CARBOHYDRATES

Contents
1. Introduction
2. Pathways of Glucose Metabolism
3. Regulation of Glucose Metabolism
4. Disease states in Glucose Metabolism
 Hyperglycemia
 Hypoglycemia
5. Diagnosis of patients with Glucose Metabolic
Alterations
 Introduction
Primary energy source stored primarily as glycogen
Disease states involved hyperglycemia and hypoglycemia
Contain C, H, and O (Cx (H20)y with C=O and –OH functional groups
Introduction
Which of the following is not a carbohydrate?
Introduction
Carbohydrate Models
 Introduction
Classification Definition
Monosaccharides  Cannot be hydrolyzed to a simpler form
Monosaccharides
or simple sugars  Fructose,
Contain 3,glucose,
4, 5, 6 carbon
galactose
atoms
or simple sugars  Fructose,
Disaccharides Formed byglucose, galactose
interaction of two monosaccharides
Disaccharides  Maltose,
Maltose =Lactose,
glucoseSucrose
+ glucose
Polysaccharides  Lactose = glucose
Linkage of + galactose
many monosaccharide units
 Sucrose = glucoseand
Starch, glycogen + fructose
glycogen
 Introduction
Classification Definition
 Cannot be hydrolyzed to a simpler form
Monosaccharides  Contain 3, 4, 5, 6 carbon atoms
or simple sugars (triose, tetroses, pentoses and hexoses, etc.)
 Examples include fructose, glucose, galactose
 Introduction
Classification Definition
 Formed by interaction of two monosaccharides
 Examples
Disaccharides Maltose = glucose + glucose
Lactose = glucose + galactose
Sucrose = glucose + fructose
 Introduction
Classification Definition
 Linkage of many monosaccharide units
Polysaccharides  Include starch, glycogen and glycogen

Starch

Cellulose

Glycogen
Contents
1. Introduction
2. Pathways of Glucose Metabolism
3. Regulation of Glucose Metabolism
4. Disease states in Glucose Metabolism
 Hyperglycemia
 Hypoglycemia
5. Diagnosis of patients with Glucose Metabolic
Alterations
Glucose Metabolism
Glucose Metabolism
 Glucose Metabolism
1

Glycolysis  Metabolism of glucose to lactate or pyruvate

for production of energy
Gluconeogenesis  carbohydrate
Formation of glucose-6-phosphate from non
source
Glycogenolysis  Breakdown of glycogen to glucose for use as
energy
Glycogenesis  Conversion of glucose to glycogen for storage
Lipogenesis  Conversion of carbohydrates to fatty acids
Lipolysis  Decomposition of fat
 Glucose Metabolism
1

Glycolysis  Metabolism of glucose to lactate or

(EMP Pathway) pyruvate for production of energy
 Glucose –Insulin ATP +lactate/pyruvate
 Glucose Metabolism
1

 Formation of G-6-P from non

Gluconeogenesis carbohydrate source
 Fats (ketone bodies), Protein (urea nitrogen)
 Glucose Metabolism
1

Glycogenesis  Conversion of glucose to glycogen

Glucose –Insulin Glycogen
 Glucose Metabolism
1

Glycogenolysis  Breakdown of glycogen to G-6-P

 Glycogen –Glucagon Glucose
 Glucose Metabolism
1

Glycolysis  Metabolism of glucose to lactate or pyruvate

for production of energy
(EMP Pathway)  Glucose –Insulin ATP + lactate/pyruvate
 Formation of glucose-6-phosphate from non
carbohydrate source
Gluconeogenesis  Fats  glucose + ketone bodies
 Protein  glucose + urea nitrogen
 Breakdown of glycogen to glucose for use as
Glycogenolysis energy
 Glycogen –Glucagon Glucose
Glycogenesis  Conversion of glucose to glycogen for storage
 Glucose –Insulin Glycogen
 Glucose Metabolism
1

