Oral Glucose

Tolerance Test
Laboratory Exercise Objectives
 To determine the array of the test that should be
performed on the patient
 To further identify the particular normal values
that are standard for each test
 To compare the standard normal values with the
obtained laboratory results
 To establish expected laboratory values
 To understand why these laboratory test was
chosen for these specific patient.
Experiment Objective
 To be familiar with the normal values of
blood sugar in the test
 To provide the significance of testing OGTT
in patients suspected with diabetes
 To be acquainted with other diseases that
can cause abnormal glucose tolerance test
result
Case
 50 year old
 122 mg/dL plasma glucose
 Family history:
 Two siblings with Type II Diabetes Mellitus
 Sedentary lifestyle and rarely went to the
gym
Oral Glucose Tolerance Test
 Sensitive
 Lack specificity
 Defines diabetes chemically
 Abnormal in many diseases
 Influenced by diet and other variables
Oral Glucose Tolerance Test
 Should be administered with in the
standard
Preparation
 Patient must be ambulatory and free from
illness or trauma
 Diet containing 150g of CHO for 3 days
 Advisable to do fasting blood glucose first
 For three days prior to the test, the subject had a
high carbohydrate diet of > 300 gm per day
 Eight hours before the test, on the day of the
experiment, the subject had nothing by mouth.
 Fasting blood sugar was taken using a
glucometer.
 The subject then ingested 75 gm glucose.
 Blood sugar was taken at 60 min, 90 min and 120
min after intake of glucose.
 The results were recorded.
High-Carbohydrate
Preparatory Diet

 The subject’s maximal ability to

metabolize sugar is tested.

 The repeated stimulation of postprandial

hyperglycemia gradually restores maximal
insulin responsiveness and reactivates the
processes needed for disposal of glucose
by different tissues.
R
E
S
U
L
T
 Result

145 60 mins= 142

140 90 mins= 124

120 mins=120
135
130
125 Glucose level
120
115
110
105
60 mins 90 mins 120
mins
Normal values
Proposed Age-Adjusted Normal Limits for Oral
Glucose Tolerance Test

AGE SLIDING FIXED Blood sugar

(mg/100 cc)
(years) LIMIT LIMIT
20 142 148
30 152 163
40 161 178
50 169 193
60 177 208
70 185 224
80 198 239
 Normal Glucose Tolerance
 Plasma glucose levels below 140 mg/100cc both fasting and
2 hr after glucose load

 Impaired Glucose Transport

 Requires a two hour plasma glucose level equal to or greater
than 140 mg/100 cc but below 200 mg/100 cc and at least
one value between 0 time and 2hr equal to or greater than
200 mg/100cc

 Definite Diabetes
 > Require either two fasting plasma glucose values 140
mg/100cc or more; or a 2 hr plasma glucose level equal to or
above 200 mg/100 cc, and at least one value between zero
time and 2 hr equal to or greater than 200 mg/100 cc
ENDOCRiNE
SYSTEM
PANCREAS
PANCREAS
 The pancreas is a
elongated organ,
light tan or pinkish in
color, that lies in
close proximity to the
duodenum. It is
covered with a very
thin connective tissue
capsule which extends
inward as septa,
partitioning the gland
into lobules.
PANCREAS
 The bulk of the
pancreas is composed
of pancreatic exocrine
cells and their
associated ducts.
Embedded within this
exocrine tissue are
roughly one million small
clusters of cells called
the Islets of
Langerhans, which are
the endocrine cells of
the pancreas and
secrete insulin, glucagon
and several other
hormones.
PANCREAS Pancreatic islets house
three major cell types:

 Alpha cells (A cells)

secrete the hormone
glucagon.
 Beta cells (B cells)
produce insulin and are
the most abundant of the
islet cells.
 Delta cells (D cells)
secrete the hormone
somatostatin, which is also
produced by a number of
other endocrine cells in the
body.
INSULIN
a) stimulates liver, fat, and muscle cells
to take up glucose.

b) stimulates liver and muscles to store

glucose as glycogen.

d) promotes buildup of fats and proteins

and inhibits their use as an energy
source.
 IN SULIN
SYN THESIS
 Insulin gene
encodes for
preproinsulin.
 Preproinsulin
contains 4
sequential
peptides:
 N-terminal

signal
peptide
 B chain

 C peptide

 A chain
 The N-terminal
signal peptide
is degraded
during the
course of
completion of
the proinsulin
molecule.
 The proinsulin
is folded into a
conformation
that permits
the disulfide
linkages
between the A
and B chains
to form.
 Converting
enzymes
cleave off the
C peptide.
 Insulin
synthesis is
completed
 IN SULI N
SECRET ION
 1

