrected within a few weeks of birth irreversible damage occurs. All
newborn have their thyroid function assessed soon after birth. In the adult lack of thyroid
hormones is characterized by poor concentration, poor memory and lack of initiative.
Some of the actions of T3 & T4 are indirect and are related to important interactions with
other hormones and neurotransmitters. T3 & T4 stimulate hormone and neurotransmitter
receptor synthesis in a variety of tissues (eg heart muscle, GI tract) and this may produce an
increased responsiveness of these tissue to regulatory factors. In heart muscle this produces
tachycardia and in the GI tract leads to increased motility.
T3 & T4 have a permissive role in the actions of hormones such as FSH and LH and
ovulation fails to occur in the absence of thyroid hormones.
Mechanism of action of T3 & T4: T3 & T4 cross the plasma membrane of target cells and
interact with specific high affinity receptors located in the nucleus and possibly mitochondria.
The receptors are proteins and they have a 10-fold greater affinity for T3 than T4.
The receptors have a number of domains. Binding of T3 to the hormone-binding domain is

thought to produce a conformational change in the receptor that unmasks the DNA-binding
domain. Interaction of the hormone-receptor complex with DNA (nuclear or mitochondrial)
increases the rate of transcription of specific genes that are then translated into protein.
The increased rate of protein synthesis stimulates oxidative energy metabolism in the target
cells to provide the extra energy required for protein synthesis. In addition, protein synthesis
produces increased amounts of specific functional proteins leading to increased cell activity and
an increased demand for energy.
Conversion of T4 to T3: T4 can be converted to T3 in tissues by removal of the 5-iodide. This

is an important mechanism for regulating the amount of active hormone in cells as T3 has 10
times the activity of T4. Removal of the 3-iodide produces inactive reverse T3 (rT3).
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Thyroid disease
Clinical problems caused by too much (hyperthyroidism) or too little (hypothyroidism)
physiologically active thyroid hormones are relatively common. The most common form of
hypothyroidism is Hashimoto disease affecting 1% of the population mostly women. It is an
autoimmune disease that results either in the destruction of the thyroid follicles or the
production of an antibody that blocks the TSH receptor on follicle cells preventing them from
responding to TSH. Patients are generally treated with oral thyroxine. The dose is adjusted
depending on the patient’s signs and symptoms and TSH levels.
Grave’s disease is the most common form of hyperthyroidism affecting ~1% of the population
mostly women. It is an autoimmune disease in which antibodies are produced that stimulates
the TSH receptors on follicle cells resulting in increased production and release of T3 & T4.
Patients may be treated with carbamizole a drug that inhibits the incorporation of iodine into
thyroglobulin.
Signs and symptoms of hypothyroidism in adults may include:
o Cold intolerance and reduced BMR.

o Weight gain
o Tiredness and lethargy
o Bradycardia.
o Neuromuscular system - weakness, muscle cramps and cerebellar ataxia (clumsiness of
movement).
o Skin dry and flaky.
o Alopecia (hair loss).
o Voice is deep and husky.
Signs and symptoms of hyperthyroidism may include:
o Heat intolerance, increased oxygen consumption and increased BMR.

o Weight loss
o Physical and mental hyperactivity
o Tachycardia
o Intestinal hyper-mobility
o Skeletal and cardiac myopathy giving rise to tiredness, weakness and breathlessness.
o Osteoporosis due to increased bone turnover and preferential resorption
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Group work
Disturbances to thyroid function
Clinical case study 1
Noor is 20 years old. She is a student of English at University of Duhok. After doing well at
school and gaining good A Levels, she performed well during her first year at University. The
second year of her course is particularly demanding. She has several essays to hand in by week
10 of this semester.
Experiences of her relatives and friends: Over the past three months, Noor's mother has
become concerned that her daughter looks gaunt. Her flat mates are becoming increasingly
irritated by her behaviour as she 'flies of the handle' for apparently trivial reasons.
Noor has noticed:

She finds it difficult to concentrate on her academic work. Over the last three months she has
become aware of her heart beat, which seems to be faster than usual. She has begun to be
embarrassed by wet patches appearing under her arms even when not exercising or in
particularly warm conditions, and has taken to buying a stronger deodorant.
Noor appears in your surgery to report what she has noticed.
a. What sort of questions might be appropriate to ask her? Write a short list here before turning
the page.
Your questioning of Noor would have revealed:

She has lost about one stone in weight over the last three months. She eats well, and if
anything, her appetite has increased. Her periods have become irregular. She has fallen behind
with her work, but has seen her tutor who is sympathetic and has granted an extension.
You then examine her, and find:

she appears generally fit and well, though thin. She finds it difficult to sit still. Her pulse is
strong, at 100 bpm (normal ~80bpm). her arterial blood pressure is 120/70 (normal value
120/80). her hands are moist, and warm. When you ask her to hold out her hands there is a
slight tremor. Examination of her chest, abdomen and eyes reveals no abnormality.
b. Try to think of two possible reasons for Noor's condition.
159
c. What other examinations would you perform to distinguish them?
d. What laboratory tests would you order?
You should have examined Noor's neck, and will have noticed a slight swelling on either
side of the mid line.
You would have ordered tests of her thyroid function:
Total serum T4 202 nM (Reference values 54-142)

Total serum T3 4.5 nM (Reference values 0.8-2.5)
TSH < 0.05 mU l-1 (Reference values 0.3-3.8)
It would also be possible to estimate the size and activity of Noor's thyroid gland by injecting
a substance that is taken up selectively by the gland and can be detected from outside the body.
e. Why is the TSH level so low?
f. What is the substance that can be used in scanning the thyroid gland?
g. Which of your two alternative diagnoses might you choose on the basis of these data?
h. How, in principle would you go about treating Noor?
160
Clinical case study 2
Ibtesam is 46 years old. She has been married for 22 years and has 3 sons, the youngest of
whom is 16. She works as a telesales operator, which involves a lot of evening work. Her
husband runs his own business and works very long hours.
Experiences of relatives and friends: Over the past few years, Ibtesam's family has become
aware that Mum is not coping as well as she did, and she seems to have very little energy. Her
husband is concerned about her. She has gained weight, her hair has become scrappy, and her
skin is not as attractive as it was. She seems to have lost much of her enthusiasm for life. Her
youngest son remarked the other day that Mum's voice seems to have changed.
Ibtesam has noticed:

she is finding it very difficult to cope with her work/life balance and it seems to take all her
energy. she is becoming increasingly concerned about her appearance. She has gained a stone
in weight over the past year, just cannot do anything with her hair and finds herself buying
more and more different varieties of face cream, which do not seem to have much effect. she
is having trouble keeping up at work and tends to forget things much more than she used to.
her periods, though still regular, have become heavy.
Ibtesam appears in your surgery to report what she has noticed.
a. What questions do you ask her? Try to write a list before turning the page.
Your questioning of Ibtesam should have revealed:

She has been feeling increasingly tired for 10 years. She 'really can't cope', and is inclined to
be weepy. She has gained weight quite recently. Her father died of a heart attack at 70. Her
mother had very similar problems to Ibtesam at the same age and has been 'taking tablets for
it' ever since. Two of her aunts had to have operations on their necks because of 'problems with
their nerves'.
Your examination of Ibtesam will reveal:

She has very thin, dry hair. Her skin is very dry. Her voice is slightly hoarse. Her pulse is
regular, at 60 bpm (normal ~80bpm). Her arterial blood pressure is normal at 125/75 mmHg.
A general physical examination is pretty normal ('unremarkable'). Examination of her eyes
reveals no problems.
161
b. Suggest three possible reasons for Ibtesam's problems. What other examinations
should you perform to distinguish them? What laboratory tests should you request? The
possibilities you should have identified are 3 of the following:
o Chronic fatigue
o Depression
o Anaemia
o Hypothyroidism
You will have noticed in your examination that Ibtesam has a swelling in her neck,
which is not tender. You will have taken blood samples for analysis of:
o Blood haemoglobin levels and full blood count - results are normal.
o Blood urea and 'electrolytes' (i.e. ions such as Na+, K+) - results are normal.
o Thyroid function tests:
Total T4 48 nM (Reference values 54-142)

Free T4 9 pM (Reference values 10-26)
TSH 15 mU/L (Reference values 0.3-3.8)
The results of a thyroid isotope scan indicated that "Both lobes of the thyroid are enlarged
but no focal abnormality seen"
You will have decided that Ibtesam has hypothyroidism.
c. Why might this have occurred?
d. Why is the TSH level above the normal range?
e. Why has her thyroid gland increased in size despite secreting less hormone?
f. How, in principle, would you set about treating Ibtesam (one sentence answer)?
g. What are the potential problems in her treatment (one sentence answer)?
162
Self-assessment
a. How is the activity of the thyroid gland controlled?
b. How areT3 and T4 transported in the blood and how do they produce effects in target tissues?
c. List the major effects of T3 in humans
d. List four of the signs and symptoms you might expect to find in a 46 year old female who
had the following endocrine test results on a fasting blood sample:
Total plasma T4 48 nM (Reference Values = 54-142 nM)

Free T4 9 pM (Reference Values = 10-26 pM)
TSH 15 mU (Reference Values = 0.3-3.8 mU)
Explain, in general terms, why these signs and symptoms occur.
e. List four of the signs and symptoms you might expect to find in a 30 year old female who
had the following endocrine test results on a fasting blood sample:
Total serum T4 200 nM (Reference Values = 54-142 nM)

Total serum T3 5 nM (Reference Values = 0.8-2.5 nM)
TSH < 0.05 mU (Reference Values = 0.3-3.8 mU)
Explain, in general terms, why these signs and symptoms occur.
163
Session Eleven
Calcium Metabolism
Pituitary and Adrenal Glands
Aims of the session
The aim of this session is that you should understand the critical importance of the control
of calcium metabolism in the body and understand the function of the pituitary and adrenal
glands and the hormones that they produce.