Lipogenesis Conversion of carbohydrates to fatty acids

Lipolysis Decomposition of fat
 Glucose Metabolism
1

Glycolysis  Glucose –Insulin ATP + lactate/pyruvate

Gluconeogenesis  Fats (ketones), Protein (urea nitrogen)
Glycogenolysis  Glycogen –Glucagon Glucose
Glycogenesis  Glucose –Insulin Glycogen
Lipogenesis  Conversion of carbohydrates to FA
Lipolysis  Decomposition of fat
CONTENTS
1. Introduction
2. Pathways of Glucose Metabolism
3. Regulation of Glucose Metabolism
4. Disease states in Glucose Metabolism
 Hyperglycemia
 Hypoglycemia
5. Diagnosis of patients with Glucose Metabolic
Alterations
Regulation of Glucose Metabolism
1. Insulin
2. Glucagon
3. Epinephrine
4. Cortisol
5. Growth hormone
6. Thyroxine
7. Somatostatin
 Regulation of Glucose Metabolism
Insulin (Hypoglycemic agent)
1. Primary hormone responsible for decreasing ↓ glucose
2. Synthesized by the β cells of the islets of Langerhan
3. ↑ glycogenesis, glycolysis, lipogenesis; and ↓ glycogenolysis.
 Regulation of Glucose Metabolism
Glucagon (hyperglycemic agent)
1. Primary hormone responsible increasing blood glucose
2. Synthesized by the α cells of the islets of Langerhan (pancreas)
3. ↑ glycogenolysis and gluconeogenesis.
 Regulation of Glucose Metabolism
Epinephrine
1. Produced by the adrenal medulla, ↑ blood glucose
2. Released during times of physical and emotional stress
3. Inhibits insulin secretion, ↑ glycogenolysis and lipolysis
 Regulation of Glucose Metabolism
Cortisol (Glucocorticoids)
1. Produced by the adrenal cortex, ↑ plasma glucose
2. ↓ intestinal entry of glucose into the cell, ↑ gluconeogenesis,
glycogenolysis and lipolysis
 Glucose Metabolism
Growth hormone
1. Produced by the anterior pituitary gland; ↑ plasma glucose
2. ↓ glucose entry to cells, ↑ glycolysis
 Glucose Metabolism
Thyroxine
1. Produced by the thyroid gland; ↑ plasma glucose
2. ↑ glycogenolysis, gluconeogenesis and glucose intestinal
absorption
 Glucose Metabolism
Somastostatin
1. Produced by the Delta cells of the islet of Langerhans in the
pancreas and hypothalamus
2. ↑ plasma glucose by inhibition of insulin, glucagon, GH, etc.
 Regulation of Glucose Metabolism
1. Insulin
2. Glucagon
3. Epinephrine
4. Cortisol
5. Growth hormone
6. Thyroxine
7. Somatostatin
CONTENTS
1. Introduction
2. Pathways of Glucose Metabolism
3. Regulation of Glucose Metabolism
4. Disease states in Glucose Metabolism
i. Hyperglycemia
ii. Hypoglycemia
5. Diagnosis of patients with Glucose Metabolic
Alterations
 Hyperglycemia
Increase
 in Plasma
Increase inGlucose
plasma glucose

Insulin is secreted in the β cells of pancreatic islets

 Hyperglycemia
Diabetes Mellitus
 Metabolic disease characterized by hyperglycemia resulting
from defects in insulin secretion, insulin action or both
Diabetes Mellitus
1. Type 1 (IDDM)
2. Type 2 (NIDDM)
3. Other
4. Gestational
 Hyperglycemia
Diabetes Mellitus Pathogenesis
Classification
1. Type 1 (IDDM)  β-Cell destruction
 Absolute insulin deficiency
 Autoantibodies
 Hyperglycemia
Diabetes Mellitus Epidemiology and Pathophysiology
Classification
1. Type 1 (IDDM)  5-10% of all cases of diabetes
 Occurs in childhood and adolescence
 Absence of Insulin with excess in glucagon
 Hyperglycemia
Diabetes Mellitus Characteristics
Classification
1. Type 1 (IDDM)  Abrupt onset
 Insulin dependence, ketosis tendency
 Sign and Symptoms
• Polydipsia
• Polyphagia
• Polyuria
 Hyperglycemia
Diabetes Mellitus
 Metabolic disease characterized by hyperglycemia resulting
from defects in insulin secretion, insulin action or both