3
4 5

6
9

8
 7

1
6

5
2

3 4
REGU LATIO N
OF INSU LIN
SECR ET ION
REG UL ATI ON
GLUCOSE,
AMINO ACIDS,
FFA/KETOACIDS,
POTASSIUM

STIMULATES
UPTAKE, STIMULATES
METABOLISM, SECRETION
STORAGE

INSULIN
 Biphasic response:

1. First phase or Immediate pulse or Initial

response
1. Rapid release of preformed insulin

– Second phase or Prolonged response

1. Rapid release of newly synthesized insulin
2. Slow removal of insulin substrate inhibiting
further release
3. Different sensitivity
 REG UL ATI ON
 Factors affecting insulin secretion

Stimulators Inhibitors

glucose secretin fasting interleukin-1

protein CCK exercise pancreastatin
ketoacids vagal activity somatostatin leptin
FFA Ach galanin
potassium glucagon endurance training
calcium GLP-1 α-adrenergic activity
GIP diazoxide
β-Adrenergic activity prostaglandin E2
sulfonylurea drugs
meglitinides
INSU LIN ACTI ON
 INSULIN RECEPTOR

 composed of two alpha

subunits and two beta
subunits linked by
disulfide bonds
 alpha chains are entirely
extracellular and house
insulin binding domains
 linked beta chains
penetrate through the
plasma membrane
INSU LIN ACTI ON
Insulin binds to receptors

Activates tyrosine kinase

autophosphorilation

Fully activates tyrosine kinase

 Serine and threonine phosporilation

Growth receptor binding protein 2 Activation of phosphatidylinositol

Activates glycogen synthase, Generates phosphatidylinositol-3-4

Signals mitogen-activated And 3,4,5 phosphates
Protein (MAP) kinase

2nd messengers
 ↓ cAMP levels

Activation of glucose transport system

GLUT-4 (for muscle and adipose tissue)

Glucose → glycogen → pyruvate → lactate → fatty acids

INSU LIN ACTI ON
INSU LIN ACTI ON
glycogenesis glycogenoly glycogenesis
sis lipogenesi
s
glycolysis
proteolysi gluconeogenes lipolysis
s is ketogene
sis
protein
synthesis
 Synthesized by the alpha cells of
the islets of Langerhans from a
preproglucagon precursor when the
blood glucose concentration falls
 Functions to increase blood
glucose concentrations
 It is known as a hyperglycemic
hormone
 It is a primary hormone that
regulates hepatic glucose production
and ketogenesis
 Its activities are affected by
glucose concentration and insulin
 Liver – major site of glucose
degradation
Increased blood glucose inhibits glucagon secretion
• Decreased in blood glucose levels from normal (90 mg/100 ml), increases
plasma concentration of glucagon (hypoglycemic)
• Increased blood glucose levels, decreases plasma glucagon
(hyperglycemic)

Increased blood amino acids stimulates glucagon secretion

• High conc. of amino acids (esp. alanine & arginine), stimulate secretion of
glucagon
• In this instance, glucagon and insulin responses are not opposites
• Glucagon promotes rapid conversion of amino acids to glucose making it
more available to tissues
Exercise stimulates glucagon secretion
• Glucagon increases fourfold to fivefold during exhaustive exercise

Fasting for several days stimulates glucagon secretion

Vagal stimulation and acetylcholine release

It can be suppresses or inhibited by:

• glucose
• fatty acids
• GLP-1 and secretin
• somatostatin (inhibits release)
• breakdown of liver glycogen
(Glycogenolysis)
• increased Gluconegenesis in the liver
 Glucagon

Adenylyl cyclase

cAMP

Protein
kinase

Glycogen Phosphorylase A Glycogen Phosphorylase B

(active) (inactive)