08:00 – 09:00 Lecture: Control of calcium.
09:00 – 10:00 Lecture: Pituitary and adrenal glands
10:30 – 01:30 Group work: Clinical case studies on calcium metabolism
You should use the information from the lecture and your reading to answer the questions.
Intended learning outcomes: By the end of this session you will be able to:
o Explain the significance of maintaining serum calcium levels within set limits
o List the hormones involved in the control of calcium levels in serum
o Describe the hormonal regulation of serum calcium
o Explain the interaction of parathyroid and vitamin D
o Explain the regulation of parathyroid hormone and vitamin D
o Explain the significance of renal function on calcium metabolism
o Describe disorders of calcium metabolism and metabolic bone disease
o List the hormones produced by the pituitary and adrenal glands together with their
functions.
o Describe in general terms the structure of the steroid hormones.
o Explain how the steroid hormones affect their target tissues.
o Explain how cortisol secretion is controlled by ACTH and CRH.
o Describe in general terms the structure and functions of adrenaline.
Self- assessment:
You should answer the self-assessment questions to ensure that you can meet the
learning objectives of the Session. In addition, you should continue to review the self-
assessment questions and Group Work of the other sessions in order to prepare yourself for
the Summative Assessment that will take place after the Christmas break.
Suggested reading:
Endocrine system, J. Hinson, P. Raven and S. Chew., (Elsevier 2007)
Marks Essentials of Medical Biochemistry p19, 336-339, 446-447
Ganong's Review of Medical Physiology Chapter 22, 23
164
Lecture notes
The gut, kidneys, and bone regulate calcium balance

Calcium plays a critical role in many cellular processes, including hormone secretion, muscle
contraction, nerve conduction, exocytosis, and the activation and inactivation of many enzymes.
As discussed in the Membranes and Receptors module Ca+2 also serves as an intracellular
second messenger by carrying information from the cell membrane into the interior of the cell.
It is therefore not surprising that the body very carefully regulates the plasma concentration of
free ionized calcium ([Ca+2]), the physiologically active form of the metal, and maintains free
plasma [Ca+2] within a narrow range (between 1.0 and 1.3 mM, or 4.0 and 5.2 mg/dl).
Phosphate is no less important. Because it is part of the adenosine triphosphate molecule,

phosphate plays a critical role in cellular energy metabolism. It also plays crucial roles in the
activation and deactivation of enzymes. However, unlike calcium, the plasma phosphate
concentration is not very strictly regulated, and its levels fluctuate throughout the day,
particularly after meals.
Calcium homeostasis and phosphate homeostasis are intimately tied to each other for two
reasons. First, calcium and phosphate are the principal components of hydroxyapatite crystals
[Ca10(PO4)6(OH)2)], which constitute by far the major portion of the mineral phase of bone.
Second, they are regulated by the same hormones, primarily parathyroid hormone (PTH) and
1,25-dihydroxyvitamin D (calcitriol) and, to a lesser extent, the hormone calcitonin. These
hormones act on three organ systems-the bone, the kidneys, and the gastrointestinal (GI) tract-
to control the levels of these two ions in plasma. However, the actions of these hormones on
calcium and phosphate are typically opposed in that a particular hormone may elevate the level
of one ion while lowering that of the other.
165
Calcium distribution and balance:
Note that all values are for a 70 Kg human, expressed in terms of elemental calcium. ECF,
extracellular fluid: Most calcium is located within bone, approximately 1 kg. The total amount
of calcium in the extracellular pool is only a fraction of this amount, about 1 g or 1000 mg. The
typical daily dietary intake of calcium is approximately 800 to 1200 mg. Dairy products are the
major dietary source of calcium. Although the intestines absorb approximately one half the
dietary calcium (~500 mg/day), they also secrete calcium for removal from the body (~325
mg/day), and, therefore, the net intestinal uptake of calcium is only approximately 175 mg/day.
The second major organ governing calcium homeostasis is bone, where calcium deposition
of about 280 mg/day is matched by an equal amount of calcium reabsorption in the steady state.
The third organ system involved, the kidneys, filter about 10 times the total extracellular pool
of calcium per day, about 10,000 mg/day. More than 98% of this Ca+2 is reabsorbed, and,
therefore, the net renal excretion of Ca+2 is less than 2% of the filtered load. In a person in Ca+2
balances, urinary excretion (~175 mg/day) is the same as net absorption by the GI tract.
In plasma, calcium exists in three physicochemical forms:

o A free ionized species,
o Bound to (more accurately, associated with) anionic sites on serum proteins
(especially albumin)
o Complexed with low-molecular-weight organic anions (e.g., citrate and oxalate).
The total concentration of all three forms in the plasma is normally 2.2 to 2.7mM (8.8 to
10.6 mg/dl). In healthy individuals, approximately 45% of calcium is free, 45% is bound to
protein, and 10% is bound to small organic anions. The ionized form is the most important with
regard to regulating the secretion of PTH and is involved in most of the biological actions of
calcium.
Important fact
It is the free ionized calcium in plasma that is physiologically active. However common
laboratory tests measure total calcium which includes that which is bound to albumin and other
proteins. The levels are then corrected depending on the level of albumin to determine if free
calcium is in the correct range or not!
What happens if plasma calcium levels alter?
The consequence of plasma calcium levels straying outside these daily limits is significant.
Hypocalcaemia (calcium too low) results in hyper-excitability in the nervous system, including
the neuromuscular junction, leading to paraesthesia, then tetany, paralysis and even
convulsions. Whereas, chronic hypercalcaemia (calcium too high) may result in the formation
of kidney stones (renal calculi), constipation, dehydration, kidney damage, tiredness and
depression.
166
Hormones involved in the regulation of serum calcium levels:
Given the consequence of dysregulation of serum calcium, it is clearly important that levels
are maintained within set limits. Two key hormones are involved in this regulation, Parathyroid
hormone (PTH) and Vitamin D. They both raise serum calcium concentrations, but act by
different mechanisms and over quite different time scales. The short term regulation of serum
calcium is under the control of PTH, whereas the active form of vitamin D (calcitriol) is
responsible for longer term regulation.
Parathyroid hormone related peptide (PTHrP) is a peptide produced by tumours which may
lead to hypercalcaemia. The measurement of PTHrP can be of assistance in determining the
cause of an otherwise unexplained hypercalcaemia. PTHrP is a peptide secreted by some cancer
cells leading to humeral hypercalcaemia of malignancy (HHM). PTHrP is produced commonly
in patients with breast or prostate cancer and occasionally in patients with myeloma. PTHrP
shares many actions with PTH leading to increased calcium release from bone, reduced renal
calcium excretion and reduced renal phosphate reabsorption. However, PTHrP does not
increase renal C-1 hydroxylase activity and therefore does not increase calcitriol concentration,
unlike parathyroid hormone.
There is a third hormone, calcitonin, which in animal models lowers serum calcium levels.
However, in humans this peptide hormone which is secreted from the thyroid gland appears to
lack pathology associated with either hypo or hyper secretion, suggesting that it has little
function. If the thyroid gland is removed or destroyed the lack of secretion of calcitonin has no
apparent effect on calcium homeostasis. However, there is some suggestion that during
pregnancy this hormone may serve to preserve the maternal skeleton.
167
Lecture notes
Pituitary & adrenal glands