Diabetes Mellitus
Classification
1. Type 1 (IDDM)
2. Type 2 (NIDDM)
3. Other
4. Gestational
 Hyperglycemia
Diabetes Mellitus Epidemiology
Classification
2. Type 2 (NIDDM)  90% of all cases of diabetes
 Adult onset
 Hyperglycemia
Diabetes Mellitus
Pathogenesis and Pathophysiology
Classification
2. Type 2 (NIDDM)  Insulin resistance w/ secretory defect
 Relative insulin deficiency
 ↑ with age, obesity and lack of exercise
 Insulin is present (hyperinsulinemia)
 Glucagon secretion is attenuated
 Hyperglycemia
Diabetes Mellitus Characteristics
Classification
2. Type 2 (NIDDM)  Non Insulin dependent
 Ketosis tendency is seldom
 Greater tendency to develop
hyperosmolar states
 Polydipsia, Polyphagia, Polyuria
 Hyperglycemia
Diabetes Mellitus
 Metabolic disease characterized by hyperglycemia resulting
from defects in insulin secretion, insulin action or both
Classification
1. Type 1 (IDDM)
2. Type 2 (NIDDM)
3. Other
4. Gestational
 Hyperglycemia
Diabetes Mellitus Pathogenesis
Classification
3. Others Associated with secondary conditions
4. Gestational Glucose intolerance during pregnancy
Due to metabolic and hormonal changes
 Hyperglycemia
Diabetes Mellitus
 Metabolic disease characterized by hyperglycemia resulting
from defects in insulin secretion, insulin action or both
Classification
1. Type 1 (IDDM)
2. Type 2 (NIDDM)
3. Other
4. Gestational
 Hyperglycemia
Laboratory Findings
1.
1. ↑
↑ glucose
glucose in
in plasma
plasma and
and urine
urine
2.
2. ↑
↑ urine
urine specific
specific gravity
gravity
2. ↑ urine specific gravity
3.
3. ↑
↑ serum
serum and
and urine
urine osmolality
osmolality
3.
4.
4. ↑ serumin
Ketones
Ketones inand urine
serum
serum osmolality
and
and urine
urine (ketonemia
(ketonemia and
and ketonuria)
ketonuria)
5. ↓ blood and urine pH (acidosis)
6. Electrolyte imbalance (↓ Na,↑ K )
 Hyperglycemia
Diagnostic Criteria for Diabetes Mellitus
1. Random plasma glucose ≥200mg/dL, + symptoms of diabetes
2. Fasting plasma glucose ≥126 mg/dL
3. 2-h plasma glucose ≥200 mg/dL during an OGTT
Categories of Fasting Plasma Glucose (FPG)
Provisional diabetes diagnosis FPG ≤126 mg/dL
Impaired fasting glucose FBG 100-125 mg/dL
Normal fasting glucose FBG <100 mg/dL
 Hyperglycemia
Diagnostic Criteria for Diabetes Mellitus
1. Random plasma glucose ≥200mg/dL, + symptoms of diabetes
2. Fasting plasma glucose ≥126 mg/dL
3. 2-h plasma glucose ≥200 mg/dL during an OGTT
Categories of Oral Glucose Tolerance
Provisional diabetes diagnosis 2-h PG ≤200 mg/dL
Impaired Glucose Tolerance 2-h PG 140-199 mg/dL
Normal Glucose Tolerance 2-h PG <140 mg/dL
CONTENTS
1. Introduction
2. Pathways of Glucose Metabolism
3. Regulation of Glucose Metabolism
4. Disease states in Glucose Metabolism
i. Hyperglycemia
ii. Hypoglycemia
5. Diagnosis of patients with Glucose Metabolic
Alterations
 Hypoglycemia
Causes of Hypoglycemia
a. Patients Appears Healthy
Insulinoma, Islet hyperplasia
No coexisting Factitial hypoglycemia (insulin/sulfonylurea)
disease
Severe exercise, Ketotic hypoglycemia
Compensated Drugs/disease
coexistent

b. Patients Appears ill

Drugs, Predisposing illness, Hospitalized patient
 Hypoglycemia

Genetic Defects in Carbohydrate Metabolism

Von Gierke Disease Glycogen build up in the liver
(glucose-6-phosphatase due to inhibition
inhibition of
of hepatic
hepatic
deficiency type 1) glycogenolysis
glycogenolysis
Galactosemia
(galactose-1- Inhibition of glycogenolysis
phosphate uridyl transferase
dificiency)
CONTENTS
1. Introduction
2. Pathways of Glucose Metabolism
3. Regulation of Glucose Metabolism
4. Disease states in Glucose Metabolism
i. Hyperglycemia
ii. Hypoglycemia
5. Diagnosis of patients with Glucose Metabolic
Alterations
Diagnosis of Glucose Metabolic Alterations