Glucose-1-phosphate
 Glucose
Glucagon
phosphorylates Fructose-6-P
Fructose-6-P

Fructose 1,6
Phosphatase activity biphosphatase
If decreased
Kinase activity

Fructose 2,6-P2
Insulin
dephosphorylates
If increased 6 Phosphofructokinase

Fructose 1,6-P2

Pyruvate
 Glucagon

FFA HMG-CoA
reductase
Adipose tissue lipase
Triglyceride Synthesis

Beta oxidation Beta oxidation

Acetyl CoA carboxylase

Increases lipolysis Decreases cholesterol

Acetyl CoA and delivery of FFA synthesis
to the liver

Malonyl CoA

Carnitine acyltransferase
• It is produced by the delta cells of islets of Langerhans
• It inhibits insulin and glucagon secretion
• It is stimulated by:
• increased blood glucose
• increased amino acids
• increased fatty acids
• increased concentrations of several of the GIT hormones
• Inhibitory effects:
• Acts in the islet of Langerhans to depress both insulin and glucagon
• Decreases motility of the stomach, duodenum and gallbladder
• Decreases secretion and absorption in the GIT
• Principal role: it extends the period of time over which the food nutrients are
assimilated in the blood
• Decreases the utilization of the absorbed nutrients by the tissues, thus
preventing rapid exhaustion of the food and therefore making it available over a
longer period of time
 It is described as having a blood glucose level that is higher than
normal, but not high enough to be classified as diabetes
 It is also been referred to as borderline or chemical diabetes or ‘pre-
diabetes’
 It carries a high risk of progressing to type 2 diabetes
 It is combination of impaired secretion of insulin and reduced insulin
sensitivity (insulin resistance)
 It is also characterized by hyperglycemia
 It exists if the fasting plasma glucose level is <140 mg/dl
 It exists if the 30-, 60- and 90-minute plasma concentration is >200
mg/dl with a 2-hour plasma glucose level between 140 and 200 mg/dl
People who have a higher risk of
developing IGT are:

 those overweight
 those with a family history of
diabetes
 women who have had gestational
diabetes
 those having hypertension or
abnormal lipid profile
 high LDL-cholesterol (also
called "bad" cholesterol)
 low HDL-cholesterol (also
called "good" cholesterol)
Risks associated with IGT:

•Increased risk of heart attack

•Coronary artery disease, hypertension
•Onset of Type 2 diabetes
Nondiabetic causes
Liver cell disease
Chronic illness, prolonged physical inactivity
Acute stress state
Starvation, malnutrition
Potassium depletion

Diseases of other Endocrine glands

Acromegaly
Islet cell tumors
 Pheochromocytoma
Drugs that alter Glucose Tolerance

C. Drugs that raise blood sugar

 Chronic glucocorticoid administration
 Oral diuretic compounds
 Estrogen
 Nicotinic acid

B. Drugs that lower blood sugar

 Salicylates
 Monoamine-Oxidase inhibitors
• following a healthy balanced diet
• weight control
• exercise
• glucose monitoring
• blood pressure monitoring
Fasting Blood Glucose Test
Oral Glucose Tolerance Test
Postprandial Blood Glucose Test
DIABETES MELLITUS
What is it?

- Diabetes mellitus is a group of

metabolic diseases characterized by high
blood sugar (glucose) levels, which result
from defects in insulin secretion, or action,
or both.
DIABETES MELLITUS
What causes it?

- Insufficient production of insulin (either

absolutely or relative to the body's needs),
production of defective insulin (which is
uncommon), or the inability of cells to use
insulin properly and efficiently leads to
diabetes.
DIABETES MELLITUS
What are the types?

► Type I DM – insulin dependent

► Type II DM – non-insulin dependent

DIABETES MELLITUS
 TYPE I DM

- Type IA DM results from beta cell destruction

that usually leads to insulin deficiency, while for
the Type IB DM lack immunologic markers.

- major susceptibility gene for type IA is

located in chromosome 6, HLA region.

- classically occurs in juvenile but can occur at

any age
DIABETES MELLITUS
 Type I DM

- had classic symptoms of diabetes called “

3 polys” that is associated with weight loss:
polyphagia(derire to aet a lot or sugar craving),
polydipsia(desire to drink water at all time) and
polyuria(have to urinate frequently).

- prone to ketosis due to reduced insulin

level, could lead to an increase in lipolysis and
release of free fatty acids.
DIABETES MELLITUS
 Type II DM