Pituitary gland
The pituitary gland is located at the base of the brain suspended from the hypothalamus by
a stalk. It lies in a deep recess of the sphenoid bone (pituitary fossa). The gland weighs 0.5 -
0.9g and is larger in females (effect of oestrogen on Lactotrophs).
The blood supply to the gland is unusual in that it has a portal system i.e. a vessel connecting
two capillary beds located in separate tissues, one in the hypothalamus and the other in the
anterior pituitary. There is also an arterial supply from the superior and inferior hypophyseal
arteries arising from internal carotid artery.
The pituitary gland develops as a fusion between an up-growth of ectodermal cells from the
roof of the primitive pharynx (buccal cavity) that forms the anterior lobe (adenohypophysis)
and a down-growth of neural tissue from the hypothalamus that forms the posterior lobe
(neurohypophysis). The two parts are histologically different and function as two different
endocrine glands. You will only be concerned with the anterior pituitary this semester.
The following hormones are produced in distinct cell types in the anterior pituitary:
o TSH is produced in the Thyrotrophs.
o ACTH produced in the Corticotrophs.
o Growth hormone produced in the Somatotrophs that represent the largest number of cells.
o LH and FSH are produced in the Gonadotrophs.
o Prolactin is produced in the Lactotrophs.
Adrenal Glands
The adrenal glands are a pair of multifunctional endocrine glands that cap the upper
poles of the kidneys and lie against the diaphragm. They are small in size and have a
combined weight of 6-8 g (slightly less in the female). The gland consists of two regions,
an outer cortex and an inner medulla and produces the following hormones:
Cortex
• Mineralocorticoids: e.g., aldosterone (C21 steroid)
• Glucocorticoids: e.g., cortisol and corticosterone (C21 steroids), major steroids
produced.
• Androgens: e.g., dehydroepiandrosterone (C19 steroid) - only produced in small
amounts.
Medulla
o Adrenaline (epinephrine)
168
Adrenal cortex
Under a connective tissue capsule with its plexus of blood vessels (capsular plexus),
three zones can be recognized by the different arrangement of the secretory cells with their
associated network of capillaries and sinusoids:
(1) Zona Glomerulosa. The cells in this outermost zone secrete the mineralocorticoids
(e.g. aldosterone) that regulate the body Na+ and K+ levels.
(2) Zona Fasciculata. The cells in this zone produce the glucocorticoids (e.g. cortisol)
that have a number of important functions including the regulation of carbohydrate
metabolism.
(3) Zona Reticularis. This is the deepest cortical zone and the cells secrete glucocorticoids
and small amounts of androgens (dehydroepiandrosterone).
Cortisol structure
Cortisol is a member of the C21 steroid family that differ from other steroids in the number
of C-atoms, presence of functional groups and distribution of C=C double bonds. All the steroid
hormones are lipophilic and are synthesized from cholesterol via progesterone in a series of
enzyme catalysed reactions.
Control of cortisol secretion
Adrenocorticotrophic Hormone (ACTH or corticotrophin) secreted from the corticotrophs

of the anterior pituitary is the main factor controlling the release of cortisol. The secretion of
ACTH is under the control of corticotrophin releasing factor (CRF), a 41 amino acid polypeptide
produced in the hypothalamus. CRF is secreted in response to physical (temperature, pain),
chemical (hypoglycaemia) and emotional stressors. There is also negative feedback by
glucocorticoids on both the hypothalamus & pituitary.
ACTH
ACTH is a 39 amino acid, single chain polypeptide hormone. The initial biosynthetic
precursor is a large protein (~250 amino acids) called pro-opiomelanocortin (POMC). Post-
translational processing of POMC at different sites produces a range of biologically active
peptides including ACTH, MSH (melanocyte stimulating hormone) and endorphins. The MSH
sequence of 13 amino acids is contained within the ACTH sequence in POMC giving ACTH
some MSH-like activity when present in excess.
ACTH has a short half-life in the circulation (~8min) and is released in pulses that follow a
circadian rhythm. Peak plasma levels occur in the early hours of the morning and the lowest
levels are seen in the late evening.
ACTH is hydrophilic and interacts with high affinity receptors on the surface of cells in the
zona fasiculata and reticularis. The binding of ACTH to these receptors leads to activation of
cholesterol esterase increasing the conversion of cholesterol esters to free cholesterol. It also
stimulates other steps in the synthesis of cortisol from cholesterol.
169
The clinical consequences of over-secretion of ACTH relate to the direct effects of ACTH on
tissues (increased pigmentation due to partial MSH activity) and the effects of ACTH on the
adrenal cortex that produces adrenal hyperplasia and over-production of cortisol. Under
secretion of ACTH produces symptoms related to the lack of glucocorticoids but not those
related to lack of mineralocorticoids as aldosterone secretion is normal (not controlled by
ACTH).
As ACTH is a peptide hormone it acts on receptors on the cell membrane of target cells. The
specific receptor for ACTH is a type of melanocortin receptor (type 2), known as MC2; it is also
sometimes called the corticotropin receptor. This receptor uses cAMP as a secondary
messenger. The mechanism of action of the peptide hormone ACTH should not be confused
with the mechanism of action of a steroid hormone, such as cortisol (see below); they are quite
different.
Transport of cortisol in plasma
Cortisol, like all steroids, is lipophilic and must be transported bound to plasma proteins. The
major transport protein is transcortin and this carries ~90% of the plasma cortisol the remaining
~10% being free and biologically active.
Mechanism of action of cortisol act upon its target cells
Cortisol can cross the plasma membranes of target cells and bind to cytoplasmic receptors.
The hormone/receptor complex then enters the nucleus to interact with specific regions of DNA.
This interaction changes the rate of transcription of specific genes and may take time to occur.
Actions of cortisol on target cells
Cortisol is an important component of the stress response and it has a number of important
effects on metabolism. The major metabolic effects are in the starved and stressed states where
it affects the availability of all major metabolic substrates by increasing proteolysis, lipolysis
and gluconeogenesis.
The metabolic actions of cortisol include:
↓ amino acid uptake, ↓ protein synthesis & ↑ proteolysis in most tissues (not liver).
↑ hepatic gluconeogenesis and glycogenolysis.
↑ lipolysis in adipose tissue
N.B. high levels of cortisol ↑ lipogenesis in adipose tissue. ↓ peripheral uptake of glucose
(anti-insulin).
In addition to its general metabolic actions, it also has direct effects on cardiac muscle, bone
and the immune system.
170
Adrenal Medulla
The adrenal medulla is, in essence, a modified sympathetic ganglion that synthesizes various
catecholamines including the hormone adrenaline (epinephrine) and the neurotransmitters
noradrenaline (norepinephrine) and dopamine.
Catecholamine synthesis
The catecholamines are synthesized in a series of enzyme-catalysed steps that convert

tyrosine to dopamine. Dopamine is then converted to noradrenaline and noradrenaline to
adrenaline. The catecholamines are stored in the medullary cells in membrane-limited vesicles.
Actions of adrenaline
Adrenaline is released as part of the fright, flight or fight response in man and it is secreted
in response to stress situations. It has effects on:
• Cardiovascular system (↑ cardiac output, ↑ blood supply to muscle).
• Central nervous system (↑ mental alertness).
• Carbohydrate metabolism (↑ glycogenolysis in liver and muscle).
• Lipid metabolism (↑ lipolysis in adipose tissue).
Clinical consequences of over-secretion of adrenaline
Overproduction of adrenaline by the adrenal medulla, usually due to a tumor

(Pheochromocytoma), may be associated with hypertension, anxiety, palpitations, pallor,
sweating and glucose intolerance.
171
Group Work
Clinical Cases
Case Study 1
Rajeha is 65 years old. She has become very tired over the last 2 years. The symptoms were
insidious and she cannot remember exactly when they began. She has been going to the toilet
to pass urine 3 or 4 times a night. She also complains of constipation and only passing very hard
stools once or twice a week. She is feeling nauseous.
Past history: Rajeha had an episode of renal colic 10 years ago; she passed the stone in her
urine.
Examination: She appears fatigued and low in mood. Her BP was 165/95mmHg. She also had
several mobile lumps in her abdomen which were thought to be faeces in the colon. You suspect
that Rajehaà has chronic hypercalcaemia and order blood tests, abdominal radiography and
urine specimens for microbiology and cytology.
You note that Rajehaà has a high serum calcium level.
a. What is the main acute regulator of serum calcium?
172
b. Where is PTH secreted from?
c. What condition normally stimulates the secretion of PTH?
d. What condition normally inhibits the secretion of PTH?
You request a serum PTH test and find that this is abnormal at 15pmol/L (normal 1.2-
6.7pmol/L).
e. What does this tell you about the function of the parathyroid glands?
f. At which two sites in the body does parathyroid hormone act to cause hypercalcaemia?
1.
2.
g. What does the high alkaline phosphatase indicate?
173
Case Study 2
A 63-year-old male factory worker was referred to the clinic with weight loss, general
malaise and a cough. He drank four pints of beer and smoked 20 cigarettes a day. There was no
history of excessive intake of vitamin supplements and he took no regular medication. Blood
tests revealed normal renal and liver function, but a serum Ca2+ of 3.8 mmol/L (Reference values
2.2-2.6 mmol/L) with an albumin of 37g/L (Normal Range 38-48 g/L). The serum PTH
concentration was below the assay detection limits.
You suspect that the patient has a malignant tumour.
a. What are the two main mechanisms by which malignancy causes hypercalcaemia?
1.
2.
b. In light of these results what type of malignancy is likely to be causing your patient`s
symptoms?
c. Why does the patient then have low PTH levels?
d. What effect does PTH normally have on vitamin D synthesis?
In a patient with hyperparathyroidism you would expect to see high levels of vitamin
D. Your patient has normal levels of vitamin D.
e. Can you explain why?
174
Self-assessment
a. Label the diagram to identify the usual position of the parathyroid glands?
b. What is the main function of the parathyroid glands?
c. Identify the cells which are responsible for secreting parathyroid hormone in this histological
photomicrograph of a section from the parathyroid glands.
d. Which chemical messenger(s) is/are involved in the control of serum calcium (Ca2+)
levels?
175
e. What is the effect on serum calcium of each of the chemical messengers which control it?
1.
2.
f. If the calcium ion (Ca2+) concentration in the extracellular fluid suddenly falls below normal,
which hormone is secreted?
g. In long term (chronic) hypocalcaemia which chemical messenger(s) is/are active?
h. What three effects does parathyroid hormone initiate in response to low calcium ions in extra
cellular fluid?
1.
2.
3.
i. Explain how regulation of parathyroid hormone secretion occurs?
j. What is stimulated by parathyroid hormone to reabsorb bone mineral, liberating calcium into
blood?
k. Where else in the body does increased parathyroid hormone act to produce a rapid increase
in serum calcium levels?
l. Which of the following is the active form of vitamin D, following activation by the kidney?
A. cholecalciferol
B. 25-hydroxyvitamin D2
C. Ergocalciferol
D. 1,25-dihydroxycholecalciferol (calcitriol)
m. How and where is vitamin D formed/ absorbed?
n. Where and why is vitamin D converted to 25-hydroxyvitamin D?
176
o. What is the half-life of 25-hydroxyvitamin D?
p. What is the half-life of calcitriol?
q. Which of the following regarding calcitriol is correct?
A. It is effective in inhibiting the parathyroid gland to secrete parathyroid hormone