Considerations:
1. WB glucose concentration is 11% lower than plasma
2. Serum / plasma must be refrigerated and separated from
the cells within 1 hr
3. Sodium flouride (gray-top) can be used to inhibit glycolytic
enzymes
4. FBG should be obtained in the morning after 8 to 10 hours
fasting (not longer than 16 hours)
Diagnosis of Glucose Metabolic Alterations

Methods:
1. Fasting Blood Glucose
2. POC
3. 2-Hr Post Prandial Sugar
4. OGTT
5. HbA1C
Diagnosis of Glucose Metabolic Alterations

Non Enzymatic Methods of Glucose Measurement

1. Nelson Somogyi
2. Hagedorn Jensen
3. Ortho-toluidine (Dubowski)

Enzymatic Methods of Glucose Measurement

1. Glucose oxidase (Saifer Gernstenfield)
2. Hexokinase (Reference method)
3. Clinitest
Diagnosis of Glucose Metabolic Alterations

Non Enzymatic Methods of Glucose Measurement

1. Nelson Somogyi
Copper
Copper reduction
reduction method
method (uses
(uses BaSO
BaSO4 to
to remove
remove saccharoids)
saccharoids)
4
Glucose
Glucose ++ arsenomolybdic
arsenomolybdic acid
acid  arsenomolybdenum blue
 arsenomolybdenum
 arsenomolybdenum blue
blue
2. Hagedorn Jensen
2. Hagedorn Jensen
Ferric reduction method (inverse colorimetry)
Ferric reduction method (inverse colorimetry)
Glucose + Ferricyanide (yellow)  Ferrocyanide (colorless)
Glucose + Ferricyanide
3. Ortho-toluidine (yellow)  Ferrocyanide (colorless)
(Dubowski)
Condensation of carbohydrates with aromatic amines producing
Schiff bases (green)
Diagnosis of Glucose Metabolic Alterations

Non Enzymatic Methods of Glucose Measurement

1. Nelson Somogyi
2. Hagedorn Jensen
3. Ortho-toluidine (Dubowski)

Enzymatic Methods of Glucose Measurement

1. Glucose oxidase (Saifer Gernstenfield)
2. Hexokinase (Reference method)
3. Clinitest
Diagnosis of Glucose Metabolic Alterations

Enzymatic Methods of Glucose Measurement

1.
1. Glucose
Glucose oxidase
oxidase (Saifer
(Saifer Gernstenfield)
Gernstenfield)
Β-
Β-DD-glucose
-glucose ++ O
O22 +H
+H22O
O –glucose
–glucose oxidase
oxidase gluconic acid + H O
 gluconic acid + H22O22
H2O2 + reduce chromogen –peroxidase oxidized chromogen + H2O
H2O2 + reduce chromogen –peroxidase oxidized chromogen + H2O
a. Couple reaction is known as Trinder’s reaction
False Low results due to ↑ uric acid, bilirubin and ascorbic acid
b. O2 Consumption electrode (polarographic glucose analyzers)
measure oxygen depletion
Diagnosis of Glucose Metabolic Alterations

Enzymatic Methods of Glucose Measurement

2. Hexokinase (reference method)
Glucose + ATP –hexokinase glucose 6-PO4 + ADP
Glucose 6-PO4 + NADP+ –G-6-PD NADPH + H+ + 6-phosphogluconate
a. ↑ in absorbance is measured at 340 nm
b. False low results due to gross hemolysis and ↑↑↑ bilirubin
Diagnosis of Glucose Metabolic Alterations