- Defect in insulin receptors in insulin

targets cells
- Patients are usually obese/overweight
- Stronger genetic basis
- Non-ketosis prone
- Usually occurs at age 40 or over
DIABETES MELLITUS
 Type II DM
- 3 pathophysiologic abnormalities:
 Insulin resistance – decreased ability of insulin
to act effectively on peripheral target tissues.
 Impaired insulin secretion – endogenous
production continues, but the amount secreted is
less than the normal at same plasma glucose
concentration.
 Increased hepatic glucose production – failure
of hyperinsulinemia to suppress
gluconeogenesis
Other Laboratory
Procedures
For Diabetic screening and
diagnosis
Criteria for Diagnosis
Symptoms of diabetes plus random/casual
blood glucose concentration greater than or
equal to 11.1 mmol/L or 200mg/dL.
Fasting plasma glucose greater than or
equal to 7 mmol/L or 126mg/dL.
Two-hour plasma glucose greater than or
equal to 11.1 mmol/L or 200 mg/dL during
an OGTT.
Criteria for Diagnosis
Based on the following premises:
Spectrum of fasting plasma glucose and the response to
an oral glucose load varies in normal individuals
DM defined as the level of glycemia at which diabetes-
specific cimplications are noted and not the level of
tolerance from a population based viewpoint
(reflects new epidemiologic and metabolic evidence as
issued by National Diabetes Group and WHO; prevalence
of retinopathy in Native Americans begins to increase at
FPG >116 mg/dL)
Risk factors for DM type II
 Family history of diabetes (parent or sibling)
 Obesity (≥ 20% of desired body weight or BMI ≥ 27 kg/m2)
 Age ≥ 45 years
 Race/ethnicity (African American, Hispanic American, Native
American, Asian American, Pacific Islander)
 History of GDM or delivery of baby over 9 lbs)
 Hypertension
 Low HDL cholesterol (≤0.90 mmol/L) levels and/or high
triglyceride levels (≥ 2.82 mmol/L)
 Polycystic ovary syndrome
Diagnosis Method
Diagnosis of diabetes MUST be based on blood glucose
estimations
Urine glucose must not be the basis for diagnosis
True blood glucose should be estimated using enzymatic
methods (Glucose Oxidase method)
Blood glucose estimation should be specified whether it has
been carried out on capillary blood, whole venous blood, or
on venous plasma
OGTT in a known diabetic is not necessary
In all other persons, an OGTT must be carried out in order to
exclude diabetes
Fasting Plasma Glucose
its widespread use as a screening test is
strongly encouraged because
 (1) a large number of individuals ho meet the current
criteria for DM are unaware that they have the disorder
 (2) epidemiologic studies suggest that type 2 DM may be
present for up to a decade before diagnosis
 (3) as many as 50% of individuals with type 2 DM have
one or more diabetes-specific complications at the time of
their diagnosis
Fasting Plasma Glucose
Venous blood glucose
after the  NORMAL: ≤ 100 mg/dL
person has  IFG: 100 ≥ 110 mg/dL
fasted  DIABETIC: ≥ 110 mg/dL
overnight (at Capillary blood glucose
least 8 hours),  NORMAL: ≤ 100 mg/dL
a single  IFG: 100 ≥ 110 mg/dL
sample of  DIABETIC: ≥ 110 mg/dL
blood is drawn Plasma venous blood glucose
and sent to the  NORMAL: ≤ 110 mg/dL
laboratory for  IFG: 110 ≥ 126 mg/dL
analysis  DIABETIC: ≥ 126 mg/dL
Fasting Plasma Glucose
usually preferred: easy to perform, faster, and
more convenient for the patient
under-diagnoses the problem: normal FPG, but
will have an elevated 2-hour PG
first abnormality that occurs is the rise in post-
prandial blood glucose
fasting levels rise to abnormal values much later
on the basis of FPG alone, complications due to
tissue damage might already be present before
diagnosis
Random Blood Glucose Test
random blood samples (if taken shortly
after eating or drinking) may be used to test
for diabetes when symptoms are present
blood glucose level of 200 mg/dl or higher
indicates diabetes
must be reconfirmed on another day with a
fasting plasma glucose or an OGTT
Intravenous glucose tolerance test
given to patients who are unable to tolerate a large
carbohydrate load orally or who have altered gastric
physiology
same preparation as with OGTT
glucose solution is injected within a 3 to 4 minute interval and
blood samples are obtained at 5-15 minute intervals over
periods varying from 30-90 minutes after the injection
glucose values are plotted and from the data, a removal rate
constant is obtained
lower values indicate an abnormal tolerance to glucose load
OGTT curves that are flat (no rise greater than 20mg/dL) are
observed as the results of various malabsorption syndromes,
in this case the test is useful if the additional presence of
diabetes is suspected
Urinalysis
 not a reliable diagnostic tool but may be
used in conjunction with blood glucose
estimation
 persons with no sugar in their urine, but
very high blood sugar levels
 less than 0.1% of glucose normally filtered
by the glomerulus appears in urine (< 130
mg/24 hr)
 Glycosuria or Glucosuria
Urinalysis
copper reduction method:
Benedict’s test
Highly non-specific • enzymatic
Can give false positive results in the
presence of other reducing agents reduction
method: Glucose
oxidase strips
Appearance of reaction Report as Glucose
equivalent
more specific
(mg/dL) but can give
Clear blue to turbid green 0 0-100 false negative
Green to yellow precipitate 1+ 100-500 results
results may be
Greenish yellow to yellow 2+ 500-1000
affected by
Orange or brown 3+ 1000-2000
ascorbic acid