B. It is effective in enhancing GI absorption of calcium
C. Its use can result in hypocalcaemia
D. All of the above
p. What role does calcitonin have in the regulation of serum calcium levels?
s. Describe the role of the hypothalamus in the control of pituitary function.
t. Explain why the pituitary is considered by some to be the Master Endocrine Gland .
u. Outline the major structural differences between the various classes of steroid hormones.
v. Describe how the secretion of cortisol is controlled.
w. Describe how cortisol is transported in the blood and how it affects its target tissues.
177
Session Twelve
Disorders of the adrenal cortex
Adaptations of metabolism
Aims of the session
The aim of the session is that you should understand disorders of the pituitary and adrenal
glands and appreciate key metabolic adaptations

08.00 - 09.00 Lecture: Clinical presentation: Disorders of the adrenal cortex
09.00 - 10.00 Lecture: Adaptations of metabolism
10.30 - 01.30 Group work: Clinical case studies.
You should use the information from the lecture and your reading to answer the questions on
clinical consequences of disturbances to adrenal function
Intended learning outcomes: By the end of the session, you should be able to:
o Explain how cortisol secretion is controlled by ACTH and CRH.
o Explain how ACTH can lead to increased pigmentation in certain areas of the body.
o Describe the main actions of cortisol.
o Explain the effects of over- and under-secretion of cortisol.
o Describe tests of adrenal cortical function
o Explain how cortisol can have weak mineralocorticoid and androgen effects.
o Describe the metabolic and hormonal response to pregnancy
o Explain the hormonal basis of gestational diabetes
o Describe the metabolic and hormonal responses to various types of exercise
o Explain the benefits of exercise
Suggested reading:
Mark’s Essentials of Medical Biochemistry, p 443-446
178
Lecture notes
Disorders of adrenocortical function

Abnormal function of the adrenal cortex produces a number of clinical problems:
Hypoactivity: Decreased activity of the adrenal cortex (Addison’s disease) may be due to:
(1) Diseases of the adrenal cortex (auto-immune destruction) - reduce glucocorticoids and
mineralocorticoids.
(2) Disorders in pituitary or hypothalamus that lead to decreased secretion of ACTH or
CRF only affects glucocorticoids.
Hyperactivity: Increased secretion of glucocorticoids (Cushing’s syndrome) may be due to

(1) Increased activity of the adrenal cortex due to tumor (adenoma).
(2) Disorders in the secretion of ACTH caused by pituitary adenoma (Cushing s disease)
or ectopic secretion of ACTH.
Congenital adrenal hyperplasia
A number of clinical conditions arise as a consequence of a genetic defect in one or more

of the enzymes required for the synthesis of cortisol. Because of the lack of cortisol the pituitary
is not subjected to feedback control and it therefore secretes large amounts of ACTH. ACTH
causes enlargement of the adrenal cortex (hyperplasia). The severity and consequences of these
conditions depend on which enzyme(s) is affected.
Clinical effects of excess cortisol secretion
The signs and symptoms may include:

o Increased muscle proteolysis and hepatic gluconeogenesis that may lead to
hyperglycaemia with associated polyuria and polydipsia (“steroid diabetes”).
o Increased muscle proteolysis leads to wasting of proximal muscles and producing
thin arms and legs and muscle weakness.
o Increased lipogenesis in adipose tissue leading to deposition of fat in abdomen, neck
and face and producing characteristic body shape, moon-shaped face and weight gain.
o Purple striae on lower abdomen, upper arms and thighs reflecting the catabolic effects
on protein structures in the skin and leading to easy bruising because of thinning of skin
and subcutaneous tissue.
o Immunosuppressive, anti-inflammatory and anti-allergic reactions of cortisol leading to
increased susceptibility to bacterial infections and producing acne.
o May be back pain and collapse of ribs due to osteoporosis caused by disturbances in
calcium metabolism and loss of bone matrix protein.
o Mineralocorticoid effects of excess cortisol may produce hypertension due to sodium
and fluid retention.
N.B. Many of these signs and symptoms occur in patients receiving long-term treatment with
glucocorticoids for various chronic inflammatory conditions.
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Clinical effects of too little cortisol secretion

Too little cortisol secretion, caused by auto-immune destruction of the adrenal gland, would
also involve the loss of the mineralocorticoids producing a complex situation that may present
as an acute emergency (Addisonian Crisis) or as a chronic debilitating disorder (Addison’s
disease):
o Insidious onset with initial non-specific symptoms of tiredness, extreme muscular

weakness, anorexia, vague abdominal pain, weight loss and occasional dizziness.
o Extreme muscular weakness and dehydration.
o A more specific sign is the increased pigmentation, particularly on the exposed areas of
the body, points of friction, buccal mucosa, scars and palmar creases due to ACTH-
mediated melanocyte stimulation.
o Decreased blood pressure due to sodium and fluid depletion.
o Postural hypotension due to fluid depletion.
o Hypoglycaemic episodes especially on fasting.
These effects may be exacerbated by stress such as trauma or severe infection and lead to
nausea, vomiting, extreme dehydration, hypotension, confusion, fever and even coma
(Addisonian crisis). This constitutes a clinical emergency that must be treated with intra-venous
cortisol and fluid replacement (dextrose in normal saline) to avoid death.
Clinical tests of adrenocortical function.
Measurement of plasma cortisol and ACTH levels and the 24hr urinary excretion of cortisol
and its breakdown products (17-hydroxysteroids) are important in investigating suspected
adrenocortical disease. In addition, dynamic function tests (e.g. dexamethasone suppression
tests and ACTH stimulation tests) may be used in the differential diagnosis of adrenocortical
disease.
Dexamethasone is a potent synthetic steroid that, when given orally would normally
suppress (by feedback inhibition) the secretion of ACTH and thus cortisol.
Dexamethasone suppression of plasma cortisol by >50% is characteristic of Cushing s
disease because for the diseased pituitary, even though it is relatively insensitive to cortisol, it
does retain some sensitivity to potent synthetic steroids. Suppression does not normally occur
in adrenal tumours or ectopic ACTH production. The administration of Synacthen (a synthetic
analogue of ACTH) intramuscularly, would normally increase plasma cortisol by >200 nmol/l.
A normal response usually excludes Addison’s disease.
Steroid hormone receptor homology

