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Reduced Counterregulation during Hypoglycemia with Raised Circulating Nonglucose Lipid Substrates: Evidence for Regional Differences in Metabolic Capacity in the Human Brain?

Department of Medicine, King’s College School of Medicine and Dentistry (M.L.E., K.M., J.L., A.P., I.C.P.C., S.A.A.), London SE59PJ, United Kingdom; and the Department of Physiology and Pharmacology, Queen’s Medical Center, University of Nottingham (I.M.), Nottingham NG7 2UH, United Kingdom

Address all correspondence and requests for reprints to: Dr. M. L. Evans, Department of Medicine, King’s College School of Medicine and Dentistry, London SE59PJ, United Kingdom.

We have investigated the potential for the human brain to use lipid fuels during acute hypoglycemia. Nine healthy male subjects underwent hyperinsulinemic (1.5 mU/kg·min) stepped hypoglycemic clamps on two occasions, infusing Intralipid (20%) and heparin (0.1 U/kg·min) on one occasion only (ILH), with an identical study without infusion of ILH acting as a control. Five subjects also underwent euglycemic clamping with Intralipid/heparin infusion.

During hypoglycemia, ILH raised circulating levels of nonesterified fatty acids, glycerol, and ß-hydroxybutyrate, although the latter did not rise until after the onset of counterregulation. With ILH, epinephrine responses [area under the curve (AUC), 127.9 ± 31.7 vs. 175.1 ± 27.4 nmol/L·180 min; P = 0.03] and GH responses (AUC, 260 ± 91 vs. 1009 ± 150, P < 0.01) were reduced and delayed (glucose thresholds, 2.8 ± 0.04 vs. 3.0 ± 0.1 mmol/L; P = 0.04), with a trend toward reduced cortisol responses. Similarly, hypoglycemic symptom scores were diminished during ILH (AUC, 647 ± 162 vs. 1222 ± 874; P = 0.03). However, there was no significant effect on the deterioration in four-choice reaction time, one measure of cognitive deterioration [glucose thresholds, 2.6 ± 0.1 vs. 2.7 ± 0.1 mmol/L, ILH vs. control (P = 0.75); AUC, 1420 ± 710 vs. 2250 ± 1080 ms/min (P = 0.59)]. During euglycemic clamping with Intralipid/heparin infusion studies, there was no rise in hormones, four-choice reaction time, or symptoms other than hunger and tiredness.

Both nonesterified fatty acids and glycerol can penetrate the mammalian brain and be metabolized. Raised levels were able to reduce neurohumoral responses to hypoglycemia, but could not protect cognitive function. This suggests that regional differences exist in human brain metabolism between glucose-sensing and cognitive areas of brain, which may be important in the understanding of the mechanisms of glucose sensing and in the genesis of hypoglycemia unawareness in insulin-dependent diabetes.

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