Brick red 4+ Over 2000

PHYSICAL EXAMINATION AND
RELATED TESTS
PHYSICAL EXAMINATION
 INSPECTION
 PALPITATION
 PERCUSSION
 AUSCULTATION
 LABORATORY TESTS
 SCREENING FOR DISEASE
WHAT TO CHECK FOR
VITAL SIGNS GENERAL APPEARANCE

HEENT CARDIOVASCULAR

RESPIRATORY CHEST

GENITOURINARY LYMPHATIC

MUSCULOSKELETAL SKIN

NEUROLOGIC PSYCHIATRIC
SUPPORTIVE TESTS FOR DM
BLOOD PRESSURE PERIPHERAL PULSES

ECG URINALYSIS

RESPIRATION RETINAL EXAMINATION

FOOT EXAMINATION NEUROLOGIC EXAMINATION

BLOOD PRESSURE &
PERIPHERAL PULSES
ORTHOSTATIC Bp  increase or decrease by 20mmHG
after standing for one minute against a supine Bp
measurement.

LOOK FOR SIGNS OF IRREGULAR HEART BEATS

ECG
1. Abnormally fast or irregular heart rhythms.
2. Abnormally slow heart rhythms.
3. Abnormal conduction of cardiac impulses
4. Evidence of the occurrence of a prior heart attack.
5. Evidence of an evolving, acute heart attack.
6. Evidence of an acute impairment to blood flow to the heart.
7. Adverse effects on the heart from various heart diseases or
systemic diseases.
8. Adverse effects on the heart from certain lung conditions.
9. Certain congenital heart abnormalities.
Evidence of abnormal blood electrolytes
Evidence of inflammation of the heart or its lining
URINALYSIS
SPECIFIC GRAVITY GLUCONURIA

Ph ANTIBODIES

PROTEINURIA KETONURIA

ELECTROLYTES LEVEL
RESPIRATION
RESPIRATORY RATE

COMPENSATION

HISTORY OF SMOKING
RETINAL EXAMINATION
FLUORECEIN ANGIOGRAPHY
B-SCAN ULTRASOUND
FUNDUS PHOTOGRAPHY

Retinal Fluorescein
photograph of a angiogram
patient indicating fluid
complaining of leakage within the
decreased vision. retina.
FOOT EXAMINATION
LOSS OF SENSATION

CHANGE IN SHAPE

FOOT ULCERS
NEUROLOGICAL TESTS
SENSORY REFLEXES

COORDINATION & GAIT MOTOR

CRANIAL NERVES
MEDICAL HISTORY
 WEIGHT/BODY MASS INDEX
 FAMILY HISTORY & COMPLICATIONS
 CARDIOVASCULAR DISEASE
 MEDICAL CONDITIONS
 SMOKING
 EXERCISE
 Genetic
Considerations
Type I DM
 Genetic contributions involve multiple genes
 Development of the disease require inheritance of a sufficient
complement of genes to confer susceptibility
 Concordance in identical twins: 30-70%
 Additional modifying factors must be present
 HLA complex polymorphisms – account for 40-50% of genetic
risk
 Region contain genes for class II MHC proteins (involved in
immune response; present antigen to helper T cells)
 Ability to present anitgemn dependent on amino acid
composition of the antigen-binding site
 Aa substitutions may alter the binding affinity of the antigens
Type I DM
 At least 17 other different genetic loci may
contribute susceptibility
 Polymorphisms in the promoter region of insulin
account for 10% of predisposition
 Genetic contributions not very strong
component
 Most individuals with these haplotypes do not
develop diabetes
 Most individuals with type I DM do not have a
first-degree relative with the disorder
Type II DM
 Stronger genetic component
 Polygenic and multi-factorial
 Various genetic loci contribute to susceptibility
 Environmental factors further module
phenotypic expression
 Concordance in identical twins: 70-90%
 Genetic defect may not manifest itself unless
and environmental even or another genetic
defect (obesity) is superimposed
 Mutations account for only a small fraction of
type II DM