The steroid receptors form part of a family of nuclear DNA-binding proteins that include the
thyroid and vitamin D receptors. They all have three main regions, a hydrophobic hormone-
binding region, a DNA-binding region rich in cysteine and basic amino acids and a variable
region. There is sequence homology in the hormone binding regions of the receptors. The
percentage homology of the hormone binding region of the glucocorticoid receptor with the
mineralocorticoid, androgen, oestrogen and thyroid receptors is ~64%, ~62%, ~31% and ~24%
respectively. Thus, cortisol will bind to the mineralocorticoid and androgen receptors with low
affinity. This binding may become significant when high levels of the hormone are present.
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Actions of other adrenal steroids
Aldosterone stimulates Na+ reabsorption in the kidney in exchange for K+ (or H+). Over
secretion of aldosterone increases Na+ and water retention and loss of K+ causing hypertension
and muscle weakness. Under secretion of aldosterone does the opposite causing hypotension.
Androgens stimulate the growth and development of male genital tract and male secondary
sexual characteristics including height, body shape, facial and body hair, lower voice pitch.
They also have anabolic actions especially on muscle protein. Over secretion of adrenal
androgens produces effects in the female that include: hair growth (hirsuitism), acne, menstrual
problems, virilisation, increased muscle bulk, deepening voice.
Oestrogens stimulate growth and development of female genital tract, breasts and female
secondary characteristics including broad hips, accumulation of fat in breasts and buttocks,
body hair distribution. They are weakly anabolic and decrease circulating cholesterol levels.
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Lecture notes
Adaptations of metabolism
Metabolic response to pregnancy
Following fertilization and implantation the placenta and foetus begin their growth and
development and this continues throughout pregnancy. A typical net weight gain by the end of
pregnancy is ~8 kg (foetus ~3.5 kg, placenta ~0.6 kg, amniotic fluid ~0.8 kg, maternal fuel
stores ~3 kg). The mother supplies everything that is needed for this growth (nutrients, vitamins,
minerals, oxygen and water). These requirements increase as growth proceeds and they exert
an ever-increasing impact on maternal metabolism.
The rate of transfer of nutrients across the placenta to the foetus is dependent on their
concentration in the maternal circulation. Thus, the environment in which the foetus develops
is controlled by maternal metabolism and these changes as pregnancy proceeds to ensure that:
o The foetus is supplied with the range nutrients it requires.
o These nutrients are supplied at the appropriate rate for each stage of development.
o This is achieved with minimal disturbances to maternal nutrient homeostasis.
o The foetus is buffered from any major disturbances in maternal nutrient supply.
The metabolism of all the major maternal nutrients is affected during pregnancy, the
magnitude of the effect depending on the stage of pregnancy. These changes are long-term
adaptive responses of maternal metabolism that are hormonally mediated. The hormones
involved are maternal insulin and a number of hormones produced by the foetal-placental unit
including oestrogens, progesterone and placental lactogen.
Role of insulin
Insulin plays a major role in controlling the changes in maternal metabolism that occur in
pregnancy. Its concentration in the maternal circulation increases as pregnancy proceeds and it
acts to promote the uptake and storage of nutrients, largely as fat in maternal adipose tissue.
Role of foetal-placental hormones
These hormones become increasingly important as pregnancy proceeds and they have a
number of effects on maternal metabolism that largely oppose the actions of insulin i.e. they
are anti-insulin .
Metabolic changes during the first half of pregnancy
The changes to maternal nutrient homeostasis during the first 20 weeks of pregnancy are
related to a preparatory increase in maternal nutrient stores (especially adipose tissue) ready for
the more rapid growth of the foetus, birth and subsequent lactation. Increasing levels of insulin
(insulin/anti-insulin ratio) promote an anabolic state in the mother that results in increased nutrient
storage.
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Metabolic changes during the second half of pregnancy
The second half of pregnancy is characterized by a marked increase in growth of the placenta
and foetus. Maternal metabolism adapts to meet an increasing demand by the foetal-placental
unit for nutrients as well as meeting the requirements of maternal tissues. The demands of the
foetal-placental unit for nutrients are met by keeping the concentration of nutrients in the
maternal circulation relatively high. This is achieved by:
o Reducing the maternal utilisation of glucose by switching tissues to fatty acids.
o Delaying the maternal disposal of nutrients after meals.
o Releasing fatty acids from the stores built up during the first half of pregnancy.
These changes in maternal metabolism are controlled by changes in the insulin/anti-insulin

ratio. Maternal insulin levels continue to increase but the production of the anti-insulin
hormones by the foetal-placental unit increases at an even faster rate and the insulin/anti-
insulin ratio therefore falls producing the required metabolic changes.
Maternal ketogenesis
An interesting aspect of the marked decrease in the insulin/anti-insulin ratio during the
second half of pregnancy is its effect on maternal ketogenesis. The increased availability of
fatty acids to the liver resulting from the mobilisation of maternal adipose tissue, coupled with
the fall in the insulin/anti-insulin ratio switches on the production of ketone bodies by the
maternal liver. These are used as a fuel by the developing foetal brain.
Gestational diabetes
Maternal insulin is a major factor in controlling the metabolic response to pregnancy and the
rate of secretion of insulin (both basal and stimulated) normally increases as pregnancy
proceeds. The ability of the β-cells to meet this increased demand for insulin secretion is
achieved by β -cell hyperplasia and β -cell hypertrophy. In addition, the rate of insulin synthesis
in the β -cells increases.
In some women the endocrine pancreas is unable to respond to the metabolic demands of
pregnancy and the pancreas fails to release the increased amounts of insulin required. As a
consequence there is a loss of control of metabolism, blood glucose increases and diabetes
results (Gestational Diabetes). After birth, when the increased metabolic demands of pregnancy
are removed and hormone levels change, the endocrine pancreas can respond adequately and
the diabetes disappears. Women who experience gestational diabetes are more likely to develop
overt diabetes later in life than women who do not experience the condition.
Metabolic response to exercise
The body needs to meet the acute oxygen and fuel demands of cardiac and skeletal muscle
during exercise and ensure that the end products of metabolism are removed. This involves a
variety of short-lived adaptations to metabolism, temperature regulation, the cardiovascular
system and the respiratory system.
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The metabolic response to exercise ensures:

o The increased energy demands of skeletal and cardiac muscle are met by mobilisation
of fuel molecules from energy stores.
o There are minimal disturbances to homeostasis by keeping the rate of mobilisation equal
to the rate of utilisation.
o The glucose supply to the brain is maintained (prevent hypoglycaemia).
o The end products of metabolism are removed as quickly as possible.
The magnitude and nature of the metabolic response depends on:

o Type of exercise (muscles used).
o Intensity and duration of exercise.
o Physical condition and nutritional status of the individual.
During high intensity activities of short duration (100m sprint run in ~10sec) skeletal muscle
has to work under anaerobic conditions as the supply of oxygen to the muscle is inadequate to
maintain aerobic metabolism. However, during lower intensity activities of longer duration (a
marathon run in ~2-3hr) the supply of oxygen to muscle is adequate to allow aerobic
metabolism. Thus, different types of exercise are associated with striking differences in the
pattern of muscle metabolism.
Energy requirements of exercise
The energy requirements of exercise largely reflect the increased activity of skeletal and
cardiac muscles, the increased activity of the respiratory muscles being less significant. In the
normal resting state (BMR) the body uses ~4 kJ/min of energy. This increases to ~80 kJ/min
during a marathon and to ~200 kJ/min during the 100m sprint. The energy for muscle
contraction comes from the hydrolysis of ATP:
ATP + H2O ADP + Pi + energy
At rest the rate of ATP turnover in skeletal muscle is ~0.06 mmol/sec/kg muscle. This
increases to ~1.2 mmol/sec/kg muscle during a Marathon and to ~3 mmol/sec/kg muscle during
the 100m sprint. The ATP concentration in muscle is ~5 mmol/kg muscle and could in theory
last for ~2 sec during a sprint. However, the ATP concentration does not fall by more than 20%
because it is regenerated from ADP by a variety of mechanisms.
Initially it is regenerated from the creatine phosphate (C~P) present in muscle (~17mmol/kg
muscle):
Creatine~P + ADP ATP + Creatine
Thus, the energy immediately available in muscle to drive contraction (ATP + C~P) will last
for ~5 sec during the 100m sprint. This means that ADP must be rapidly converted back to ATP
by coupling it to the oxidation of fuel molecules if contraction is to continue and the race
finished.
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Fuel molecules
Fuel molecules are present in tissue energy stores and in the circulation. The major tissue
stores of energy that can be called upon during exercise are glycogen (~300g in muscle and
~100g in liver) and triacylglycerols (~15kg in adipose tissue and a smaller amount in muscle
cells). The major circulating fuel molecules are glucose (~5mM) and free fatty acids (~0.5mM).
The glycogen stores of muscle could provide the muscles with enough energy, under aerobic
conditions (i.e. when completely oxidized to CO2), for ~60 min of low intensity exercise
(marathon running). However, under anaerobic conditions (sprinting), where the end product is
lactic acid, the glycogen stores would only last ~2 min. This striking difference reflects both
the difference in the rate of ATP consumption during the two types of exercise (see above) and
the relative amounts of ATP produced during the two processes (33 miles of ATP/mole glucose
as glycogen under aerobic conditions and only 3 miles of ATP/mole of glucose as glycogen
under anaerobic conditions).
The glycogen stores of liver could provide muscle with enough glucose for ~18min of low
intensity exercise (marathon running). However, this store of glucose is required to prevent
hypoglycaemia and the associated impairment of CNS function. In addition, there are a number
of advantages of using muscle glycogen over circulating glucose:
o Availability not affected by blood supply.
o No need for membrane transport into muscle cells.
o Produces G-6-P without using ATP (glycogen phosphorylase uses Pi).
o Mobilisation can be very rapid - highly branched structure allows many sites for
enzyme attack and glycogen phosphorylase activity can be changed rapidly by a
mixture of covalent modification (phosphorylation) and allosteric activation
(ADP and Ca+2).
A serious problem that limits the anaerobic metabolism of glucose in muscle (from glycogen
or from circulating glucose) is the buildup of lactate and H+. The accumulation of H+ is so
dramatic (2 miles of H+ for every mole of glucose metabolised) that it exceeds the buffering
capacity of the muscle cells and impairs their function producing fatigue. Thus, anaerobic
metabolism cannot continue as the sole source of ATP generation much beyond 200m. The
impairment of muscle function by H+ involves a number of a number of mechanisms including:
o Inhibition of glycolysis by H+.
o H+ interferes with actin/myosin interaction.
o H+ causes sarcoplasmic reticulum to bind calcium (inhibits contraction).
The triacylglycerol stores of adipose tissue are large (~15kg) and could provide the muscles
with fatty acids. The oxidation of these fatty acids under aerobic conditions would provide
sufficient energy for ~48 hr of low intensity exercise. However, there are a number of factors
that limit the use of fatty acids by muscle. These include:
o Rate of fatty acid release from adipose tissue (rate of lipolysis).
o Limited capacity of the blood to transport fatty acids (requires binding to albumin).
o Rate of fatty uptake into muscle cells and into muscle mitochondria.
o Fatty acid oxidation requires more oxygen/mole of ATP produced than glucose.
o Fatty acids can only be metabolised under aerobic conditions.
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The total amount of glucose and free fatty acids in the extracellular fluid are ~12g and ~4g
respectively. These will provide ~180kJ and ~100kJ when oxidised completely to CO2 and
H2O. Thus, the total amount of potential energy available in the circulation is ~280kJ, enough
for ~4 min of marathon running.
Metabolic response to short-duration high intensity exercise (100m sprint)
The athlete goes as fast as possible with no thought for endurance and covers the distance in
~10 sec. The metabolic response is rapid and is largely confined to skeletal muscle that works
anaerobically. It is controlled by the nervous system (noradrenaline) with some input endocrine
systems (adrenaline). The metabolic response includes:
o Muscle ATP and C~P are used initially (~5sec).
o Muscle glycogen is rapidly mobilized to provide glucose 6-P (~5sec).
o Glucose 6-P is metabolised via glycolysis to provide ATP from ADP by substrate
level phosphorylation.
o Glycolysis is carried out under anaerobic conditions as oxygen supply to muscle is
inadequate for aerobic metabolism.
o Dramatic increase in rate of anaerobic glycolysis ( 1000 times) produces lactate and
H+ (at maximum rate ~20 mmol of H+ are produced every sec).
o Buildup of H+ produces fatigue.
Metabolic response to medium duration medium intensity exercise (1500m)
The athlete must consider endurance as well as speed since the race will last ~3.5min. The
body regenerates ATP by a mixture of aerobic (~60%) and anaerobic (~40%) metabolism of
glycogen. The body must eliminate a large amount of CO2 but there is no major problem with
H+ as the amount produced can be buffered by the muscle.
There are three phases to the race:

o The initial sprint which uses muscle ATP, C~P and anaerobic glycogen metabolism.
o A long middle phase in which ATP is produced aerobically from glycogen in muscle.
This relies on an adequate supply of O2 to muscles.
o A final finishing burst which relies on the anaerobic metabolism of glycogen and
produces lactate.
Metabolic response to long duration low intensity exercise e.g. marathon running
The Marathon is run over a distance of 42.2km (26miles 385yds) and the elite athlete
completes the distance in 125-135min. The carbohydrate stores in the body are insufficient to
provide enough energy to complete the distance and muscle cells have to oxidise fatty acids.
The metabolic changes during a marathon are more gradual than those that occur during
sprinting and involve several tissues.
The major features of the metabolic response are:
o The muscles work aerobically (supply of oxygen increased by cardiovascular
response) and can use all types of fuel molecules (not just glucose).
o The origin and type of fuel changes as exercise proceeds.
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Control of these changes is largely hormonal (insulin, adrenaline, growth hormone,

glucagon and cortisol) with some input from the nervous system (noradrenaline).
Fuel molecules used during a marathon

o The major fuel used during the initial phase of a marathon is muscle glycogen and if
this was the sole source of energy it would last ~60min when metabolised aerobically.
Many marathon runners try to prolong the utilisation of glycogen by eating carbohydrate
rich diets to increase their glycogen stores. This is most effective after exercise as
exercise promotes the storage of glucose as muscle glycogen rather than its conversion
to lipid.
o As the marathon proceeds there is increased utilisation of circulating blood glucose by
muscles. The blood glucose concentration stays relatively constant however, as the
glucose removed by muscles is replaced by glucose released from the liver. This glucose
comes from the liver s limited glycogen stores (~75%) and from gluconeogenesis
(~25%).
o There are limited substrates available for liver gluconeogenesis and eventually the blood
glucose level may fall - exhaustion!
o Because of the aerobic conditions that the muscle cells are working under they able to
use fatty acids as a source of energy and this utilisation increases with time.
Approximate contribution to O2 consumption during a marathon by a non-elite runner
Control of the metabolic responses during a marathon
The metabolic responses are gradual and progressive and are controlled largely by the
endocrine system. The major changes are:
o Insulin levels fall progressively as a result of inhibition of insulin secretion by
adrenaline and noradrenaline.
o Adrenaline, noradrenaline and growth hormone levels increase rapidly.
o Glucagon and cortisol levels increase gradually.
The net effect of these changes is a progressive fall in the insulin/anti-insulin ratio:
o Increases glycogenolysis in liver.
o Increases gluconeogenesis in liver (uses lactate and glycerol).
o Increases lipolysis in adipose tissue.
o No effect on ketogenesis in liver (insulin still present).
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Fatigue
Fatigue is the inability to maintain a given power output affecting the intensity and/or
duration of exercise. There are number of causes both psychological and biochemical.
The biochemical causes include:
o Depletion of muscle glycogen.
o Accumulation of H+ in muscle.
o Dehydration (reduces capacity for sweating, reduces heat loss, increases body
temp).
Whole body response to prolonged exercise
o Increased fuel consumption by muscles, need to be supplied with fuels.*

o Increased ATP production and utilisation by muscles (~20% efficiency).
o Increased heat production, heat must be dissipated - sweating.
o Increased delivery of O2 to muscles - vasodilation of arterioles.*
o Increased removal of CO2, H+ and lactate from muscles.
o Increased cardiac output - beats faster, larger stroke volume.*
o Redistribution of blood flow away from gut and kidneys to muscles.
o Changes in breathing - increases in rate and depth.
* = can be affected by training
Whole body response to training
Training-long term adaptations to improve capacity for physical work (stamina). The
adaptations largely affect cardiovascular and musculo-skeletal systems with minimal changes
to respiratory system and are all readily reversible. The cardiovascular changes include:
o More 2,3- bisphosphoglycerate in blood (lowers affinity of haemoglobin for O2).
o Heart beats slower for same cardiac output.
The changes to skeletal muscle include increased:
o Glucose transport proteins in cell membrane (GLUT 4).
o Storage of glycogen.
o Potential for oxidative metabolism especially fatty acids - more mitochondria and more
oxidative enzymes in mitochondria.
o Number and size of muscle fibres.
o Vascularization (capillary density) of muscles - improves O2 supply.
o Myoglobin content of muscle (ability to store O2 in muscle).
Benefits of exercise
o Body composition changes (↓adipose , ↑ muscle ).*
o Glucose tolerance improves (↑muscle glycogenesis ).*
o Insulin sensitivity of tissues increases.*
o Blood triglycerides decrease (VLDL & LDL↓ , ↑ HDL )*
o Blood pressure falls.*
o Psychological effects - feeling of well-being
o Especially important for diabetics
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Sprinter or marathon runner
The fibres of skeletal muscle vary widely in both their physical properties (e.g. speed of
contraction) and metabolic properties (e.g. oxidative capacity). Two major types of fibre (Type
I and Type II) can be distinguished histologically. Type II can be further divided into types IIA
and IIB but this sub-division is beyond the scope of the present discussion. The fibre
composition of skeletal muscle is largely genetically determined and long distance runners have
over 70% type I fibres while sprinters have over 70% type II in their muscles. The major
differences between type I and type II fibres are:
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Group work
Clinical cases
Case 1
A 45 year-old lady, consulted you complaining of a rapid increase in weight of 7kg over the
preceding 2 months without an increase in appetite. She reported that her face had become puffy
and her skirts and trousers were now far too tight around her waist. She was quite unhappy to
have to buy size 16 clothes where previously size 12-14 had been comfortable. In spite of her
increase in weight she thought that her arms and legs had become thinner.
Examination revealed a plethoric (flushed), moon-shaped face, abdominal obesity with purplish
stretch marks and a blood pressure of 170/110 (reference ~130/85). Urine testing showed the
presence of glucose.
She admitted that she had been attending a private specialist, during the preceding two months,
for treatment of a skin condition and was taking tablets that had made her skin condition very
much better.
a. What endocrine abnormality is suggested by her symptoms? Explain your answer.
b. What tablets might she have been taking for her allergic skin condition?
c. What other conditions might be treated in the same way?
d. How do you account for the patient’s abdominal obesity?
190
e. How do you account for the patient`s observation that her arms and legs had become
thinner?
Initial laboratory investigations on a fasting blood sample from the patient were:
f. Comment on these results and explain why any abnormalities may have occurred.
g. If the patient had not been receiving drug treatment for her skin allergy what other causes
of her condition would you consider?
h. How could you distinguish between these possibilities?
i. What advice would you give the patient?
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Case 2
A 68 year-old woman with poorly controlled hypertension and type 2 diabetes

mellitus for 5 years, was referred to an endocrinologist for her obesity. Examination
revealed abdominal obesity with moon shaped plethoric face and a blood pressure of
210/115. Cushing`s syndrome was suspected and laboratory investigations undertaken.
The initial laboratory findings were as follows:
a. Are these results compatible with a diagnosis of Cushing`s syndrome? Explain your
answer.
b. What further investigations would you undertake?
On the basis of the results of these investigations a diagnosis of pituitary-dependent Cushing`s