Enzymatic Methods of Glucose Measurement

2. Hexokinase (reference method)
Glucose + ATP –hexokinase glucose 6-PO4 + ADP
Glucose 6-PO4 + NADP+ –G-6-PD NADPH + H+ + 6-phosphogluconate
Diagnosis of Glucose Metabolic Alterations

Non Enzymatic Methods of Glucose Measurement

1. Nelson Somogyi
2. Hagedorn Jensen
3. Ortho-toluidine (Dubowski)

Enzymatic Methods of Glucose Measurement

1. Glucose oxidase (Saifer Gernstenfield)
2. Hexokinase (Reference method)
3. Clinitest
Diagnosis of Glucose Metabolic Alterations

Methods:
1. Fasting Blood Glucose
2. POC
3. 2-Hr Post Prandial Sugar
4. OGTT
5. HbA1C
Diagnosis of Glucose Metabolic Alterations

Self-Monitoring of Blood Glucose

1. Type 1 diabetes – 3 to 4 times/day
Diagnosis of Glucose Metabolic Alterations

Methods:
1. Fasting Blood Glucose
2. POC
3. 2-Hr Post Prandial Sugar
4. OGTT
5. HbA1C
Diagnosis of Glucose Metabolic Alterations

2-Hour Postprandial Tests

A solution (75g of glucose) is
administered and a specimen is
drawn 2 hrs. later

Oral Glucose Tolerance Test

FBS is taken. Glucose load is
administered. Blood glucose is
determined in 30 min, 1st , 2nd
and 3rd hrs.
Diagnosis of Glucose Metabolic Alterations

Methods:
1. Fasting Blood Glucose
2. POC
3. 2-Hr Post Prandial Sugar
4. OGTT
5. HbA1C
Diagnosis of Glucose Metabolic Alterations

HbA1C Measurement
• Index for long term plasma glucose control (2-3 month period)
• Based on charged differences between HbA1C and Non-HbA1C
• Specimen requirement is EDTA WB sample. N.V  4.5 to 8.0%
Diagnosis of Glucose Metabolic Alterations

Methods of HbA1C Measurement based on:

A. Structural differences
1. Immunoassays
2. Affinity Chromatography
B. Charge differences
1. Cation-exchange Chromatography
2. Electrophoresis
3. Isoelectric focusing
4. HPLC
Diagnosis of Glucose Metabolic Alterations

Methods:
1. Fasting Blood Glucose
2. POC
3. 2-Hr Post Prandial Sugar
4. OGTT
5. HbA1C
CONTENTS
1. Introduction
2. Pathways of Glucose Metabolism
3. Regulation of Glucose Metabolism
4. Disease states in Glucose Metabolism
i. Hyperglycemia
ii. Hypoglycemia
5. Diagnosis of patients with Glucose Metabolic
Alterations
Thank You 
Diagnosis of Glucose Metabolic Alterations

Ketone
Produced by the liver through
metabolism of stored lipids
3 ketone bodies
• Acetone (2%)
• Acetoacetic acid(20%)
• 3-β-hydroxybutyric acid (78%)
Ketonemia
accumulation of ketones in blood
Ketonuria
accumulation of
ketones in urine
Diagnosis of Glucose Metabolic Alterations

Mtds. of Ketone Measurement

1. Gerhardt’s Test
• Acetoacetic acid + Ferric chloride
 Red color
2. Nitroprusside
• Acetoacetic acid + nitroprusside
–alkaline pH Purple
color
3. Enzymatic
• NADH + H+ + acetoacetic acid
–β-HBD NAD +
β-hydroxybutyric acid
Diagnosis of Glucose Metabolic Alterations

Methods:
1. Fasting Blood Glucose
2. POC
3. 2-Hr Post Prandial Sugar
4. OGTT
5. HbA1C
6. Ketone
7. Microalbuminuria
Diagnosis of Glucose Metabolic Alterations

Microalbuminuria
Early stage diabetic renal nephropathy
Persistent albuminuria (30-299 mg/24h or alb./crea. 30-300 µg/mg
Diagnosis of Glucose Metabolic Alterations

Methods:
1. Fasting Blood Glucose
2. POC
3. 2-Hr Post Prandial Sugar
4. OGTT
5. HbA1C
6. Ketone
7. Microalbuminuria