disease was made.
c. What results would have led to this diagnosis?
A MRI scan was performed which demonstrated an asymmetrically enlarged pituitary gland,
consistent with a pituitary adenoma (an abnormal growth of secretory endocrine tissue). This
was successfully removed by trans-sphenoidal surgery.
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Case 3
A 25 year-old lady presented to you with weakness, fatigue, dizziness on standing, anorexia
and weight loss over the preceding year. She had also noticed that the creases in her hands
(palmar creases) had become darker in colour. Her blood pressure was 95/75 lying and 85/65
on standing (postural hypotension). a. What endocrine abnormalities might you consider?
Initial laboratory investigations on a fasting blood sample were as follows:
b. What diagnosis are these results compatible with? Explain your answer
c. How do you explain the patient s observation that her palmar creases had become darker?
d. How would you treat this lady`s condition?
e. This lady is brought into A & E having collapsed. What might be the most likely cause of
this and what treatment would you give in this emergency situation?
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Self-assessment
a. Explain why cortisol, a glucocorticoid, can have mineralocorticoid and androgen-like effects
when present in high concentrations.
b. Describe and account for five of the signs and symptoms you might expect to find in a male
patient who had the following endocrine test results on a 9am fasting blood sample:
Cortisol 1400 nmol.l-1 (reference values = 150-700 nmol.l-1)
c. Describe and account for five of the signs and symptoms you might expect to find in a female
patient who had the following endocrine test results on a 9am fasting blood sample:
Cortisol 78 nmol.l-1 (reference values = 150-700 nmol.l-1)
ACTH 120 ng.l-1 (reference values = 10-80 ng.l-1)
d. How would you expect such an individual to respond to a stress such as trauma or a severe
infection?
e. Explain why high circulating levels of ACTH can lead to increased pigmentation in certain
areas of the body.
194
f. Describe the functions and actions of adrenaline (epinephrine) in humans.
g. Outline the metabolic and hormonal changes that occur during the running of a marathon.
h. Outline the metabolic and hormonal changes that occur during the running of a 100m race.
i. List the benefits of exercise to patients with diabetes.
j. Outline the metabolic response to pregnancy.
k. Explain why some women develop Gestational Diabetes.
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Session Thirteen
Review
Aims of the session
The aim of this session is to provide an opportunity to review the contents of the module

09:00 - 10:00 Review
10:30 - 01:30 Review
Module staff will be available to answer any last minute queries arising from your revision of
the module.

On completion of this module you should be able to:
o Describe in outline the structures, functions, modes of action and the control of
secretion of the major hormones involved in the control of metabolism.
o Describe in outline the metabolic changes that occur during feeding, fasting,
starvation, pregnancy and exercise and explain how they are controlled.
o Explain why the blood glucose concentration is normally held relatively constant and
explain the metabolic and clinical consequences of untreated type 1 and type 2 diabetes.
o Analyse simple clinical case histories involving disorders of the thyroid, pituitary and
adrenal glands.
196
Appendices
Appendix i Energy Cost of Physical Activities
Appendix ii Essential Amino Acids
The following amino acids are essential for an adult and cannot be synthesized in the body:
Lysine, Isoleucine, Leucine, Threonine, Valine, Tryptophan, Phenylalanine & Methionine
Small Quantities of histidine & arginine can be synthesized in the body and a dietary supply
normally only becomes necessary during periods of active growth such as during Pregnancy:
Tyrosine can be synthesized in the body from phenylalanine and it may become essential if the
diet is low in phenylalanine. Similarly, Cysteine can be synthesized from Methionine in the
body and may become essential if the diet is low in Methionine.
Appendix iii Estimated Average Requirement (EAR)
The allowances, expressed as average daily intakes over time, are intended to provide good
nutrition for any stated group of people. Diets should be based on a variety of common foods
in order to provide other nutrients for which human requirements are less well defined.
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Estimated Average Requirements for energy and protein
Pregnant and Breast-Feeding Women (additional requirements)
Appendix iv Vitamins & Minerals
Fat-Soluble Vitamins:
A (retinol), D (cholecalciferol), E (tocopherols) & K (menaquinone)
Water-Soluble Vitamins:
C (ascorbic acid)
B-complex: B1 (thiamin), B2 (riboflavin), B3 (niacin), B6 (pyridoxine), Folic acid, B12,
Biotin, Pantothenic acid.
Major minerals
Ca, P, Mg, S, Na, K, Cl.
Trace elements
Fe, Zn, I, Se, Cu, Mn, F, Cr, Mo
198
Appendix v. Gibbs free energy (G).
The energy released in an exergonic reaction that is available to do work is known as free
energy (sometimes called Gibbs free energy). In order to compare the free energy changes of
different reactions it is necessary to standardize the conditions under which they occur. The
standard conditions used are:
o 1M concentrations of reactants and products
o 25ºC
o 1 atmosphere pressure
o pH 7.0
Under these conditions the free energy change of the reaction is known as the standard free
energy change (ΔGº’).
The actual free energy change of a reaction (ΔG) under the conditions that exist in cells is
related to the standard free energy change by the following equation:
Where R= gas constant (8.315 J/mol/ºK), T= temperature in ºK, [products]=

concentration of products, [reactants] = concentration of reactants.
The actual free energy change of a reaction in the cell can be quite different from the standard
free energy change as the:
o Concentrations of reactants and products are rarely 1M in the cell
o Temperature is usually 37ºC rather than 25ºC
It is even possible for a reaction that does not occur spontaneously under standard conditions
(+ve ΔGº’) to occur spontaneously in the cell (-ve ΔG º’). In order for this to occur [products]
must be small enough when compared with [reactants] to give the second term on the right hand
side of equation 2 a value which is more negative that the positive value of the first term
(remember the log of number less than 1 is negative).
The free energy change of a reaction (ΔG) defines:

o Whether the reaction can or cannot happen spontaneously
o The direction of any reaction
o the extent of any reaction i.e., how far the reaction is from equilibrium
o The amount of useful energy that is available from the reaction
It does not define:

o When the reaction will take place
o At what rate the reaction occur
o The reaction mechanism (independent of reaction mechanism)
Metabolic pathways in the cell are normally in steady state (net flow from initial reactant to
final product) rather than at equilibrium (no net flow). However, individual reactions can lie
close to equilibrium and others can be far from equilibrium. Reactions that have a small ΔGº’
(+ve or -ve) are normally close to equilibrium in the cell and their rate is determined largely by
199
the concentrations of reactants (substrate) and products. They can usually be reversed by
changing the relative amounts of substrate and product.
Reactions that have a large -ve ΔGº’ are normally far from equilibrium in the cell and are
essentially irreversible. These reactions play an important role in determining the overall flow
through a metabolic pathway and they are often the important sites of regulation.
Overview of glycolysis showing reversible and irreversible steps:
Glucose B C D E F G H I Pyruvate.
Appendix vi. Major roles of tissues in metabolism.
All tissues require a continuous supply of fuel (to generate ATP) and nutrients (synthesis of
cell components). In addition, some tissues interconvert and/or store nutrients.
Energy from glucose (also ketone bodies under certain conditions).

Glucose oxidised to CO2, requires O2.
CNS
No fuel storage, requires continuous supply of fuels and oxygen.
Cannot use fatty acids.
Energy from glucose, lactate, fatty acids or ketone bodies.
Fuels oxidised to CO2, requires O2.
Heart Muscle
No fuel storage, requires continuous supply of fuels and oxygen.
Contains creatine/creatine phosphate.
Energy from glucose or fatty acids.
Adipose tissue Synthesizes fatty acids from glucose and some amino acids.
Stores triacylglycerols, needs glucose (to make glycerol phosphate).
Energy from glucose, fatty acids or ketone bodies.
Stores glycogen and some triacylglycerol.
Skeletal Muscle Some muscle protein can be broken down in an emergency.
Can oxidise glucose to lactate under anaerobic conditions.
Contains creatine/creatine phosphate.
Energy from fatty acids, amino acids or alcohol.
Stores glycogen.
Makes glucose, ketone bodies, cholesterol and triacylglycerols.
Makes important proteins e.g. albumin (major plasma protein),
lipid transport proteins(apoproteins), blood clotting proteins.
Liver Disposes of excess amino acids Produces urea.
Involved in inactivation and disposal of endogenous chemicals such
as bilirubin and cholesterol (small change in structure and increased
water solubility).
Involved in inactivation and disposal of exogenous chemicals such as drugs.
Disposes of waste products in the bile or in the urine (via the kidney).
Makes glucose during starvation.
Disposes of water-soluble waste products of metabolism.
Kidney
If renal threshold is exceeded glucose, lactate and ketone bodies can
be lost from the body.
Red blood cells Energy from glucose.
No mitochondria, oxidise glucose to lactate.
Lungs Dispose of CO2 and volatile metabolites (e.g. acetone, alcohol).
200
Appendix vii. Overview of the 4 stages of catabolism
The catabolism of energy providing nutrients can be divided into four stages:
Stage 1:
o Occurs in gastrointestinal tract (extracellular)
o A few simple pathways
o Hydrolysis of complex molecules to simpler building block molecules
o Building block molecules absorbed into the circulation
o No release of useful energy
Stage 2:
o Many complex intracellular pathways (cytoplasmic and mitochondrial)
o Not all pathways occur in all tissues
o Building block molecules converted to a small number of simpler organic precursors.
o Oxidative processes requiring oxidised carrier molecules (NAD+, NADP+ and FAD)
o Some free energy conserved as ATP (substrate level phosphorylation
o Produces useful intermediates
Stage 3:
o Occurs in mitochondria
o Single pathway -Tricarboxylic acid cycle (TCA cycle)
o Oxidative process requiring oxidised carrier molecules (NAD+ and FAD)
o Does not occur in the absence of O
o Converts acetate to 2CO
o Some free energy conserved as ATP (GTP)
o Produces organic precursors used in biosynthesis.
Stage 4:
o Occurs in mitochondria
o Two pathways that are coupled-electron transport & ATP synthesis
o NADH and FADH re-oxidised and the expense of O that is reduced to H O
o Lots of free energy conserved as ATP
o Requires O2.
201
Appendix viii. Reference Values in Blood, Serum or Plasma
Please note that these values can vary according to the local laboratory or Trust.
You will not be expected to learn these values, but you should be aware of the normal values
of particularly glucose and potassium.
Source: Clinical Medicine, Kumar & Clark, 7th Ed. 2009, Saunders.
202
Appendix ix Food Diary
Leicestershire Nutrition and Dietetic Service
Food Record- Diary
Name .......................................................................
Address ....................................................................
Postal code ...............................................................
Date of Birth ............................................................
NHS Number ...........................................................
Date .........................................................................
Please return completed booklet to:
Name .......................................................................
Address ....................................................................
Food Record- Diary
Please use this diary to record everything you eat and drink for three days prior to your
appointment with the Dietitian. Record each day separately on the pages provided.
Try to record all food and drinks that you take, along with an approximate quantity, and the
time of day they are taken. There is also space to record any medications or supplements that
you take.
Example:
Day: Wednesday Time up: 7.30am Time to bed: 11pm
Time of Day Description of food/drink Amount consumed
Cornflakes 4 tablespoons
Breakfast Semi-skimmed milk 200ml
8am Water Glass
Mid Coffee (decaf) no milk no
morning sugar Cup
203
11am Digestive biscuit

Tuna mayo sandwich (bought) 2 slices
Lunch Crisps 1 pack
1.30pm Chocolate milkshake 200ml bottle
Mid
afternoon
3.30pm Orange juice Glass
Cottage pie
minced beef
Evening (bought) 2 tablespoons potato
6pm Peas and sweetcorn 1 tablespoon mince
Chocolate cheesecake 2 tablespoons
Tea milk no sugar 2 slices (1/4 dinner plate)
Evening 9 pm Red wine 2 large glasses
Medications and Supplements taken:

Description Time taken
Multivitamin Before breakfast
Antacid After lunch and evening meal
Day: Time up: Time to bed:

Day: Time up: Time to bed:

204
Appendix x. The Eatwell Plate
205
Appendix xi Reference Values in Blood, Serum or Plasma
Please note that these values can vary according to the local laboratory or Trust.
You will not be expected to learn these values, but you should be aware of the normal values of
particularly glucose, potassium, sodium and cholesterol.
206
Malnutrition Universal Screening Tool (MUST)
MUST is a five-step screening tool to identify adults, who are malnourished, at risk of
malnutrition (undernutrition), or obese. It also includes management guidelines which can be
used to develop a care plan.
It is for use in hospitals, community and other care settings and can be used by all care workers.
This guide contains:

o A flow chart showing the 5 steps to use for screening and management
o BMI chart
o Weight loss tables
Alternative measurements when BMI cannot be obtained by measuring weight and height.
The 5 MUST steps
Step 1
Measure height and weight to get a BMI score using chart provided. If unable to obtain height
and weight, use the alternative procedures shown in this guide.
Step 2
Note percentage unplanned weight loss and score using tables provided.
Step 3
Establish acute disease effect and score.
Step 4
Add scores from steps 1, 2 and 3 together to obtain overall risk of malnutrition.
Step 5
Use management guidelines and/or local policy to develop care plan.
Please refer to the MUST explanatory book let for more information when weight and height
cannot be measured, and when screening patient groups in which extra care in interpretation is
needed (e.g., those with fluid disturbances, plaster casts, amputations, critical illness and
pregnant or lactating women). The booklet can also be used for training.
See the MUST report for supporting evidence. Please note that MUST has not been designed
to detect deficiencies or excessive intakes of vitamins and minerals and is of use only in adults.
207
Step 1 BMI score (& BMI)
208
209
Step 2 Weight loss score
210
Alternative measurements and considerations

Step 1: BMI (body mass index)
If height cannot be measured

o Use recently documented or self-reported height (if reliable and realistic)
o If the subject does not know or is unable to report their height, use one of the
alternative measurements to estimate height (ulna, knee height or demispan).
If height & weight cannot be obtained

o Use mid upper arm circumference (MUAC) measurement to estimate BMI category
Step 2: Recent unplanned weight loss
If recent weight loss cannot be calculated, use self-reported weight loss (if reliable and
realistic).
Subjective criteria
If height, weight or BMI cannot be obtained, the following criteria which relate to them can
assist your professional judgment of the subject's nutritional risk.
1- BMI
o Clinical impression thin, acceptable weight, overweight
o Obvious wasting (very thin) and obesity (very overweight) can also be noted
2- Unplanned weight loss

o Clothes and/or jewellery have become loose fitting (weight loss).
o History of decreased food intake, reduced appetite or swallowing problems over
3-6 months and underlying
o disease or psycho-social/physical disabilities likely to cause weight loss
3- Acute disease effect

o No nutritional intake or likelihood of no intake for more than 5 days.
Further details on taking alternative measurements, special circumstances and subjective

criteria can be found in the MUST explanatory booklet. A copy can be downloaded at
www.bapen.org.uk or purchased from the BAPEN office. The full evidence-base for MUST is
contained in the MUST.
Report and is also available for purchase from the BAPEN office.
Alternative measurements: instructions and tables

If height cannot be obtained, use length of forearm (ulna) to calculate height using tables
below. (See the MUST explanatory booklet for details of other alternative measurements (knee
height and demispan) that can also be used to estimate height).
211
Estimating height from ulna length
Estimating BMI category from mid upper arm circumference (MUAC)
212

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University of Duhok College of Medicine Module of Metabolism Student Book 2021-2022

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University of Duhok-College of Medicine- Metabolism Module Workbook 2021-2022

There are three major areas of study in the module:

1. Nutrition and Whole-Body Metabolism: considers the energy and nutrient

Summary of Intended Learning Outcomes:

On completion of this module you should be able to:

The lectures in the module will be given by:

Answers to self-assessment questions: Answers to the self-assessment questions for each

PowerPoint presentations: PowerPoint presentations will normally be posted on blackboard

• Marks Essential of Medical Biochemistry- A Clinical Approach. M. Lieberman, a

Nutrition and body weight

Structure of the Session:

Intended learning outcomes:

Chemical bond energy

Daily Energy Expenditure

(1) Basal Metabolic Rate (BMR):

1. Skeletal muscle 30%

(2) Voluntary Physical Activity:

BMR + 30% of the BMR for a sedentary person

(3) Diet-Induced Thermogenesis (DIT):

Calculations of Daily Energy Expenditure

Recommended Dietary Allowance/Amount (RDA)

Fats are important to the diet, however, because:

Other Dietary Requirements

Adult male Adult female Adult obese male

Ideal/desirable body weight

Underweight < 18.5 men and women

Weight Loss & Dieting

Diet Analysis-The Eatwell plate

• All people on registration for surgeries

Homeostasis, Control Systems and Biological Rhythms

Characteristics of control systems

Homeostasis in the Body

Key point: it is important to understand the concept that homeostasis underpins

Body Water Homeostasis

Example of a control system: the Hypothalamic-Pituitary-Adrenal Axis

The hypothalamic-pituitary-adrenal (HPA) axis is a good example of an important control

BMI, Obesity and Malnutrition

a. What is Ahmad's body mass index?

k. Why was feeding protein-rich food detrimental to the Sudanese children?

b. Explain the clinical consequences of severe protein deficiency in children.

c. Define the components of your daily energy expenditure.

g. List four key components of control systems

i. Describe in outline the hypothaamic-pituitary-adrenal (HPA) axis.

Aims of the session

Structure of the Session:

Intended learning outcomes

• Define cell metabolism and explain its functions.

Clinically important cell nutrients and waste products

Nutrient/waste product Normal fasting plasma concentration

Origins and fates of cell nutrients

Cell nutrients circulating in the blood come from a variety of sources:

Functions of cell metabolism

Cells metabolize nutrients to provide:

Simple overview of metabolism

Catabolism and Anabolism

The major carrier molecules are:

The reactions that serve to deoxidize reduced carrier molecules include:

• Reactions in which the substance is reduced (use NADH or FADH2)

CH3COCOOH + NADH + H+ CH3CHOHCOOH + NAD+

• Biosynthetic reactions involving reduction steps

ΔG = ΔH - TΔS where T is the temperature in K (o C + 273)

Coupling of exergonic to endergonic reactions; the roles of ATP and ADP

High energy and low energy signals